Management of Spontaneous Pneumothorax
2001; Elsevier BV; Volume: 119; Issue: 2 Linguagem: Inglês
10.1378/chest.119.2.590
ISSN1931-3543
AutoresMichael H. Baumann, Charlie Strange, John E. Heffner, Richard W. Light, Thomas J. Kirby, Jeffrey S. Klein, James D. Luketich, Edward A. Panacek, Steven A. Sahn,
Tópico(s)Emergency and Acute Care Studies
ResumoObjectiveProvide explicit expert-basedconsensus recommendations for the management of adults with primary andsecondary spontaneous pneumothoraces in an emergency department andinpatient hospital setting. The use of opinion was made explicit byemploying a structured questionnaire, appropriateness scores, andconsensus scores with a Delphi technique. The guideline was designed tobe relevant to physicians who make management decisions for the care ofpatients with pneumothorax.OptionsDecisionsfor observation, chest tube placement, surgical interventions, andradiographic imaging.OutcomesEffectiveness ofpneumothorax resolution, duration of and patient tolerance of care, andpneumothorax recurrence.EvidenceLiterature reviewfrom 1967 to January 1999 and Delphi questionnaire submitted in threeiterations to a multidisciplinary physician panel.ValuesThe guideline development group determined byconsensus the relevant outcomes to be considered in developing the, Delphi questionnaire.Benefits, harms, and costsThetype and magnitude of benefits, harms, and costs expected for patientsfrom guideline implementation.RecommendationsManagement decisions vary between patients with primary or secondarypneumothoraces, with observation of small pneumothoraces beingappropriate only for primary pneumothoraces. The level of consensusvaries regarding the specific interventions indicated, but agreementexists for the general principles of care.ValidationRecommendations were peer reviewed by physician experts and werereviewed by the American College of Chest Physicians (ACCP) Health and, Science Policy Committee.ImplementationTheguideline recommendations will be published in printed and electronicform with distribution of synopses for patients and health careproviders. Contents of the guideline will be incorporated intocontinuing medical education programs.SponsorsTheACCP. Provide explicit expert-basedconsensus recommendations for the management of adults with primary andsecondary spontaneous pneumothoraces in an emergency department andinpatient hospital setting. The use of opinion was made explicit byemploying a structured questionnaire, appropriateness scores, andconsensus scores with a Delphi technique. The guideline was designed tobe relevant to physicians who make management decisions for the care ofpatients with pneumothorax. Decisionsfor observation, chest tube placement, surgical interventions, andradiographic imaging. Effectiveness ofpneumothorax resolution, duration of and patient tolerance of care, andpneumothorax recurrence. Literature reviewfrom 1967 to January 1999 and Delphi questionnaire submitted in threeiterations to a multidisciplinary physician panel. The guideline development group determined byconsensus the relevant outcomes to be considered in developing the, Delphi questionnaire. Thetype and magnitude of benefits, harms, and costs expected for patientsfrom guideline implementation. Management decisions vary between patients with primary or secondarypneumothoraces, with observation of small pneumothoraces beingappropriate only for primary pneumothoraces. The level of consensusvaries regarding the specific interventions indicated, but agreementexists for the general principles of care. Recommendations were peer reviewed by physician experts and werereviewed by the American College of Chest Physicians (ACCP) Health and, Science Policy Committee. Theguideline recommendations will be published in printed and electronicform with distribution of synopses for patients and health careproviders. Contents of the guideline will be incorporated intocontinuing medical education programs. TheACCP. Spontaneous pneumothoraces, which occur in the absence of thoracic trauma, areclassified as primary or secondary.1Light RW Management of spontaneous pneumothorax.Am Rev Respir Dis. 1993; 148: 245-248Crossref PubMed Scopus (133) Google Scholar Primary spontaneouspneumothoraces affect patients who do not have clinically apparent lungdisorders. Secondary pneumothoraces occur in the setting of underlyingpulmonary disease, which most often is COPD.Although primary and secondary spontaneous pneumothoraces affect>20,000 patients per year in the United States2Melton LJ Hepper NGG Offord KP Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950–1974.Am Rev Respir Dis 1979. 1974; 120: 1379-1382Google Scholar andaccount for nearly $130,000,000 in health-care expenditures eachyear,3Baumann MH Strange C Treatment of spontaneous pneumothorax: a more aggressive approach?.Chest. 