Posted: April 20th, 2022

Pneumothorax: A Decision Analysis

Administration of the Second Episode of Spontaneous
Pneumothorax: A Decision Analysis
Pierre-Emmanuel Falcoz, MD, Christine Binquet, MD, Franc¸ois Clement, MD,
Djamel Kaili, MD, Catherine Quantin, MD, PhD, Sidney Chocron, MD, PhD, and
Joseph-Philippe Etievent, MD
Division of Thoracic and Cardiovascular Surgical procedure, Jean-Minjoz Hospital, Besanc¸on, Division of Biostatistics, College
Hospital, Dijon, France
Background. Optimum administration for sufferers presenting a second episode of spontaneous pneumothorax
stays controversial. The intention of this examine was to
examine two attainable remedy methods, video-Helped
thoracic surgical procedure (VATS) and conservative administration,
as a way to assess which of the 2 was higher tailored for
the remedy of the second episode of spontaneous
pneumothorax.
Strategies. The authors suggest a choice analytic
mannequin together with a cost-effectiveness examine to match
two medical methods: VATS (reference technique) and
conservative administration (different technique). Information
had been obtained from a Medline seek for English language articles and price estimates had been derived from the
monetary and public well being departments of our hospital.
The mannequin was analyzed to find out the baseline technique resulting in the best anticipated effectiveness and the
lowest anticipated price.
Outcomes. Conservative administration provided a slight
benefit in anticipated effectiveness worth (99.99 vs 99.93
for VATS). VATS produced the bottom anticipated price
(€4347 vs €7536 for conservative administration). The incremental cost-effectiveness ratio was €57,750. Inside the
ranges examined, the sensitivity Assessment introduced constant outcomes by way of effectiveness and advocated
conservative administration as one of the best technique. When it comes to
price, apart from size of keep, the sensitivity
Assessment was insensitive in estimating the totally different chances, and favored VATS over conservative
administration.
Conclusions. Within the administration of the second episode
of spontaneous pneumothorax, VATS provides substantial
financial savings in price for under a slight lower in effectiveness,
compared with conservative administration.
(Ann Thorac Surg 2003;76:1843–eight)
© 2003 by The Society of Thoracic Surgeons
Spontaneous pneumothorax (SP) is a disabling disor- der which will current both in younger and in any other case
wholesome sufferers (major pneumothorax) or as a complication of an underlying lung illness (secondary pneumothorax). For the reason that 1960s medical trials have led to
opposing suggestions for administration of SP, an
difficulty nonetheless beneath debate notably for the administration
of the second episode.
Conservative administration (CM) has lengthy been the
typically accepted remedy technique for the second
episode of SP (pleural drainage and a “wait and see”
strategy) [1, 2]. Because of advances in thoracoscopic
instrumentation (comparable to optics, devices, and endoscopic staplers) remedy technique has progressively
modified for the reason that early 1990s, and video-Helped thoracic surgical procedure (VATS) has set a brand new normal of excellence
for treating the second episode of SP [3–5].
However, there’s nonetheless controversy as to what the
finest technique is for a affected person presenting a second episode
of SP. The reply to this Question Assignment stays unclear attributable to
the shortage of managed medical trials evaluating the 2
attainable remedy methods. We suggest a choice
analytic mannequin to look at this clinically necessary difficulty.
The intention of this examine was to match two attainable
remedy methods, VATS and CM, as a way to assess The sensitivity Assessment produced constant outcomes by way of effectiveness throughout the various ranges studied, and it really helpful conservative administration because the optimum methodology. Value-wise, apart from period of keep, the sensitivity Assessment was insensitive when predicting the totally different chances and most popular VATS over cautious administration, based on the outcomes.
Conclusions. When in comparison with cautious administration for the second episode of spontaneous pneumothorax, VATS ends in important price financial savings with only a modest drop in effectiveness when in comparison with the primary episode.
Thoracic Surgical procedure (Ann Thorac Surg 2003;76:1843–eight)
The Society of Thoracic Surgeons revealed a report in 2003.
Sudden pneumothorax (SP) is a debilitating situation that may present itself in younger, in any other case wholesome sufferers (major pneumothorax) or on account of an underlying lung illness (complication of underlying lung illness) (secondary pneumothorax). For the reason that 1960s, medical trials have resulted in diametrically opposed suggestions for the remedy of SP, a subject that continues to be debated right this moment, notably in regard to the administration of the second episode.
