Ambulatory management of primary spontaneous pneumothorax may reduce length of hospital stay

Ambulatory management of primary spontaneous pneumothorax reduced the duration of hospital stay and readmissions, was associated with an increase in adverse events, according to new data from the RAMPP trial.

“Most people manage as per the [British Thoracic Society] guidelines, which suggests that if you have a big pneumothorax and are breathless, you should aspirate first, and if that fails, you should go on to have a chest tube and admission to the hospital,” Rob J. Hallifax, PhD, MRCP, BMBCh, MSci, academic clinical lecturer in respiratory medicine at Oxford University, said during a presentation at the virtual European Respiratory Society International Congress. “The problem is, needle aspiration itself only works in about 40% to 50% [of cases], so the majority of patients end up having a chest tube and get admitted. Data from randomized trials suggest that the hospital stay is around 4 to 8 days for these patients, and these are fit, young patients without comorbidities, so there must be a better way of doing this.”

Researchers conducted the multicenter, randomized, controlled RAMPP trial, which enrolled 236 patients with primary spontaneous pneumothorax at 24 U.K. hospitals over 3 years. Patients were randomly assigned to ambulatory care with Pleural Vent insertion (Rocket Medical; n = 117; mean age, 31 years; 82% men) or standard care, which included needle aspiration with or without standard chest tube insertion (n = 119; mean age, 30 years; 82% men).

Primary outcome was total length of hospital stay including readmission up to 30 days after randomization. Secondary outcomes included pain and breathlessness scores, need for further procedure, complications and recurrence rates.

Median hospital stay in the ambulatory group was 0 days with most patients going home the same day without further readmission compared with a median of 4 days in the standard care group (P < .0001). The standard care group had a greater number of pleural procedures, with 1.4 per patient compared with 1.2 in the ambulatory care group (P < .0001). Thirty-five percent of patients who received another procedure in the standard care group required chest drain insertion, and 21% of patients in the ambulatory care group who received another procedure required chest drain insertion, Hallifax said during the presentation.

“We wanted to make sure this new device was not more painful and that it treated breathlessness the same as [standard care]. There was no change in the curves, but a large change in pain and breathless scores, so we treated patients effectively over those first 4 days,” Hallifax said.

Adverse events occurred only in the ambulatory care arm, with 12% of that group experiencing a serious adverse event.

“We think this is partly because of our definition of adverse events becoming serious when they required admission to hospital,” Hallifax said. “Now, if you were in the ambulatory group and you were home, any serious event that led you to come in was then required to be serious, but if you were already in the hospital in the standard care arm then that couldn’t be defined as serious.”

Serious adverse events related to intervention in this group included enlarging pneumothorax (3%), device blocking event requiring chest drain insertion (3%) and other admission (2%). Other serious adverse events were unrelated to the intervention of care.

“Ambulatory treatment in primary pneumothorax works. We can safely manage patients as outpatients with a median stay of 0 days. Patients need to be aware that some will require further admission and chest drain, it won’t work for everybody, but this allows us to have an informed discussion with patients,” Hallifax said. “I think it is time for a new treatment pathway for these patients with primary pneumothorax.”