1997; 112: 789-804Abstract Full Text Full Text PDF PubMed Scopus (144) Google Scholar generally accepted and methodologically soundguidelines for the care of these patients do not exist. Consequently, observational studies demonstrate extensive practice variation in themanagement of this relatively common condition.4Baumann MH Strange C The clinician's perspective on pneumothorax management.Chest. 1997; 112: 822-828Abstract Full Text Full Text PDF PubMed Scopus (92) Google ScholarTo address this variation in care, the American College of Chest Physicians (ACCP) commissioned the development of a practice guidelinefor the management of spontaneous pneumothorax. The guideline committeerecognized that insufficient data existed from randomized controlledtrials to develop an evidence-based document and that recommendationswould largely derive from expert opinion. Because informal approachesfor developing expert-based statements are subject to extensive bias, the guideline developers selected the Delphi technique5Dalkey NC Helmer O An experimental application of the Delphi method to the use of experts. Publication RM-727-PR. Rand Corp, Santa Monica, CA1962Google Scholar toformalize the expert panel's consensus process and explicitly stateopinion. The methodology for this consensus guideline providesclinicians with a description of the level of consensus achieved foreach treatment recommendation and identifies clinical settings whereinmultiple options for care exist. The guideline pertains to adultpatients with primary spontaneous pneumothorax and patients withsecondary pneumothorax associated with COPD. Many of therecommendations will have relevance to secondary pneumothoracesaffecting patients with underlying lung disorders other than COPD.Materials and MethodsThe guideline development process used the Delphi method tocreate and quantify group consensus (Fig 1). The Delphi method was developed by RAND Corporation (Santa Monica, CA) researchers in the 1950s.5Dalkey NC Helmer O An experimental application of the Delphi method to the use of experts. Publication RM-727-PR. Rand Corp, Santa Monica, CA1962Google Scholar Characteristics of the, Delphi method are anonymity, controlled feedback, and statistical groupresponse.6Delbecq AL Van de Ven AH Gustafson DH Group techniques for program planning. Scott Foresman Co., Glenview, IL1975: 83-107Google Scholar Anonymity derives from the absence offace-to-face interaction. Participants respond independently toquestionnaires, and responses are communicated to other participantswithout being attributed to specific individuals. Controlled feedbackoccurs during several questionnaire iterations. Opinions expressedduring one round of the questionnaire are returned to the group duringthe next round in the form of statistical summaries. The statisticalgroup response is the final stage of the Delphi method with the groupconsensus expressed as a statistical score. The results of thequestionnaire are expressed using summary decision rules that quantifythe level of consensus and the appropriateness of managementrecommendations.7Jones J Hunter D Consensus methods for medical and health services research.BMJ. 1995; 311: 376-380Crossref PubMed Scopus (2272) Google ScholarGuideline Development Committee and Expert Panel MembersThe ACCP Health and Science Policy Committee selected thecontent chairman, the content co-chairman, and the methodologychairman. The chairmen selected six members of a multidisciplinaryguideline development committee on the basis of the members’ previouspublications on the topic of pneumothorax.The chairmen met with the project development committee to organize the, Delphi process and to select members of the expert panel. Panel memberswere selected from specialty fields proportionally related to thedistribution of publications on the management of pneumothorax amongspecialty and subspecialty journals. This proportionality wasdetermined by a MEDLINE literature search from 1966 to 1997 (seebelow). Experts were eligible for selection if they had published apeer-reviewed article on pneumothorax during the previous 5 years. Eachmember provided a written statement disclosing the existence of anycorporate relationships related to the care of patients withpneumothoraces. The distribution of panel members among medicalspecialties were as follows: pulmonary/critical care, 12 members(38%); thoracic surgery, 12 members (38%); general surgery, 1 member(3%); interventional radiology, 3 members (9%); and emergencymedicine, 4 members (13%).Literature SearchA MEDLINE literature search of English language articles wasperformed for the period from 1966 to 1997. The MeSH heading ofspontaneous pneumothorax was combined with the terms randomizedcontrolled trials, meta-analysis, andguidelines. Recent review articles were searched foradditional randomized controlled trials. Retrieved articles weredistributed to panel members. The literature search was repeated duringeach of the three iterations of the Delphi questionnaire, with the lastliterature search occurring in January 1999. Retrieved articles weregraded by the two content chairmen on the basis of the articles’ studydesigns (Table 1).8Taylor RW Pulmonary artery catheter consensus conference: consensus statement.New Horizons. 