{
  "abstract": "Introduction Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician’s discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We evaluated the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces.Methods The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial was a multicentre, pragmatic parallel group, individually randomised controlled noninferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces was non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. Adults with traumatic pneumothoraces, in whom treating clinician(s) believed either a chest drain or conservative management was a suitable initial treatment option were eligible for inclusion. The primary outcome was a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation (excluding the initial chest drain in that arm).Results Among 400 patients randomised from 41 UK National Health Service hospitals between Aug 2022-Jan 2025, 394 were included in the primary analysis. Randomised patients were predominantly male (74%), with a pneumothorax size of 2–5 cm (57%), with 33% having a pneumothorax >5 cm. Participants were predominantly spontaneously ventilating at the point of randomisation (89%) and had blunt chest wall trauma (92%).In the conservatively managed group, 49/199 (25%) met the primary outcome, and 15/195 (8%) in the chest drain arm; Risk Difference 0.17 (95% CI 0.10–0.24). However, 112/199 56% of conservatively managed patients required no pleural intervention within 30 days.Conclusions An initial conservative approach to traumatic pneumothorax management is not non-inferior to initial drainage in terms of the need for subsequent emergency pleural intervention. Full results on clinical effectiveness and implications for practice will be discussed.",
  "authors": [
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "A Annaw"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "J Banks"
    },
    {
      "affiliations": [
        "University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK",
        "University of the West of England, Bristol, UK"
      ],
      "name": "JR Benger"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "N Blythe"
    },
    {
      "affiliations": [
        "University of the West of England, Bristol, UK"
      ],
      "name": "C Clement"
    },
    {
      "affiliations": [
        "North Bristol NHS Trust, Bristol, UK"
      ],
      "name": "K Coates"
    },
    {
      "affiliations": [
        "NHS Arden and Greater East Midlands Commissioning Support Unit, UK"
      ],
      "name": "A Edwards"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "D Gaunt"
    },
    {
      "affiliations": [
        "University of Warwick, Coventry, UK"
      ],
      "name": "R Kandiyali"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "A Lane"
    },
    {
      "affiliations": [
        "The University of Sheffield, Sheffield, UK",
        "Northern Care Alliance NHS Foundation Trust, Manchester, UK"
      ],
      "name": "F Lecky"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK",
        "North Bristol NHS Trust, Bristol, UK"
      ],
      "name": "NA Maskell"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "C Metcalfe"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "S Rees"
    },
    {
      "affiliations": [
        "North Bristol NHS Trust, Bristol, UK"
      ],
      "name": "J Thompson"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK",
        "North Bristol NHS Trust, Bristol, UK"
      ],
      "name": "S Walker"
    },
    {
      "affiliations": [
        "University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK"
      ],
      "name": "D West"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK",
        "North Bristol NHS Trust, Bristol, UK"
      ],
      "name": "E Carlton"
    },
    {
      "affiliations": [
        "University of Bristol, Bristol, UK"
      ],
      "name": "on behalf of the CoMiTED Investigators"
    }
  ],
  "title": "S6 Conservative management in traumatic pneumothoraces in the emergency department (CoMiTED): a randomised controlled trial",
  "uid": "2c84b17b-01c5-59b8-a679-12a545f7c759"
}