Consensus-based conservative remedy (CM) for the second episode of SP (pleural drainage and a “wait and see” strategy) has lengthy been the usual remedy technique [1, 2]. For the reason that early 1990s, advances in thoracoscopic instrumentation (comparable to optics, devices, and endoscopic staplers) have allowed remedy methods to evolve regularly. Video-Helped thoracic surgical procedure (VATS) has established a brand new normal of excellence for treating the second episode of SP [3–5].
Regardless of this, there’s nonetheless debate on the optimum remedy plan for a affected person who has skilled a second episode of SP of their lifetime. It’s not possible to know the reply to this Question Assignment as a result of there have been no managed medical trials evaluating the 2 different remedy choices on this space. As a way to examine this clinically important subject, we current a choice analytic strategy.
The aim of this examine was to look at two totally different remedy methods, VATS and CM, as a way to decide which was superior.
which of the 2 was higher tailored for the remedy of
the second episode of SP.
Materials and Strategies
The Mannequin
This examine was carried out utilizing a choice Assessment
design. Decision Assessment is a quantitative methodology for
synthesizing knowledge from quite a few sources to guage
remedy alternate options [6]. All resolution analyses contain
the next fundamental parts: the choice methods
and potential outcomes related to every technique are
specified within the resolution mannequin; the chances for every
of those outcomes are estimated from probably the most applicable obtainable knowledge and assigned to every resolution level in
the mannequin; and an Assessment is carried out to calculate the
anticipated worth of every remedy different. By calculating the anticipated worth, a well-liked technique is recognized.
All analyses had been carried out with Information model three.5 (TreeAge Software program Inc, Williamstown, MA), a choice analyAccepted for publication June three, 2003.
Handle reprint requests to Dr Falcoz, Division of Thoracic and
Cardiovascular Surgical procedure, Hoˆ pital Jean-Minjoz, Boulevard Fleming, 25000
Besanc¸on, France; e-mail: [email protected]

© 2003 by The Society of Thoracic Surgeons
Printed by Elsevier Inc 0003-4975/03/$30.00
doi:10.1016/S0003-4975(03)01324-9
AssignmentTutorOnline

GENERAL THORACIC
sis software program program. The choice tree used on this
Assessment is illustrated in Determine 1.
Within the current examine, the outcomes of every technique
had been examined each by way of effectiveness and price. By
performing a cost-effectiveness Assessment, we obtained a
extra built-in view of the decision-making difficulty. Thus,
the mannequin was analyzed to find out the baseline technique that results in the best anticipated effectiveness and
lowest anticipated price.
The monetary influence of the administration of the second
episode of SP could also be thought of from totally different views, for instance: the doctor’s time or health-care
prices. Our mannequin appears to be like at monetary influence from the
nationwide medical health insurance perspective. As a result of it was not
attainable to find out actual prices, solely direct prices had been
taken under consideration. No try was made to incorporate
noninstitutional prices, both direct or oblique, born by
the sufferers and their households or by society.
Assumptions
In designing the choice tree, a number of assumptions had been
made as a way to simplify the Assessment. Issues
that adopted an episode of SP had been categorized into
three teams, whatever the chosen remedy technique: short-term (lower than 1 month), medium-term (much less
than three months), and long-term (lower than 2 years). All
potential problems had been thought of both as imperfect outcomes or main problems. Imperfect outcomes
had been: minor air leak, pleural effusion, incomplete reexpansion of the lung (failing pleurodesis), and short-term
ipsilateral recurrent pneumothorax. Main problems
had been: hemothorax or pleural an infection following surgical procedure
or chest tube insertion, extended air leak, and middleand long-term ipsilateral recurrent pneumothorax. For
every VATS, the likelihood of conversion to thoracotomy
was taken under consideration.
Utility and Chances of Probability Occasions
The idea of utility is a measure of a choice maker’s
relative choice for an consequence state. Every of the
well being states on the terminal nodes of the choice tree,
which characterize the ultimate outcomes, are thus assigned a
utility worth that quantifies preferences for these states
[7]. Within the context of the current resolution tree, the ultimate
outcomes beneath examine had been both definitive decision
or ensuing problems. They had been estimated over a
2-year interval as a result of most recurrences happen in the course of the
first 2 years after the preliminary pneumothorax [8]. The utility
of a affected person having a definitive decision, which is the
optimum consequence, was assigned a worth of 100. The utility
of a affected person experiencing a course with ensuing problems was assigned a worth of zero.
Desk 1 summarizes the primary knowledge chances and
estimates of their values used within the resolution Assessment.
Fig 1. Decision timber representing the selection of
administration methods for the second episode
of spontaneous pneumothorax. The 2 medical
methods to be chosen from are represented at
the sq. resolution node of the primary tree (A).
