Chest
Volume 119, Issue 2, February 2001, Pages 590-602
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Consensus Statement
Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement

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Objective

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.

Options

Decisionsfor observation, chest tube placement, surgical interventions, andradiographic imaging.

Outcomes

Effectiveness ofpneumothorax resolution, duration of and patient tolerance of care, andpneumothorax recurrence.

Evidence

Literature reviewfrom 1967 to January 1999 and Delphi questionnaire submitted in threeiterations to a multidisciplinary physician panel.

Values

The guideline development group determined byconsensus the relevant outcomes to be considered in developing the, Delphi questionnaire.

Benefits, harms, and costs

Thetype and magnitude of benefits, harms, and costs expected for patientsfrom guideline implementation.

Recommendations

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.

Validation

Recommendations were peer reviewed by physician experts and werereviewed by the American College of Chest Physicians (ACCP) Health and, Science Policy Committee.

Implementation

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.

Sponsors

TheACCP.

Section snippets

Materials and Methods

The 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.5 Characteristics of the, Delphi method are anonymity, controlled feedback, and statistical groupresponse.6 Anonymity derives from the absence offace-to-face interaction. Participants respond independently toquestionnaires, and responses are communicated to other participantswithout being

Literature Search

The literature search retrieved nine articles,121314151617181920which included eight randomized controlled trials1213141516171819(Table 7), no meta-analyses, and one practice guideline.20 Theanalysis of the retrieved articles indicated that all of the guidelinerecommendations were grade E (lowest grade of evidence).

Delphi Technique

Three questionnaire iterations were completed with 100% participation in the first iteration, 97% participation (31 of 32) inthe second iteration (a thoracic surgeon dropped out),

Comparison to Previous Guidelines

Only one previous guideline exists for the management ofpneumothorax.20 A panel of two physicians representing the, Standards of Care Committee of the British Thoracic Society (BTS)developed this guideline by disseminating a draft to 450 physicianmembers of the BTS. The two authors modified the draft on the basis ofthe 1,052 comments received from 150 responding physicians. Theguideline methodology did not use a formal literature search. Theaudience of the BTS guideline was hospital-based

Strengths and Limitations of the Guideline

The present guideline used the Delphi method, which combineslimited evidence with expert opinion and inference in a manner thatlimits group bias to the greatest degree possible.29 Theguideline adhered to evidence-based medicine principles of beingrelevant to specific circumstances and patients.30 Becausethe recommendations are largely expert opinion based, however, they donot represent sufficiently strong evidence to form the basis forhealth-care policy.31 Physicians applying

Guideline Implementation and Consensus Data

The complete guideline and the consensus tables for theentire questionnaire are available on the internet(www.chestnet.org/publications/18098/index.html). A summaryof the guideline and algorithms are available on the Internet and areavailable for distribution by the ACCP. A quick reference guide alsowill be available.

Priorities for Future Research

The extensive search of the literature underscores the paucity ofhigh-grade data from clinical trials on which recommendations for thecare of patients with pneumothoraces can be based. Major limitations ofthe literature include the following: pooling of patients with primaryand secondary pneumothoraces; nonstandardized interventions; lack ofinformation on clinical course (natural history of untreatedpneumothorax in different clinical settings); risk stratification onthe basis of factors such as

Content Chairman

Michael H. Baumann, MD, FCCP (Pulmonary), Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Mississippi Medical Center, Jackson, MS.

Content Co-Chairman

Charlie Strange, MD, FCCP (Pulmonary), Associate Professor of, Medicine, Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston, SC.

Methodology Chairman

John E. Heffner, MD, FCCP (Pulmonary), Professor of Medicine, Associate Dean, Medical University of South Carolina, Charleston, SC.

Project Development Committee Members

Richard

Additional References Cited by the Panel in the, Questionnaire Iterations

Bense L, Lewander R, Eklund G, et al. Nonsmoking, non-α1-antitrypsin deficiency-induced emphysemain nonsmokers with healed spontaneous pneumothorax, identified bycomputed tomography of the lungs. Chest 1993; 103:433–438

Bertrand P, Regnard J, Spaggiari L, et al. Immediate andlong-term results after surgical treatment of primary spontaneouspneumothorax by VATS. Ann Thorac Surg 1996; 61:1641–1645

Campisi P, Voitk AJ. Outpatient treatment of spontaneouspneumothorax in a community hospital using a

References (31)

  • RW Taylor

    Pulmonary artery catheter consensus conference: consensus statement

    New Horizons

    (1997)
  • JE Heffner et al.

    Attributes of ATS documents that guide clinical practice

    Am J Respir Crit Care Med

    (1997)
  • RH Brooks et al.

    A method for the detailed assessment of the appropriateness of medical technologies: a Rand note. Publication N-3376- HHS

    (1991)
  • DA Kahn et al.

    Consensus methods in practice guideline development: a review and description of a new method

    Psychopharmacol Bull

    (1997)
  • DA Waller et al.

    Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax

    Ann Thorac Surg

    (1994)
  • Cited by (0)

    Additional information about the questionnaire, consensus tables, andother data are available at www.chestnet.org/publications/18098/index.html.

    A complete list of the consensus group is located in Appendix 1.

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