1997; 5: 175-194PubMed Google Scholar The methodology chairman resolved grading disagreementswith a majority vote.Table 1Levels of Evidence for Studies Evaluating TreatmentEffectiveness*Adapted from Taylor.8Level of Evidence and GradeStudy DesignLevel ILarge, randomized trials with clear-cut results; low risk of false-positive (α) error or false-negative (β) errorLevel IISmall, randomized trials with uncertain results; moderate to high risk of false-positive and/or false-negative errorLevel IIINonrandomized, contemporaneous controlLevel IVNonrandomized, historical control subjects, and expert opinionLevel VCase series, uncontrolled studies, and expert opinionGrade ASupported by at least two level I investigationsGrade BSupported by only one level I investigationGrade CSupported by level II investigations onlyGrade DSupported by at least one level III investigationGrade ESupported by level IV or level V evidence* Adapted from Taylor.8Taylor RW Pulmonary artery catheter consensus conference: consensus statement.New Horizons. 1997; 5: 175-194PubMed Google Scholar Open table in a new tab Additional articles were identified by the panel members and werecommunicated to the development group through the Delphi questionnaire. Abstracts of these articles were distributed to the panel during thenext round of the questionnaire.Delphi QuestionnaireThe guideline development committee met to design aquestionnaire that would query panel members about management decisionsin the care of patients with primary spontaneous pneumothoraces andsecondary pneumothoraces due to COPD. The committee constructed adecision tree for the care of patients with pneumothoraces and selecteddecision branch points for inclusion into the questionnaire that wereconsidered by the committee to be key management practices. Thecommittee did not discuss the appropriateness of these practices so asto avoid influencing the questionnaire development or bias members inattendance who would later respond to the questionnaire.Most questions were case-based scenarios with multiple managementoptions presented as choices (Fig 2). Panel members were asked to respond to the appropriateness of eachoption using a 9-point Likert scale (Table 2). A few questions were open-ended, multiple choice, or requested a“yes” or “no” response.Figure 2A sample item on the questionnaire showing thestatistical summaries of the panel members’ responses from theprevious round. The solid dots above and below the Likert scalesindicate the median responses. The bars above and below the Likertscale show the middle 50% and the middle 80% responses, respectively. The open dots represent outlier responses.View Large Image Figure ViewerDownload (PPT)Table 2Expert Opinion RatingsLikert ScaleDefinition9Extremely appropriate: treatment of choice (may have more than one per question).7 and 8Appropriate: a first-line treatment you would often use.4–6Equivocal: a second-line treatment you would sometimes use (eg, after first line had failed).2 and 3Usually inappropriate: at most, a third-line treatment you would rarely use.1Extremely inappropriate: a treatment you would never use. Open table in a new tab The multidisciplinary experts were allowed to skip questionnaire itemsby indicating that they did not have sufficient knowledge or experienceto respond to a particular question. Panel members also were asked toindicate whether their responses were based on opinion oran interpretation of published investigations. Panel members wereprovided a space to present an argument or literature citations insupport of their opinions.The questionnaire listed on its face page definitions of terms andclinical assumptions (Tables 3,4).Table 3Questionnaire Definition of TermsTermsDefinitionSpontaneous pneumothoraxNo antecedent traumatic or iatrogenic causePrimary spontaneous pneumothoraxNo clinically apparent underlying lung abnormalities or underlying conditions known to promote pneumothorax (eg, HIV disease)Secondary spontaneous pneumothoraxClinically apparent underlying lung diseasePneumothorax sizeDetermined by distance from the lung apex to the ipsilateral thoracic cupola at the parietal surface as determined by an upright standard radiographSmall pneumothorax< 3 cm apex-to-cupola distanceLarge pneumothorax≥ 3 cm apex-to-cupola distancePatient age groups, yrYoung18–40Older≥ 40Clinical stabilityStable patientAll of the following present: respiratory