The possibilities and estimates of their values
are listed in Desk 1. the selection between
methods (resolution node); E the prevalence
of probability occasions (probability node); and a
logic examine within the simulation (terminal node).
(CM conservative administration; VATS
video-Helped thoracic surgical procedure.)
1844 FALCOZ ET AL Ann Thorac Surg
MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX 2003;76:1843–eight
GENERAL THORACIC
These values are based mostly on a important evaluate of the obtainable literature concerning SP administration. We carried out
a scientific Medline seek for all English language
articles courting from 1966 and falling beneath the medical
topic headings “spontaneous pneumothorax,” “pleural
drainage,” “thoracoscopy,” and “video-Helped thoracic
surgical procedure” alone and together with the phrases “randomized managed trials,” “meta-analysis,” and “pointers.” This survey of the medical literature was completed to
get hold of a baseline worth and a spread for all variables of
curiosity. Decision tree values had been assigned by making use of
important appraisal standards (methodologic high quality, largest
variety of instances reported, most up-to-date info, and
relevance to our examine inhabitants) within the articles retrieved [9].
Value Information
Prices, expressed in euros (€), had been supplied by the
monetary division of our hospital. They’re these of
the precise procedures for pneumothorax. The overall price of
each surgical and anesthetic procedures was taken into
account. The anesthetic price was €188.1 for VATS and
thoracotomy, and €20.9 for CM. The surgical price was
€418 for VATS and thoracotomy, and €41.eight for CM. The
price per day of hospitalization was €584.19 (starting from
€416.93 to €724.03).
The general public well being division supplied the imply and
normal deviation of size of keep over a 5-year interval
(1998 to 2002) of 133 sufferers struggling a second episode of
SP: 5.four 1.eight days for VATS (n 82 sufferers), 10.5 three.5
days for thoracotomy (n 17 sufferers), and 9.four 6.9 days
for CM (n 34 sufferers).
Sensitivity Analysis
The soundness of the outcomes obtained from the mannequin for
imply chances and prices was assessed by means of sensitivity Assessment. Sensitivity Assessment is a technique of various chances over an outlined vary to find out how
the optimum alternative would change if the worth of an opportunity
occasion modified [10]. Sensitivity Assessment may be carried out
on particular person chances (one-way sensitivity Assessment)
or by various two chances on the similar time (two-way
sensitivity Assessment). One-way sensitivity Assessment was
carried out for every likelihood within the resolution tree, and
the worth at which the optimum technique modified (threshold worth) was recognized. Two-way sensitivity Assessment
was carried out for all chances discovered to be related
in one-way sensitivity Assessment.
Outcomes
Baseline Analysis
The baseline Assessment (Desk 2) was based mostly on the assumptions described above and used the aforementioned
chances (Desk 1), prices estimates, and formalized
utility scores.
Conservative administration provided a slight improve in
anticipated effectiveness as in comparison with VATS. The incremental effectiveness, obtained by calculating the distinction between the anticipated effectiveness values related to the 2 methods, was zero.06. This worth
signifies that CM would have supplied six further
recoveries for 10,000 sufferers. Equally, when focusing
on the hierarchical alternative between VATS and thoracotomy, our Assessment means that VATS would have supplied 95 further recoveries for 10,000 sufferers present process surgical procedure.
The technique producing the bottom anticipated price was
VATS. The price-effectiveness ratio for one restoration was
€44 for VATS and €75 for CM. The incremental costeffectiveness ratio was €57,750 for CM, which implies that
the price of one further restoration by CM, when in comparison with VATS, was €57,750.
Sensitivity Analysis
As a result of the chances for the assorted outcomes used
on this Assessment may conceivably fluctuate, sensitivity testing
was carried out to evaluate the validity of the conclusions
over a variety of chances.
When it comes to effectiveness, the sensitivity Assessment demTable 1. Literature-Primarily based Vary of Chances Evaluating
VATS With Conservative Administration
Parameter
Baseline
Worth
(%)
Sensitivity
Analysis
Vary (%) References
Definitive decision after
CM
70 48–84 [11a–13]
Issues after CM 30 16–52 [11a, 14a]
Imperfect outcomes 27 5–50 [15a, 16]
Main problems three zero–three [15a, 17, 18]
Definitive decision after
VATS
90 86–98 [11a, 12, 14a]
Issues after
VATS
10 5–10 [11a, 19]
Imperfect outcomes 7.5 zero–22 [20–22]
Main problems 2.5 zero–24 [20, 21, 23]
Conversion to
thoracotomy
7 2–10 [12, 19]
Definitive decision after
thoracotomy
99 99–99.5 [14a, 24]
a Overview articles compiling totally different research.
