Conservative management versus invasive management of significant traumatic pneumothoraces in the emergency department (the CoMiTED trial): A study protocol for a randomised non-inferiority trial

Nicola M. Blythe, Katherine Coates, Jonathan R. Benger, Ammar Annaw, Jonathan Banks, Clare Clement, Madeleine Clout, Antoinette Edwards, Daisy Gaunt, Rebecca Kandiyali, J. Athene Lane, Fiona Lecky, Nick A. Maskell, Chris Metcalfe, Marie Platt, Sophie Rees, Jodi Taylor, Julian Thompson, Steven Walker, Douglas WestEdward Carlton*

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review


Introduction Traumatic pneumothoraces are present in one of five victims of severe trauma. 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 are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces. Methods and analysis The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months. Ethics and dissemination This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal. Trial registration number ISRCTN35574247.

Original languageEnglish
Article numbere087464
JournalBMJ Open
Issue number6
Publication statusPublished - 17 Jun 2024

Bibliographical note

Publisher Copyright:
© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.


  • accident and emergency medicine
  • conservative management
  • Randomized Controlled Trial
  • trauma management
  • traumatic pneumothorax


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