CHARLESTON, SC—The paucity of data from large, randomized clinical trials and of clearly defined, evidence-based guidelines has led to widely varying approaches to the management of spontaneous pneumothorax. The publication of new recommendations developed by the American College of Chest Physicians (ACCP) could change that.[1]

For instance, content cochair Charlie Strange, MD, noted that the ACCP Delphi Consensus Statement on the Management of Spontaneous Pneumothorax places a new emphasis on the observation of some pneumothorax patients. “Previously, many of us had drained almost all pneumothoraces that we saw in the emergency room setting, not knowing if the pneumothorax was going to enlarge,” he told PULMONARY REVIEWS. “But this is the first document that has ever formalized [a] recommendation for observation. [T]hat changes practice for [many] physicians,” added Dr. Strange, an Associate Professor of Pulmonary and Critical Care Medicine at the Medical University of South Carolina, Charleston.

QUESTIONNAIRES AND LITERATURE SEARCHES

Guideline authors used the Delphi method and a literature search to identify the varying medical opinions and unify them into a scientifically sound consensus. An international panel of 32 multidisciplinary specialists responded to questions (most of which were case-study–based) in three evolving surveys about management decisions in the care of patients with primary and secondary pneumothoraces.

The literature search turned up nine articles published between 1966 and 1999, including eight randomized controlled trials and one practice guideline from the British Thoracic Society.[2] Evidence presented in the articles was graded A (supported by at least two level I investigations) through E (supported by level IV or level V evidence). In addition, the panel members cited evidence from the literature to support their input.

The questionnaire responses were statistically analyzed and returned to participants with the supporting documentation. A final version of the questionnaire, incorporating the results and analyses of the previous two, further refined the consensus and resulted in the current guidelines.

GUIDELINE RECOMMENDATIONS

Clinically stable patients with small primary pneumothoraces. These patients, whose pneumothoraces measure less than 3 cm from apex to cupola, should be observed for three to six hours in the emergency department. If a follow-up chest film shows no enlargement of the pneumothorax and the patient has access to reliable medical care, he or she may be discharged with instructions to seek follow-up care, including chest film, within 12 to 48 hours.

Aspiration of the pneumothorax is not considered an appropriate course of action, except in patients whose pneumothoraces have enlarged. Hospitalization is recommended if patients do not have access to good follow-up care or to an emergency department. Symptoms that are present for longer than 24 hours and patient age are not factors in treatment decisions for this or the following scenarios.

Clinically stable patients with large primary pneumothoraces. In most cases, stable patients whose pneumothoraces measure 3 cm or more from apex to cupola should be hospitalized and the lung reexpanded by either a small-bore catheter or a chest tube. The panel is in general agreement that the catheters or chest tubes may be attached to a Heimlich valve or a water seal device and left in place until the lung reexpands and air leaks have resolved. If the lung fails to reexpand, suction should be applied, although there is some consensus that suction may be used concurrently with tube placement.

Patients refusing hospitalization may be discharged with an indwelling catheter after removal of pleural air and lung reexpansion, with instructions to seek follow-up care within 48 hours.

Clinically unstable patients with large primary pneumothoraces. These patients should be hospitalized with insertion of a small-bore catheter or a chest tube to reexpand the lung. A larger chest tube may be used in patients at risk for developing a bronchopleural fistula with a large air leak or in those requiring positive-pressure ventilation.

Secondary spontaneous pneumothoraces. All patients with secondary pneumothoraces should be hospitalized, according to the guidelines. Some panelists suggest that the placement of chest tubes depends on the extent of the patients’ symptoms and the progression of their pneumothoraces.

The panel argues against observation alone because of the associated risk of mortality with secondary spontaneous pneumothorax. The panelists mostly agree, however, that patients should not be referred for thoracoscopy until stabilized.

OTHER PROTOCOLS

The ACCP consensus statement also provides the following recommendations on spontaneous pneumothorax treatment:

• Persistent air leaks may be observed for four days in patients with primary pneumothorax and for up to five days in patients with secondary pneumothorax before surgical intervention is considered. Thoracoscopy is generally recommended over thoracotomy, and chemical pleurodesis through a chest tube is recommended only for patients who refuse surgery or in whom surgery is contraindicated.

• The majority of panel members (85%) recommend deferring recurrence prevention procedures in clinically stable patients until the second occurrence of pneumothorax, although the remainder say they would offer intervention to patients at the time of the first occurrence. For patients with underlying pulmonary disease, 81% of the panelists recommend recurrence prevention procedures at the time of the first occurrence because of the risk of mortality with secondary pneumothoraces.

• Recommendations for removal of chest tubes are similar for all scenarios. There is no clear consensus as to whether the tube should be clamped before removal, but most panelists agree that chest tubes should be removed in stages. Chest films also should be ordered to confirm resolution—five to 12 hours after the last evidence of an air leak in the case of primary pneumothorax and 13 to 23 hours after air leak resolution in the case of secondary pneumothorax—prior to removing a chest tube.

The complete guideline can be viewed at www.chestnet.org/publications/18098/index.html. Guideline authors suggest that the lack of literature found to support the ACCP recommendations means that more research is needed in the form of “prospective studies that have adequate sample sizes and follow-up periods to show effects.”

—Kindra Bradley

References
1. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001;119:590-602.

2. Miller AC, Harvey JE. Guidelines for the management of spontaneous pneumothorax: Standards of Care Committee, British Thoracic Society. BMJ. 1999;307:114-116.

Return to table of contents