The baseline worth is one of the best estimate for every likelihood (common of the
outcomes from the totally different research to estimate the likelihood). The vary
displays the bottom and highest estimates from the retrieved research.

CM conservative administration;
surgical procedure. VATS video-Helped thoracic
Desk 2. Abstract of Baseline Outcomes Evaluating VATS
With Conservative Administration
VATS CM

Effectiveness
Incremental effectiveness
Value (€)
Incremental price (€)
Value-effectiveness ratio (€)
Incremental cost-effectiveness ratio (€) 99.93
—
four,347
—
44
— 99.99
zero.06
7,536
three,189
75
57,750
CM conservative administration; VATS video-Helped thoracic
surgical procedure.
Ann Thorac Surg FALCOZ ET AL 1845
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GENERAL THORACIC
onstrated constant outcomes and advocated CM because the
higher of the 2 methods whatever the likelihood
involved. Inside the ranges examined, the totally different variables within the mannequin influenced the load of VATS, however
didn’t change the popular technique. Examples are
given in Determine 2, which illustrates the impact of definitive
decision after VATS (Fig 2A) and the impact of definitive
decision after CM (Fig 2B) on the 2 administration
methods.
When it comes to prices, the sensitivity Assessment was insensitive to modifications within the estimate of the values, aside from
size of keep, and favored VATS over CM for the
remedy of the second episode of SP. One-way sensitivity Assessment for VATS didn’t reveal any threshold (Fig
2C). One-way sensitivity Assessment for CM revealed that
the brink worth at which methods had been equal
for size of keep was four.9 days (Fig 2D). Two-way sensitivity Assessment indicated how the optimum technique
modified because the size of keep associated to every technique
diversified (Fig three). A mixture of those two lengths of keep
corresponds to some extent on the graph. For any mixture, if the purpose lies within the black space, VATS is the
optimum alternative and within the white space, it’s CM. The
boundary line between the 2 areas represents a collection
of threshold values at which the 2 methods yield an
equal consequence.
Remark
Within the discipline of SP, a consensus rising within the literature
signifies clearly what to do for an preliminary episode of SP
(CM) or the third episode (VATS). Conversely, the necessity
for and methodology of selling ample pleural symphysis on the second episode has given rise to nice controversy. The usefulness of VATS versus CM for the
second episode of SP stays controversial. Though
some facilities suggest VATS [5, 19, 25], others, who
report a excessive recurrence and complication fee and
suggest extra warning [1, 2], advocate CM. Clearly
there’s nonetheless a lot debate over which strategy is extra
applicable in any given affected person. The British Thoracic
Society [26] and the American Faculty of Chest Physicians [27] have each revealed pointers for the quick and subsequent administration of sufferers with SP.
On one hand, the rules of the British Thoracic
Society make no distinction between sufferers with first
and recurrent episodes of SP. Alternatively, most of
the panel members of the American Faculty of Chest
Fig 2. One-way sensitivity Assessment demonstrating the impact of various variables by way of effectiveness and price. The higher graphs illustrate
the impact of definitive decision after VATS (A) and after CM (B) on anticipated effectiveness. The decrease graphs illustrate the impact of size of
keep for VATS (C) and for CM (2 d) on anticipated price (D). The brink worth at which methods had been equal was four.9 days. ■ CM; E
VATS. (CM conservative administration; T threshold worth; VATS video-Helped thoracic surgical procedure.)
1846 FALCOZ ET AL Ann Thorac Surg
MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX 2003;76:1843–eight
GENERAL THORACIC
Physicians suggest VATS on the second episode.
As a result of a consensus has not been clearly established
from these fundamental suggestions, even amongst specialists,
and given the shortage of managed medical trials, we determined
to deal with this controversial Question Assignment utilizing formal resolution Assessment.
Using resolution Assessment in surgical procedure is gaining
curiosity [28, 29]. In a fancy decision-making surroundings, the place medical observe is influenced by revealed
medical trials, consensus statements and detailed formal
examination of procedures, physicians could carry out inadequately in establishing the usual of care in the event that they
rely solely on their medical judgment based mostly uniquely on
previous expertise. Since none of us can intuitively estimate
chances precisely, resolution Assessment turns into helpful when it’s fascinating to match different remedy
methods quantitatively. However, this methodology has
its personal limitations. Among the limitations of our resolution Assessment imposed by the assumptions and tree
construction deserve point out. First, the opportunity of having
to carry out a thoracotomy was taken under consideration. We
determined to not exclude this feature from our mannequin in
order to go away the surgeon the selection of which approach
he judged the extra applicable to deal with a serious complication (eg, hemothorax). Second, we used estimated prices
of the particular procedures for SP to match the price of the
two methods. The perfect strategy would have been to
take a look at the actual price of every process and mannequin these
prices explicitly. Such a price Assessment was past the
scope of the present work and not likely justified in a
comparative examine.
