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 (a tube inserted between ribs) 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 study (enrolling 70 newborn infants) that compared needle aspiration followed by immediate removal to chest tube placement for the treatment of pneumothorax and one study (72 newborn infants) that compared needle aspiration with the angiocatheter left in situ to chest tube placement for the treatment of pneumothorax. Evidence is up to date as of June 2018.

Key results: The use of needle aspiration compared to chest tube placement did not reduce mortality or any complications related to the procedure. About 30% of the infants with pneumothorax who were treated with needle aspiration followed by immediate removal never required the placement of an intercostal tube; none of the infants with pneumothorax who were treated with needle aspiration left in situ required the placement of an intercostal tube. However multiple factors might explain this finding.

Quality of evidence: The two small trials identified do not provide sufficient information to determine which of the two techniques is better to treat pneumothorax in neonates. However it seems that needle aspiration might reduce the need for an intercostal tube in a relevant proportion of newborn infants.

Authors' conclusions: 

There is insufficient evidence to establish the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax. The two included trials showed no differences in mortality; however the information size is low. Needle aspiration reduces the need for intercostal tube drainage placement. Limited or no evidence is available on other clinically relevant outcomes.

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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 can be treated with either aspiration with a syringe (using a needle or an angiocatheter) or a chest tube inserted in the anterior pleural space and then connected to a Heimlich valve or an underwater seal with continuous suction.

Objectives: 

To compare the efficacy and safety of needle aspiration (either with immediate removal of the needle or with the needle left in situ) to intercostal tube drainage in the management of neonatal pneumothorax (PTX).

Search strategy: 

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 4 June 2018), Embase (1980 to 4 June 2018), and CINAHL (1982 to 4 June 2018). 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 trials, 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.

We used the GRADE approach to assess the quality of evidence.

Main results: 

Two randomised controlled trials (142 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality when the needle was removed immediately after aspiration (risk ratio (RR) 3.92, 95% confidence interval (CI) 0.88 to 17.58; participants = 70; studies = 1) or left in situ (RR 1.50, 95% CI 0.27 to 8.45; participants = 72; studies = 1) or complications related to the procedure. With immediate removal of the needle following aspiration, 30% of the newborns did not require the placement of an intercostal tube drainage. 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 very low.

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