The clinician's perspective on pneumothorax management

Chest. 1997 Sep;112(3):822-8. doi: 10.1378/chest.112.3.822.

Abstract

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 chi2 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.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Bacterial Agents / therapeutic use
  • Bronchial Fistula / therapy*
  • Chest Tubes
  • Chi-Square Distribution
  • Constriction
  • Doxycycline / therapeutic use
  • Equipment Design
  • Fistula / therapy*
  • Guidelines as Topic
  • Humans
  • Pleural Diseases / therapy*
  • Pleurodesis
  • Pneumothorax / therapy*
  • Powders
  • Practice Patterns, Physicians'*
  • Pulmonary Medicine
  • Randomized Controlled Trials as Topic
  • Recurrence
  • Respiration, Artificial
  • Respiratory Distress Syndrome, Adult / complications
  • Suction
  • Surveys and Questionnaires
  • Talc / therapeutic use
  • Thoracic Surgery
  • Thoracoscopy
  • Thoracotomy
  • Time Factors
  • Video Recording

Substances

  • Anti-Bacterial Agents
  • Powders
  • Talc
  • Doxycycline