Co esponding au ho : Mazi Mohammed Alanazi.
Copy igh © 2025 Au ho (s) e ain he copy igh o his a icle. This a icle is published unde he e ms o he C ea i e Commons A ibu ion License 4.0.
In e cos al ube d ainage s manual aspi a ion clinical e ec i eness and sa e y
conside a ions o ea ing spon aneous pneumo ho ax in eme gency depa men
Mazi Mohammed Alanazi 1, *, Khalid saleh albalawi 2 and Asma ahmed almadani 2
1 Saudi and Jo danian Boa d Eme gency Medicine, Head o Eme gency Resea ch Uni , Eme gency Depa men , Fi s Heal h,
Clus e , Riyadh, Saudi A abia.
2 Eme gency medicine esiden , Eme gency Depa men , King Fahad specialis hospi al, Dammam, Saudi A abia.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1905-1910
Publica ion his o y: Recei ed on 04 Ap il 2025; e ised on 11 May 2025; accep ed on 13 May 2025
A icle DOI: h ps://doi.o g/10.30574/wja .2025.26.2.1886
Abs ac
P ima y spon aneous pneumo ho ax is a ype o pneumo ho ax occu in a pa ien who has no unde lying pulmona y
disease. The pu pose o his s udy was o conduc a sys ema ic e alua ion o esea ch on he e icacy o ube
ho acos omy s manual aspi a ion in ea ing spon aneous pneumo ho ax. The 2009 P e e ed Repo ing I ems o
Sys ema ic Re iews and Me a-Analyses (PRISMA) s a emen used as he guide o his in es iga ion. F om 2012 o 2024,
we sea ched he Coch ane Lib a y, PubMed, and EMBASE. Only ull- ex publica ions published in English we e included
in he sea ch. We also sea ched e iew e e ences and included he ele an publica ions we ound o ensu e ha all
ele an li e a u e was e iewed o ou analysis. A o al o 342 pa ien s om 5 andomized con olled ials we e
included in his in es iga ion. A sho e hospi al s ay and ewe ad e se e en s a e he ou comes o beginning
ea men s wi h manual aspi a ion as opposed o ube ho acos omy. Manual aspi a ion is an e ec i e i s ea men
o pa ien s expe iencing hei i s episode o p ima y spon aneous pneumo ho ax. The manual aspi a ion echnique
is simila o ube ho acos omy in e ms o quick lung e-expansion in spon aneous pneumo ho ax pa ien s.
Keywo ds: In e cos al Tube D ainage; Tho acos omy; Manual Aspi a ion; P ima y Spon aneous Pneumo ho ax;
Eme gency Depa men
1. In oduc ion
Pneumo ho ax (PTX) ha occu s spon aneously in a pa ien who has no unde lying pulmona y illness is known as
p ima y spon aneous pneumo ho ax (PSP) [1]. PSP has a di e se pa hophysiology ha includes he up u e o bullae
o blebs, which a e lung pa enchymal al e a ions esembling emphysema b ough on by in lamma ion and blockage o
he dis al ai way [2,3]. PSP can be ea ed wi h ube ho acos omy (TT), manual aspi a ion (MA), su gical in e en ion,
and moni o ing wi h O2 inhala ion [4]. The e is ag eemen ha obse a ion wi h O2 inhala ion is he bes cou se o
ac ion o PSP pa ien s who ha e a mino PTX (size less han 25%) [4,5]. In e na ional ecommenda ions and clinical
p ac ice a y, and he e a e no clea guidelines o PSP pa ien s wi h a la ge PTX (size mo e han 25) [6]. The pauci y o
high-quali y in o ma ion ga he ed om se e al p ospec i e esea ch is he cause o hese dispa i ies [4].
Res o ing no mal ana omical ci cums ances by elimina ing he ai om he pleu al space and p e en ing ecu ences
a e he wo main objec i es o he he apeu ic plan o SP. While he second objec i e only pe ains o indi iduals who
ha e ecu en PTX, he i s aim is applicable o all pa ien s who expe ience an acu e episode o PTX. The ecu ence
a es ollowing he ini ial PSP episode a e p edic ed o be be ween 23 and 37% [7]. Lung e-expansion and ai
e acua ion om he pleu al space a e equen issues ha pulmonologis s, ho acic su geons, and gene al su geons deal
wi h on a daily basis. Ches ube d ainage wi h unde wa e seal o suc ion, manual aspi a ion, and conse a i e he apy
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1905-1910
1906
wi h oxygen supplemen a ion a e among he a ailable he apeu ic op ions [8]. In his s udy we aimed o sys ema ically
e iew s udies discussed he e ec i eness o MA s TT in he ea men o SP.
