Brown, S., Ball, E. L., Perrin, K., Asha, S. E., Braithwaite, I., Egerton-Warburton, D., Jones, P. G., Keijzers, G., Kinnear, F. B., Kwan, B., Lam, K. V., Lee, Y., Nowitz, M., Read, C. A., Simpson, G., Smith, J. A., Summers, Q. A., Weatherall, M., Beasley, R., & PSP Investigators (2020). Conservative versus Interventional Treatment for Spontaneous Pneumothorax. The New England journal of medicine, 382(5), 405–415. https://doi.org/10.1056/NEJMoa1910775

This article is a non inferiority randomized control trial whose aim was to evaluate whether conservative management is as effective as interventional management of a moderate to large primary spontaneous pneumothorax. They recruited 316 patients ranging from the age of 14-50 years with a first known spontaneous pneumothorax. These patients were randomly assigned to either a conservative observational approach (162) or a more immediate interventional management (154). They were followed for 12 months, with the primary measured outcome of lung reexpansion in 8 weeks. Overall they found that conservative management was noninferior to interventional management, with a lower risk of side effects. About 94.4% of patients had lung re-expansion within 8 weeks, compared to 98.5% of people who received medical intervention.

I chose this article because it was a recently published article that included a moderate number of participants, and addressed a question that one of my patients had. This was a 22 y/o thin male who had developed a spontaneous pneumothorax, and he asked me if the chest tube placement was absolutely necessary. Normally conservative observation is recommended in large PTXs when patients have mild symptoms, with no hemodynamic instability, and can ambulate without effort. However the primary data presented in this article was not without bias, treating physicians were aware of each trial group and could have biased interventional management over observational management. Additionally not all patients returned at 8 weeks for the final radiograph, which was needed to show resolution. Some patients arrived days later. This discrepancy leads to a decreased confidence interval with resolution when examining the conservatice approach. Yet the median time for resolution between both groups was 2 weeks. Overall the researchers spared 85% of patients from invasive intervention, and they have supplied sequential radiographic evidence indicating that conservative observation can have lower risk of serious adverse events or pneumothorax recurrence than interventional management.