Ambulatory management of large primary spontaneous pneumothorax.

In a recent issue of the European Respiratory Journal, MASSONGO et al. [1] reported the results of a prospective study dealing with ambulatory management of primary spontaneous pneumothorax (PSP) using a pigtail catheter with one-way valve in a series of 60 consecutive patients. The authors reported a success rate of 83%, a 1-year recurrence rate of 17% and full outpatient management in 50% of the patients. However, they included in their analysis 12 (20%) patients with small PSP and no breathlessness, which were treated conservatively, and all of these patients demonstrated complete re-expansion by day 7. As the definition of success was based on the complete or nearly complete re-expansion of the lung on chest radiography at 7 days, these 12 patients alter the results, as the size of the pneumothorax determines the rate of resolution [2]. Therefore, in large PSP, the success rate is actually 79% (38 out of 48) and 37% (18 out of 48) had full outpatient management. However, we strongly agree with the usefulness of such management of spontaneous pneumothoraces. We would like to highlight the importance of the four ‘‘discharge safety criteria’’ described by the authors: 1) patient in stable condition; 2) time to reach the hospital from patient’s home ,1 h by any means of transport; 3) patient not living alone; and 4) patient able to understand and implement instructions given in the case of problems. We think that with this technique, patient could be discharge even at night. Therefore, the fifth criterion (time of discharge earlier than 20:00 h) seems not so relevant. To conclude, we would like to thank MASSONGO et al. [1] for this work, which shows that ambulatory management of large PSP is safe, efficient and cost-effective. This technique is not mentioned in current guidelines [2–4] and should be included in future recommendations. As recently stated by BRIMS and MASKELL [5], prospective studies are lacking in this field and we need randomised clinical trials to clearly demonstrate the benefit of this ambulatory management, such as that described by the authors of the present paper.