2. Me hod
This s udy was conduc ed acco ding o The P e e ed Repo ing I ems o Sys ema ic e iews and Me a-Analyses
(PRISMA) s a emen , published in 2009. Using he sea ch ph ases ( ho acos omy, aspi a ion, spon aneous
pneumo ho ax, in e cos al, ube, and ca he e ), we looked h ough EMBASE, PubMed, and he Coch ane Lib a y
be ween 2012 and 2024. Sea ch was limi ed o ull ex a icles published in English language. To make su e ha all
pe inen esea ch we e examined o ou analysis, we addi ionally looked h ough e iew e e ences and inco po a ed
he pe inen pape s we disco e ed.
We conside ed s udies which included adul pa ien s (olde han 18 yea s) wi h a i s episode o ecu ence o PSP
(de ined as SP in pa ien s wi hou p io lung illness) who equi ed an in e en ion, had no concomi an condi ions, and
we e RCTs. S udies we e disquali ied i hey p o ided insu icien o una ailable da a; e iews o expe imen al ials;
only included pa ien s wi h SSP; include pa ien s wi h ension pneumo ho ax, o auma ic pneumo ho ax.
Immedia e success a e, hospi aliza ion a e, hospi al s ay, ecu ence ime, ches su ge y a e, and complica ion a e
we e among he ou comes ha we e assessed. Immedia e success was he main ou come. Full o almos ull and
con inuous lung expansion igh a e MA was conside ed immedia e success. Fo TT, immedia e success was de ined
as ull lung expansion, no ai leaks, and emo al o he ches d ain wi hin 72 hou s o he ube being inse ed.
Ini ially, duplica e s udies we e no included. The i les we e examined by wo sepa a e schola s. The abs ac was
examined o see whe he he s udy could be e ie ed o he s udy i he i le indica ed any chance o he s udy ul illing
he inclusion equi emen s. The wo esea che s hen independen ly e alua ed he en i e ex s o he pape s ha we e
e ie ed in acco dance wi h he quali ying equi emen s. The wo esea che s ho oughly discussed and se led any
disag eemen s, wi h a hi d esea che making he inal decision i needed.
Using a sys ema ic da a ex ac ion app oach, wo esea che s independen ly e ie ed he pe inen da a on he esul s
o each o he included s udies. Da a collec ion o m include ( he yea o publica ion, names o he au ho s, esea ch
design, s udy pu pose, numbe o pa ien s in each g oup, pa ien cha ac e is ics, and key indings).
3. Resul
In his s udy we included 5 andomized con olled ials (Fig 1) wi h a o al o 342 pa ien s (Table 1). The success a e
o MA was 68%, whe eas o TT, i was 80.60% acco ding o Pa lak e al., (2012) [9]. A e wo weeks, he success a es
o bo h g oups we e 100%. Fo MA, he hospi al s ay di e ed conside ably (2.4 e sus 4.4). Compa ed o TT, MA had
dec eased one-yea ecu ence a es, albei hese di e ences we e no s a is ically signi ican . Fas success was
p edic ed by bo h emale sex and auma ic PTX. One pa ien died du ing ollow-up om hea ailu e. Ou o he 40
pa ien s who had hei i s episode o PSP, 21 and 19 pa ien s we e alloca ed o he MA g oup and he TT g oup,
espec i ely, acco ding o he Kim e al., 2019 [10] esea ch. The hospi al s ays o each g oup we e 2.1 and 5.4 days,
espec i ely. Howe e , he e was no signi ican di e ence in he i s ea men success a e o he 1-mon h and 1-yea
ecu ence a es. Acco ding o Thelle e al. (2017) [11] s udy he ini ial success a e o MS was 69%, whe eas he a e
o TT, acco ding o. Sub-analyses o SSP showed ha MA's posi i e e ec s we e emained signi ican . The e was li le
di e ence in he one-week success a es. The TT was he sole ins ance o p oblems. Main indings o he s udies included
we e p esen ed in (Table 2).
