Current practice and attitudes in emergency department management of primary spontaneous pneumothorax in Australia and New Zealand: a scenario-based/survey

Background: Management of primary spontaneous pneumothorax (PSP) has long been contentious. Aims: To identify the factors influencing interventional versus conservative management and to assess current practice patterns for moderate-to-large PSP in emergency department (ED) patients. Methods: Anonymous online survey of emergency medicine, respiratory medicine and thoracic surgery specialists and trainees in Australia and New Zealand. Data collected included rating the decision-making importance of potential drivers of interventional versus conservative management for PSP, initial management preference for stable patients with moderate-large PSP based on three X-ray-based scenarios (one moderate-large, one almost total collapse without mediastinal shift and one large with mediastinal shift) and awareness of evidence and current guidelines for the management of PSP. Results: There were 456 responses; 85.5% were from Australia. The most commonly reported factors influencing treatment decision-making were vital signs (96.7%) and patient-reported dyspnoea (84.3%). There was variation between specialty groups in initial treatment preference for all scenarios (P < 0.001) and a reduction in preference for conservative treatment as the magnitude of radiological features increased (93.8% vs 61.5% vs 32.1% respectively). Guideline recommendation awareness was low except for the 2023 British Thoracic Society guideline (60.4%). Conclusion: This study demonstrates variation of opinion regarding the initial management of stable patients with moderate to large PSP and an increasing preference for intervention as the magnitude of radiological features increases. Guideline awareness was low, highlighting the need for an evidence-based approach to PSP management in the ED that is widely understood and accepted across speciality groups and that prioritises patient symptoms over X-ray findings.