The aspiration of pneumothorax in the newborn with a small needle compared to a larger tube placed through the intercostal space

Review question: Does the use of a needle to aspirate pneumothorax compared to an intercostal tube reduce mortality in newborns?

Background: Pneumothorax is the presence of air in the pleural space (the space between the lung and the chest wall). It is a serious condition in the newborn and may be treated by needle aspiration or chest tube placement. The former is less invasive and might avoid the need for the insertion of a chest tube, thus reducing the duration of hospital stay. However the failure of needle aspiration might subsequently lead to the need for chest tube insertion, an additional invasive procedure. This systematic review evaluates the available evidence on the effectiveness of these two techniques in treating pneumothorax in neonates.

Study characteristics: We included one trial enrolling 72 newborn infants that compared needle aspiration with the angiocatheter left in situ to chest tube placement for the treatment of pneumothorax.

Results: The use of needle aspiration with the angiocatheter left in situ compared to chest tube placement does not reduce mortality or any complications related to the procedure. Infants with pneumothorax who were assigned to the less invasive technique (needle aspiration with the angiocatheter left in place) never required the placement of an intercostal tube and had a shorter duration of tube placement.

Conclusions: The one small trial identified does not provide sufficient information to determine which of the two techniques is better to treat pneumothorax in neonates.

Authors' conclusions: 

At present there is insufficient evidence to determine the efficacy and safety of needle aspiration versus intercostal tube drainage in the management of neonatal pneumothorax. Randomised controlled trials comparing the two techniques are warranted.

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Background: 

Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It may be treated with either needle aspiration or insertion of a chest tube. The former consists of aspiration of air with a syringe through a needle or an angiocatheter, usually through the second or third intercostal space in the midclavicular line. The chest tube is usually placed in the anterior pleural space passing through the sixth intercostal space into the pleural opening, turned anteriorly and directed to the location of the pneumothorax, and then connected to a Heimlich valve or an underwater seal with continuous suction.

Objectives: 

To compare the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax.

Search strategy: 

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 11), MEDLINE via PubMed (1966 to 30 November 2015), EMBASE (1980 to 30 November 2015), and CINAHL (1982 to 30 November 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria: 

Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax.

Data collection and analysis: 

For each of the included trial, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.

Main results: 

One randomised controlled trial (72 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.27 to 8.45) or complications related to the procedure. After needle aspiration, the angiocatheter was left in situ (mean 27.1 hours) and not removed immediately after the aspiration. The angiocatheter was in place for a shorter duration than the intercostal tube (mean difference (MD) −11.20 hours, 95% CI −15.51 to −6.89). None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is low.

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