Regardless of the above limitations from the standpoint of
baseline chances, our Assessment reveals solely a slight
benefit by way of anticipated effectiveness for CM. The
distinction we bear in mind in our Assessment between
CM and VATS (incremental effectiveness worth of zero.06)
could also be considerably disturbing to readers. This worth is
fairly small and, consequently, the distinction between
the 2 methods is just slight. Nevertheless, from the
perspective of resolution Assessment, it’s not the amount however
the sense of the distinction between two remedy methods that guides the selection of the choice [6]. It’s
particularly noteworthy that sensitivity Assessment didn’t
have a major influence on the baseline outcomes. Within the
absence of variation within the sensitivity Assessment, the interpretation of outcomes may be thought of dependable and strong.
As well as, though the first purpose of this examine was
to match two attainable remedy methods, VATS and
CM, within the administration of a second episode of SP, the
current mannequin additionally gives info for a hierarchical alternative between VATS and thoracotomy, protecting in
thoughts that thoracotomy is usually reserved for sufferers with
technically extra complicated issues. Be that as it might,
VATS would have supplied 95 further recoveries for
10,000 sufferers present process surgical procedure for a second episode
of SP. Therefore, it must be thought of each time surgical procedure
is important. This discovering has already been reported in
many research coping with VATS versus thoracotomy for
SP [19, 24, 27], particularly in major SP [25].
Within the current examine, VATS was the technique discovered to
produce the bottom anticipated price. This end result was principally attributable to a shorter “cost-consuming” size of keep.
Schramel and colleagues [30] highlighted this in a price
Assessment examine evaluating VATS and CM. The size of
keep for VATS was 5.four 1.eight days in our examine, 6.9 days
(starting from 2 to 15 days) in Crisci and Coloni’s examine
[31], whereas it was 11 four days in Schramel associates’
examine [30] and a pair of.9 zero.9 in Hazelrigg and coworkers’
examine [32]. In contemplating the discordance within the size of
keep between these research (postoperative size of keep
for European sufferers is often for much longer than for
US sufferers) it was needed to look at the influence on
the outcomes of those variations in period. By various the
size of keep for CM, the one-way sensitivity Assessment
revealed that the brink worth at which outcomes
had been equal was four.9 days. CM must be most popular
under this threshold worth, and VATS above it. The
two-way sensitivity Assessment signifies the popular technique in perform of the imply size of keep (Fig three). The
shorter the size of keep for VATS, the smaller the realm
through which CM was the optimum technique. Subsequently, relying on the size of keep in a given establishment, the
clinician could effectively select one technique or the opposite.
Value effectiveness is turning into increasingly necessary within the alternative of remedy. The incremental costeffectiveness ratio present in our examine was roughly
€58,000 for CM. Deciding whether or not a method is price
efficient is a subjective interpretation of the costeffectiveness ratio. Though there isn’t a absolute cutoff
Fig three. Two-way sensitivity Assessment of the relation between the
size of keep for VATS and CM that illustrates how the optimum
technique modifications based on the size of keep when all different chances are maintained on the baseline. The black space signifies
VATS as the popular technique; the white space signifies CM because the
most popular technique. The bottom-case state of affairs, indicated by a star, is
outlined by a imply size of keep of 5.four days for VATS and 9.four days
for CM. (CM conservative administration; VATS video-Helped
thoracic surgical procedure.)
Ann Thorac Surg FALCOZ ET AL 1847
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GENERAL THORACIC
degree, there’s a consensus that a cost-effectiveness ratio
beneath the accepted restrict of €50,000 corresponds to a
cost-effective technique [33]. Therefore, CM is unquestionably not
price efficient for the administration of the second episode
of SP in our examine.
In conclusion, the outcomes we obtained utilizing resolution
Assessment for the administration of the second episode of SP
reveal that VATS provides substantial financial savings in price for
solely a slight lower in effectiveness compared
with CM. Establishments whose chances replicate these
introduced in our Assessment could effectively wish to take into account
performing VATS in all sufferers present process a second
episode of SP. However, additional medical trials ought to
Help to validate the formal analytic outcomes discovered on this
examine.
The authors thank Nancy Richardson-Peuteuil for her editorial
help, and Catherine Lejeune for her useful feedback.
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GENERAL THORACIC

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