J Trauma Acute Care Surg. 2021 Jul 2. doi: 10.1097/TA.0000000000003322. Online ahead of print.
ABSTRACT
BACKGROUND: The aim of this systematic review was to investigate the safety and effectiveness of conservative management versus prophylactic intercostal catheter (ICC) insertion for the management of occult pneumothoraces in mechanically ventilated patients.
METHODS: PubMed, Embase, CINAHL, Web of Science, Cochrane Central and other trial registries were searched. Eligible studies were critically appraised using standardised instruments. Meta-analysis was performed with mixed-methods logistic regression where appropriate and sensitivity analyses were performed with alternative statistical methods (StataTM 15 or RevMan 5.3) or summarised in narrative. Randomised controlled trials (RCTs) and cohort studies were analysed separately.
RESULTS: Twelve studies with a total of 354 participants were included; three RCTs (178 participants) and nine cohort studies (176 participants). The majority of the included studies, particularly the cohort studies, were well conducted. Two of the RCTs were rated as low quality. Statistically significant differences were observed in the RCT analysis: ICC insertion (any reason) (OR 2.86, 95% CI 1.26-6.43, 2 RCTs) in favour of prophylactic ICC; ICC complications (OR 0.12, 95% CI 0.02-0.62, 2 RCTs) in favour of conservative management. Non statistically significant differences were observed for progression of pneumothorax, ICC insertion (progression to simple pneumothorax) and ICC insertion (non-pneumothorax reasons). Results of analyses showed high imprecision (wide confidence limits). Conservative management showed a low rate of tension pneumothorax (2.8%). Complications were higher in the ICC group (19.5% vs 5.8%).
CONCLUSIONS: Available evidence suggests that conservative management is safe for the management of occult pneumothoraces in mechanically ventilated patients, especially when undergoing short-term (<4 days) ventilation. We recommend that patients undergoing mechanical ventilation for a procedure alone and patients suspected to be ventilated less than four days can be conservatively managed.
LEVELS OF EVIDENCE: level 3.
STUDY TYPE: systematic review and meta-analysis.
PMID:34225346 | DOI:10.1097/TA.0000000000003322