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1905-1910
1907
Figu e 1 PRISMA conso cha o s udies selec ed
Table 1 s udy aim and main indings o he include s udies
Ci a ion
Me hod
S udy aim
Manual
aspi a ion g oup
Tho acos omy
g oup
Pa lak e al.,
2012 [9]
P ospec i e,
andomised
ial
To de e mine he ou come o ube
ho acos omy e sus manual aspi a ion in
cases o simple p ima y spon aneous
pneumo ho ax
25
31
Kim e al.,
2019 [10]
P ospec i e
Randomized
T ial
The ou come o closed ho acos omy and
needle aspi a ion in PSP episode ha
equi ed in e en ion.
21
19
Ramouz e
al., 2018 [12]
Randomized
con olled
ial
To assess TT's and MA's e ec i eness in
ea ing PSP.
35
35
Thelle e al.,
2017 [11]
Randomized
con olled
ial
Au ho s hypo hesized ha MA would be
be e han TT in he i s ea men o bo h
PSP and SSP based on clinical expe ience.
Using he leng h o hospi al s ay as he main
ou come, hey sough o es he hypo hesis
in a andomized esea ch.
64
63
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1905-1910
1908
Ko czyński
e al., 2015
[13]
Randomized
con olled
ial
To examine he sho - e m e ec s o MA
he apy o SP agains TT
22
27
Table 2 indings o he s udies included
Ci a ion
Findings
Pa lak e al.,
2012 [9]
Fo MA, he immedia e success a e was 68%, whe eas o TT, i was 80.60%. Bo h g oups had
100% success a es a e wo weeks. The hospi al s ay was signi ican ly di e en o MA (2.4 e sus
4.4). Al hough no s a is ically signi ican , he one-yea ecu ence a es in MA we e lowe han
hose in TT. Female sex and auma ic PTX we e p edic o s o quick success. Hea ailu e claimed
he li e o one pa ien du ing ollow-up.
Kim e al.,
2019 [10]
Twen y-one and nine een pa ien s we e assigned o he MA g oup and he TT g oup, espec i ely,
ou o he o y pa ien s who had expe ienced hei i s episode o PSP. Each g oup spen 2.1 and
5.4 days in he hospi al, espec i ely. The 1-mon h and 1-yea ecu ence a es, as well as he ini ial
ea men success a e, did no , howe e , di e signi ican ly.
Ramouz e al.,
2018 [12]
Pa ien s in he TT and MA g oups expe ienced ini ial ea men success a es o 68.5% and 54.2%,
espec i ely, wi h no disce nible di e ence be ween he esea ch g oups. A e a week, 91.4% o
pa ien s in he MA g oup and 94.2% o pa ien s in he TT g oup showed ull lung expansion.
Thi een pa ien s had a pneumo ho ax ecu ence (4 in he MA g oup and 9 in he TT g oup). In he
i s hou ollowing he su ge y, he i s pos ope a i e day, and he i s week ollowing he
in e en ion, he mean pain in ensi y was conside ably lowe in he MA g oup.
Thelle e al.,
2017 [11]
The e we e 127 pa ien s o al, 48 o whom had SSP. 63 indi iduals had TT, while 65 pa ien s had
MA. MA had a subs an ially sho e median hospi al s ay (2.4 days) han TT (4.6 days). In
compa ison, he SSP subg oup's equi alen alues we e 2.54 days, while MA and TT's we e 5.53
days. Fo MS, he immedia e success a e was 69%, whe eas o TT, i was 32%. Sub-analyses o
SSP e ealed ha he a o able impac o MA was s ill conside able. The one-week success a es
did no di e much. The only ime he e we e complica ions was du ing he TT.
Ko czyński e
al., 2015 [13]
The baseline cha ac e is ics o he pa ien s in he wo ea men g oups did no di e signi ican ly.
The MA and TT g oups had i s line he apy success a es o 64% and 82%, espec i ely; he
di e ence was no s a is ically signi ican . Compa ed o TT, he median du a ion o he apy wi h
MA was much sho e .