rate, < 24 breaths/min; heart rate, > 60 beats/min or < 120 beats/min; normal BP; room air O2 saturation, > 90%; and patient can speak in whole sentences between breathsUnstable patientAny patient not fulfilling the definition of stableDrainage tubesSmall chest tube or small percutaneous catheter≤ 14FModerate-sized chest tube16F to 22FLarge chest tube24F to 36FSimple aspirationInsertion of a needle or cannula with removal of pleural air followed by immediate removal of the needle or cannulaSclerosis (pleurodesis) procedureChemical pleurodesisIntrapleural instillation of a sclerosing agent through a chest tube or percutaneous catheterOpen or surgical pleurodesisPleurodesis performed with a thoracoscope or through a limited or full thoracotomy Open table in a new tab Table 4Clinical AssumptionsPatients will comply with treatment recommendations and can obtain prompt emergency medical careQuestions related to secondary spontaneous pneumothoraces pertain to patients with underlying COPDPatients have no comorbidities not mentioned in the case scenariosPneumothorax is the cause of the patient's presenting clinical manifestationsCare recommendations do not consider patient preferencesFirst-time pneumothorax unless otherwise indicated Open table in a new tab Administration of the QuestionnaireThe first Delphi questionnaire was mailed to the panel memberswith a request for its completion and return within 2 weeks. Responseson the returned questionnaires were summarized. A second questionnairewas developed that included a summary of the panel members’ responsesto each of the first questionnaire's items, a synopsis of the panelmembers’ comments, and a list of the articles cited by the panelmembers in support of their questionnaire responses. Questionnaireitems that were identified by the panel members as ambiguous wererefined.Summaries of item responses were placed adjacent to the specific itemand were described as follows. The number of panel members respondingto each item was listed. Bar and dot symbols were placed adjacent tothe Likert scales to indicate median responses, middle 50% range, andthe range for all responses. Similar summary statistics were presentedfor open-ended questions that requested a numeric response. A numberreported the proportion of panel members responding “yes” or“no” to an item. Panel members were provided with a key for eachquestionnaire that explained the data summary techniques.This second questionnaire was mailed to panel members. Responses to thesecond questionnaire's items, the panel members’ comments, and citedliterature were summarized and incorporated into a third questionnairethat was mailed to the panel members. Bar and dot symbols (Fig 2) wereplaced over the Likert scales to indicate median responses, the middle50% range, the middle 80% range, and outlier responses. The thirdmailing included printed copies of the abstracts from the articlescited by panel members in support of their responses to specificquestionnaire items.Description of Level of Consensus and Degree of Evidence- Based SupportResponses to the third questionnaire's items that used the9-point Likert scale were summarized and applied to a prioridefinitions to determine levels of consensus (Table 5). Evidence cited in the questionnaire by panel members to support theirquestionnaire responses also was cited in the guideline text with anevidence grade.Table 5Consensus Definitions*Definitions refer to Likert scale (Nos. 1 to9) for responses. See Table 2.TermDefinitionPerfect consensusAll respondents agree on an answerVery good consensusMedian and middle 50% (interquartile range) of respondents are found at one integer (eg, median and interquartile range are both at 8) or 80% of respondents are within one integer of the median (eg, median is 8, 80% respondents are from 7 to 9)Good consensus50% of respondents are within one integer of the median (eg, median is 8, 50% of respondents are from 7 to 9) or 80% of the respondents are within two integers of the median (eg, median is 7, 80% of respondents are from 5 to 9).Some consensus50% or respondents are within two integers of the median (eg, median is 7, 50% of respondents are from 5 to 9) or 80% of respondents are within three integers of the median (eg, median is 6, 80% of respondents are from 3 to 9).No consensusAll other responses.