Chest
Volume 112, Issue 3, September 1997, Pages 822-828
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Special Report
The Clinician's Perspective on Pneumothorax Management

https://doi.org/10.1378/chest.112.3.822Get rights and content

Objective

We sought to determine the current practice habits among clinicians treating spontaneous pneumothorax and bronchopleural fistula.

Methods

Practice habits were determined by a randomized postal survey of 3,000 American College of Chest Physicians members. Group comparisons are performed by X2 analysis with p<0.05 being significant.

Results

Four hundred nine respondents (13.6%) included 176 practicing pulmonologists (43.0%), 67 academic pulmonologists (16.4%), 102 thoracic surgeons (25.0%), and 64 others (15.6%). More than 50% of respondents treat a first small primary spontaneous pneumothorax (PSP) by simple observation, a first small secondary spontaneous pneumothorax (SSP) by chest tube, persistent air leak in both PSP and SSP with chest tube+video-assisted thoracoscopy, and use a 20 to 24F chest tube in mechanically ventilated ARDS-related tension pneumothorax. First recurrences of PSP and SSP were treated by a variety of interventions that included simple observation (PSP=14%, SSP=4%), chest tube (22%/17%), chest tube+sclerosis (20%/16%), chest tube+video-assisted thoracoscopy (36%/48%), and chest tube+thoracotomy (5%/12%). The most popular sclerosing agents are doxycycline (48%), talc slurry (24%), and talc poudrage (19%). More than 75% of physicians intervened in a persistent air leak between 5 and 10 days. Chest tubes are initially placed to suction by 48% of respondents in PSP and removed >24 h after air leak ceases in 79%. Chest tube clamping prior to removal is employed by 67% of respondents. Significant differences exist between thoracic surgeons and pulmonologists with surgeons placing more chest tubes for first-time PSP and performing chest tube+video-assisted thoracoscopy for first recurrences of PSP more often than pulmonologists. Thoracic surgeons seldom use sclerosis in spontaneous pneumothorax compared to pulmonologists.

Conclusions

Marked practice variation exists in clinicians' approaches to the management of spontaneous pneumothorax and bronchopleural fistulas that is partially explained by differences between pulmonologists and thoracic surgeons. A national consensus statement is needed to guide randomized studies in pneumothorax management.

Section snippets

Materials and Methods

A pneumothorax questionnaire was mailed to 3,000 random US ACCP members in August 1995. The mailing contained a computerized survey response form, the survey questionnaire (Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7), a self-addressed return envelope, and a cover letter requesting the recipients' participation and explaining the purpose of the survey. Responses were accepted until the end of December 1995.

Results

Of the 3,000 surveys sent, 409 were completed and returned (13.6%). The mean (±SEM) number of respondents to answer each survey question was 369.4±5.9. Practicing pulmonologists comprised 43% (n=176) of the respondents; academic pulmonologists, 16.4% (n=67); thoracic surgeons, 25% (n=102); and all others, 7.3% (n=30); 8.3% (n=34) of respondents omitted the initial occupation question.

Respondents had a broad geographic representation as determined by number coding placed on the response forms.

Discussion

Practice variation is common in the treatment of spontaneous pneumothoraces and bronchopleural fistulas. Recent reviews of the management of spontaneous pneumothorax1, 2, 3 and bronchopleural fistulas4 offer therapeutic advice that by necessity must be empirical in the absence of randomized trials. Practice variation and physician empiricism in the management of spontaneous pneumothoraces may be the result of one of three broad problems.

First is the absence of sufficient research to formulate

Acknowledgments

The authors wish to thank the members of the ACCP participating in the pneumothorax survey and Kathy Jewett, of the ACCP national office, for her assistance.

References (10)

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Supported by the University of Mississippi Medical Center Department of Medicine Developmental Fund.

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