4. Discussion
The pu pose o his s udy was o e alua e he clinical e ec i eness and sa e y o MA agains TT in he ea men o SP.
We included s udies which e alua ed bo h ea men me hods in pa ien s wi h PSP, SSP o bo h. Rega ding he
e ec i eness o i s -line he apy, Ko czyński e al. (2015) showed no s a is ical di e ence be ween small bo e MA and
TT. Abou 64% o indi iduals ea ed wi h MA and 82% o hose ea ed wi h TT we e able o each he ea men a ge .
The success a e was somewha skewed owa d he la e app oach, which may ha e clinical signi icance e en i he
di e ence was s a is ically small. Fu he mo e, i is impossible o ule ou he possibili y ha TT migh bene i om
highe s a is ical powe o he di e ence i he e we e mo e indi iduals in bo h ea men g oups [13]. These indings
a e consis en wi h a esea ch by Ayed e al. [14] ha indica ed ha pa ien s ea ed wi h ches ube d ainage (68%)
and small bo e manual aspi a ion (62%), had simila he apeu ic e ec i eness.
The indings o he andomized con olled s udy by Ramouz e al. (12) e ealed no disce nible di e ence be ween he
MA and TT app oaches in e ms o he ea men 's immedia e and one-week success a e; ne e heless, pa ien s who
bene i ed om he MA echnique expe ienced less se e e pain and a sho e hospi al s ay. Al hough he e was no
disce nible di e ence in he leng h o hospi al s ay o he isk o pneumo ho ax ecu ence, he TT app oach p oduced
supe io esul s and a highe success a e in an ea ly ial by And i e e al. ha e alua ed 61 pa ien s wi h SP. A bias in
he mean leng h o hospi aliza ion esul ed om he ex ended hospi al s ays in MA pa ien s assessed in he And i e
esea ch, which was ela ed o ce ain pa ien s' 72-hou in e en ion delay [15].
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1905-1910
1909
The leng h o hospi aliza ion ollowing MA is abou hal ha o TT, acco ding o he Thelle e al. esea ch. Bo h PSP and
SSP pa ien s showed his esul . Compa ed o TT, he a e o complica ions was minimal o NA [11]. The esul s o o he
andomized s udies compa ing TT and MA ha e been inconsis en wi h ega d o he impac on hospi al s ay du a ion.
Despi e a 72-hou delay in MA in e en ion, se e al esea che s epo ed no di e ence be ween he wo ea men
app oaches [15]. O he s disco e ed ha pa ien s ea ed wi h MA had a sho e hospi al s ay han hose ea ed wi h
TT [9,14,16]. Acco ding o he indings o p e ious ials [9,14,16], MA is easy o use, sa e, causes li le discom o o
he pa ien , and has no disce nible a ia ion in 1-yea ecu ence a es.
NA is no always ad ised as he ini ial cou se o he apy o pa ien s wi h seconda y pneumo ho ax, acco ding o
ecommenda ions [17,18]. SSP may ha e a di icul - o-heal ai leak [1] and a educed ole ance o he impac o he
pneumo ho ax on dyspnea [19], which has been he jus i ica ion o he ini ial d ainage he apy in his g oup. The leng h
o hospi al s ay in he NA g oup was a ound hal ha o he CTD g oup, acco ding o sepa a e analyses o people wi h
SSP in ou esea ch. Addi ionally, Thelle e al. disco e ed ha NA had a conside able edge o e CTD in e ms o ins an
success o bo h PSP and SSP. The ecommenda ions o he ini ial managemen o pneumo ho ax should be eassessed
i his disco e y is suppo ed by mo e esea ch.
5. Conclusion
Compa ed o TT, s a ing in e en ion wi h MA esul s in ewe ad e se e en s and a sho e hospi al s ay. When a
pa ien has hei i s episode o PSP, MA is a good i s he apy. In e ms o immedia e lung e-expansion in pa ien s
wi h SP, MA app oach is compa able o TT.
Compliance wi h e hical s anda ds
Disclosu e o con lic o in e es
No con lic o in e es o be disclosed.
S a emen o in o med consen
In o med consen was ob ained om all indi idual pa icipan s included in he s udy.
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