* Definitions refer to Likert scale (Nos. 1 to9) for responses. See Table 2. Open table in a new tab Description of Appropriateness of Management OptionsManagement options were graded regarding appropriateness usingthe summary results of the Likert scale (Table 6). Depending on the panel recommendations and the level of consensusachieved, the guideline uses the words “must,” “should,” and“may” to identify recommendations that are standards (must),guidelines (should), or options (may) for care9Heffner JE Aitken M Geist L et al.Attributes of ATS documents that guide clinical practice.Am J Respir Crit Care Med. 1997; 156: 2015-2025Crossref PubMed Scopus (21) Google Scholar(Table 6). This language is keyed directly to the panel members’ scoredresponses. Management approaches are described as inappropriate when ahigh degree of consensus indicated that the intervention must not beemployed for any patient in any clinical circumstance. Because of thelack of high-grade evidence in the management of pneumothorax and theexpert-opinion basis of the guideline, few interventions are describedas inappropriate.Table 6Management Definitions*Median scores for responses to questionnaireitems asking for ranking of appropriateness are given on a scale of 1to 9. See Table 2 for definitions.Management OptionsMedian (Middle 50% Range)Strength of RecommendationPreferred management in most circumstances7–9“Must” if perfect consensus; “should” otherwise(7–9)Acceptable management in many circumstances7–9 (4–9)“Should” if no preferred management exists; “may” if a preferred management existsAcceptable management in certain circumstances4–6 (4–9)“May”Acceptable management in rare circumstances2 and 3 (1–≤ 4)“May”Inappropriate management(1–3)“Must not” if perfect consensus; “should not” otherwiseIndeterminateAll other median and range combinations including “no consensus”†See Table 5.No management recommendation* Median scores for responses to questionnaireitems asking for ranking of appropriateness are given on a scale of 1to 9. See Table 2 for definitions.† See Table 5. Open table in a new tab Although based on previously reported approaches,10Brooks RH Chassin M Fink A et al.A method for the detailed assessment of the appropriateness of medical technologies: a Rand note. Publication N-3376- HHS. Rand Corp, Santa Monica, CA1991Google Scholar11Kahn DA Docherty JP Carpenter D et al.Consensus methods in practice guideline development: a review and description of a new method.Psychopharmacol Bull. 1997; 33: 631-639PubMed Google Scholarmethods for assessing and reporting the level of consensus andappropriateness were developed during this project and are unique tothis guideline statement.Results and Management RecommendationsLiterature SearchThe literature search retrieved nine articles,12Waller DA Forty J Morritt GN Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax.Ann Thorac Surg. 1994; 58: 372-376Abstract Full Text PDF PubMed Scopus (234) Google Scholar13van den Brande P Staelens I Chemical pleurodesis in primary spontaneous pneumothorax.Thorac Cardiovasc Surg. 1989; 37: 180-182Crossref PubMed Scopus (14) Google Scholar14Ma Y Li J Liu Y Short wave diathermy for small spontaneous pneumothorax.Thorax. 1997; 52: 561-566Crossref PubMed Scopus (10) Google Scholar15Light RW O'Hara VS Moritz TE et al.Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax.JAMA. 1990; 264: 2224-2230Crossref PubMed Scopus (191) Google Scholar16Engdahl O Boe J Sandstedt S Interpleural bupivacaine for analgesia during chest drainage treatment for pneumothorax: a randomized double-blind study.Acta Anaesthesiol Scand. 1993; 37: 149-153Crossref PubMed Scopus (22) Google Scholar17Andrivet P Djedaini K Teboul J-L et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-340Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar18Almind M Lange P Viskum K Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis.Thorax. 1989; 44: 627-630Crossref PubMed Scopus (147) Google Scholar19Harvey J Prescott RJ Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs.British Thoracic Society Research Committee BMJ. 1994; 309: 1338-1339Google Scholar20Miller AC Harvey JE Guidelines for the management of spontaneous pneumothorax: Standards of Care Committee, British Thoracic Society.BMJ. 1993; 307: 114-116Crossref PubMed Google Scholarwhich included eight randomized controlled trials12Waller DA Forty J Morritt GN Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax.Ann Thorac Surg. 1994; 58: 372-376Abstract Full Text PDF PubMed Scopus (234) Google Scholar13van den Brande P Staelens I Chemical pleurodesis in primary spontaneous pneumothorax.Thorac Cardiovasc Surg. 1989; 37: 180-182Crossref PubMed Scopus (14) Google Scholar14Ma Y Li J Liu Y Short wave diathermy for small spontaneous pneumothorax.Thorax. 1997; 52: 561-566Crossref PubMed Scopus (10) Google Scholar15Light RW O'Hara VS Moritz TE et al.Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax.JAMA. 1990; 264: 2224-2230Crossref PubMed Scopus (191) Google Scholar16Engdahl O Boe J Sandstedt S Interpleural bupivacaine for analgesia during chest drainage treatment for pneumothorax: a randomized double-blind study.Acta Anaesthesiol Scand. 1993; 37: 149-153Crossref PubMed Scopus (22) Google Scholar17Andrivet P Djedaini K Teboul J-L et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-340Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar18Almind M Lange P Viskum K Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis.Thorax. 1989; 44: 627-630Crossref PubMed Scopus (147) Google Scholar19Harvey J Prescott RJ Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs.British Thoracic Society Research Committee BMJ. 1994; 309: 1338-1339Google Scholar(Table 7), no meta-analyses, and one practice guideline.20Miller AC Harvey JE Guidelines for the management of spontaneous pneumothorax: Standards of Care Committee, British Thoracic Society.BMJ. 1993; 307: 114-116Crossref PubMed Google Scholar Theanalysis of the retrieved articles indicated that all of the guidelinerecommendations were grade E (lowest grade of evidence).Table 7Characteristics of Randomized Controlled SpontaneousPneumothorax Trials*VATS = video-assisted thoracoscopicsurgery.StudyCohorts and Patient CharacteristicsResults SummaryGeneral treatment trialsMa et al14Ma Y Li J Liu Y Short wave diathermy for small spontaneous pneumothorax.Thorax. 1997; 52: 561-566Crossref PubMed Scopus (10) Google ScholarShort-wave diathermy treatment vs observation; n = 11 in each groupAir absorption rate significantly greater with short-wave diathermyAndrivet et al17Andrivet P Djedaini K Teboul J-L et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-340Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar28 patients treated with thoracic drainage and 33 with needle aspirationHigher success rate for patients undergoing thoracic drainage than with needle aspiration; no difference in mean length of hospital stayHarvey and Prescott19Harvey J Prescott RJ Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs.British Thoracic Society Research Committee BMJ. 1994; 309: 1338-1339Google ScholarSimple aspiration (n = 35) vs intercostal tube drainage (n = 38)Longer hospital stay and greater daily pain in patients with intercostal tube drainsEngdahl et al16Engdahl O Boe J Sandstedt S Interpleural bupivacaine for analgesia during chest drainage treatment for pneumothorax: a randomized double-blind study.Acta Anaesthesiol Scand. 1993; 37: 149-153Crossref PubMed Scopus (22) Google ScholarIndwelling chest drains with interpleural bupivacaine (n = 11) vs saline solution placebo (n = 11)Visual analog pain scale scores lower in the bupivacaine groupPleurodesis trialsLight et al15Light RW O'Hara VS Moritz TE et al.Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax.JAMA. 1990; 264: 2224-2230Crossref PubMed Scopus (191) Google ScholarSpontaneous pneumothorax patients with chest tubes randomized to intrapleural tetracycline (n = 113) vs control group (n = 116)5-year study period: pneumothorax recurrence rates lower in the tetracycline groupAlmind et al18Almind M Lange P Viskum K Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis, and tetracycline pleurodesis.Thorax. 1989; 44: 627-630Crossref PubMed Scopus (147) Google ScholarSpontaneous pneumothorax patients in three treatment groups: simple drainage (n = 34); drainage/tetracycline (n = 33); and drainage/talc (n = 29)Talc with significant pneumothorax recurrence reduction compared to simple drainage; tetracycline recurrence reduction no different than other two groups.van den Brande and Staelens13van den Brande P Staelens I Chemical pleurodesis in primary spontaneous pneumothorax.Thorac Cardiovasc Surg. 1989; 37: 180-182Crossref PubMed Scopus (14) Google ScholarPrimary spontaneous pneumothorax only: 10 patients with drainage+ tetracycline/glucose; 10 patients with drainage alonePleurodesis with reduction in early but not late recurrencesSurgical trialWaller et al12Waller DA Forty J Morritt GN Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax.Ann Thorac Surg. 1994; 58: 372-376Abstract Full Text PDF PubMed Scopus (234) Google Scholar30 patients with VATS vs 30 patients with posterolateral thoracotomy for persistent air leak or pneumothorax recurrenceGreater postoperative decline in lung function in thoracotomy group; no difference in postoperative stay, recurrence, or morphine use; longer operating time for VATS* VATS = video-assisted thoracoscopicsurgery. Open table in a new tab Delphi TechniqueThree questionnaire iterations were completed with 100% participation in the first iteration, 97% participation (31 of 32) inthe second iteration (a thoracic surgeon dropped out), and 94% participation (30 of 32) in the third iteration (two thoracic surgeonsdropped out). The guideline incorporates the consensus opinions of the30 members who completed all three questionnaires. The degree ofconsensus increased or remained stable during the Delphi process formost questionnaire items (68%).Primary Spontaneous PneumothoraxClinically Stable Patients With Small PneumothoracesClinically stable patients with small pneumothoraces should be observedin the emergency d
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