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• W2617731055 abstract "To the Editor:We appreciate the opportunity to respond in print to the concerns of Drs. Miller and Harvey regarding the grading by the American College of Chest Physicians (ACCP) expert panel1Baumann MH Strange C Heffner JE et al.Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.Chest. 2001; 119: 590-602Abstract Full Text Full Text PDF PubMed Scopus (857) Google Scholar of simple pneumothorax aspiration as being less desirable as compared with short-term catheter drainage. Drs. Miller and Harvey were two of the six esteemed panel members from the United Kingdom who participated in the ACCP consensus group along with 26 other worldwide experts. We had multiple communications with Drs. Miller and Harvey about their faith in simple aspiration both during the Delphi process and after each distribution of the article drafts to them and other panel members. The reiterative distribution of panel members’ opinions among the expert consensus group through the Delphi technique provided them with extensive opportunities to convince their colleagues of the virtues of simple aspiration.After completion of the year-long consensus process, however, the majority of experts remained unconvinced and favored observation for small primary spontaneous pneumothoraces in stable patients and insertion of a small-bore chest catheter in symptomatic patients who required an intervention to reexpand the lung. The panel did state that simple aspiration may be indicated for clinically stable patients with small pneumothoraces that progress with observation.This consensus opinion is not surprising considering the lack of investigative data favoring simple aspiration over catheter drainage. Drs. Miller and Harvey refer to a prospective randomized study performed by Harvey and Prescott2Harvey J Prescott RJ Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs.BMJ. 1994; 309: 1338-1339Crossref PubMed Scopus (149) Google Scholar in support of simple aspiration as primary therapy. This article was distributed to the panel members, but it was not considered sufficiently high grade to support simple aspiration. The study sample was small (n = 73) and important design elements were not described, including methods for randomization, allocation concealment, definition of outcomes, and techniques of chest tube insertion. Also, methods for selecting patients for pleurectomy as a measured (and obsolete) outcome were not described. And finally, more patients with complete pneumothoraces were assigned to the chest tube (n = 18) as compared to the simple aspiration group (n = 10). Other methodologic flaws of this study and related concerns have been described elsewhere.3Currie DC Simple aspiration for spontaneous pneumothorax may not reduce the need for pleurectomy [letter].BMJ. 1995; 310: 256Crossref Scopus (2) Google Scholar4Grant IWB Simple aspiration for spontaneous pneumothorax.BMJ. 1995; 310: 468-469Crossref PubMed Google Scholar These major weaknesses in design did not convince the consensus panel to accept this article as level II evidence in support of a grade C recommendation for simple aspiration.Drs. Miller and Harvey also cite the study by Andrivet and colleagues in support of simple aspiration stating that this treatment has a similar success rate (approximately 70%), as compared with chest tube drainage.5Andrivet P Djedaini K Teboul JL et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-339Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar In actual fact, this small study (which was distributed to panel members and tallied in Table 7 of the published statement) reported a higher success rate with chest tube drainage (93%, n = 28) as compared with simple aspiration (67%, n = 33). A subsequent group of patients (n = 35) in an uncontrolled phase of this study had only a 68.5% success rate with simple aspiration. Andrivet and colleagues concluded that thoracic drainage “via a chest tube was significantly more effective in the treatment of pneumothorax” than simple aspiration.5Andrivet P Djedaini K Teboul JL et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-339Abstract Full Text Full Text PDF PubMed Scopus (161) Google ScholarOur consensus panel was also aware of the unpublished British Thoracic Society (BTS) survey that Drs. Miller and Harvey mention in their letter. We did not believe, however, that approbation, noted in this survey, by British practitioners of the 1993 BTS pneumothorax guideline recommendations6Miller AC Harvey JE Guidelines for the management of spontaneous pneumothorax.BMJ. 1993; 307: 114-116Crossref PubMed Google Scholar for simple aspiration could substitute for investigative data. Moreover, two recent publications report that the majority of UK physicians do not conform to the 1993 BTS guidelines in managing patients with spontaneous pneumothorax.7Soulsby T British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work?.J Accid Emerg Med. 1998; 15: 317-321Crossref PubMed Scopus (56) Google Scholar8Courtney P McKane W Audit of the management of spontaneous pneumothorax.Ulster Med J. 1998; 67: 41-43PubMed Google ScholarWe regret the description of the ACCP document as “biased.” The 32 members of the expert panel were selected through an explicit methodology described in the statement and represent the leading published experts in this field. Also, the entire Delphi consensus panel, the ACCP Health and Science Policy Committee, and the Executive Committee of the ACCP Board of Regents reviewed, revised, and approved the statement before its publication. The writing committee responded to the minority concerns of Drs. Miller and Harvey by referring to the BTS guidelines in the published statement and by stating that “two panel members argued that simple aspiration is usually effective for stable patients.” The consensus document could not do more to represent the opinions of a small minority of the expert panel without unjustifiably altering the majority consensus.We recognize that extensive practice variation exists in the management of spontaneous pneumothorax. Indeed, reports of this practice variation prompted the design of the ACCP Delphi study.9Baumann MH Strange C The clinician's perspective on pneumothorax management.Chest. 1997; 112: 822-828Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar A critical analysis of the literature demonstrates that insufficient high-grade data exist to support the development of an evidence-based guideline on pneumothorax management. To its credit, the ACCP proposed that a statement necessarily based on expert consensus in the absence of high-grade outcome data should use an explicit consensus methodology and quantify the degree of consensus for each of its recommendations. We believe that the Delphi pneumothorax statement ably fulfilled this charge. But more importantly, we had hoped that the ACCP recommendations—limited as they are being based on consensus—would promote a broader dialogue on this important topic and stimulate needed, well-designed clinical studies. The letter by Drs. Miller and Harvey represents the first of what we hope to be an ongoing and vigorous discussion of pneumothorax care and the initiation of appropriately designed outcomes research. To the Editor:We appreciate the opportunity to respond in print to the concerns of Drs. Miller and Harvey regarding the grading by the American College of Chest Physicians (ACCP) expert panel1Baumann MH Strange C Heffner JE et al.Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.Chest. 2001; 119: 590-602Abstract Full Text Full Text PDF PubMed Scopus (857) Google Scholar of simple pneumothorax aspiration as being less desirable as compared with short-term catheter drainage. Drs. Miller and Harvey were two of the six esteemed panel members from the United Kingdom who participated in the ACCP consensus group along with 26 other worldwide experts. We had multiple communications with Drs. Miller and Harvey about their faith in simple aspiration both during the Delphi process and after each distribution of the article drafts to them and other panel members. The reiterative distribution of panel members’ opinions among the expert consensus group through the Delphi technique provided them with extensive opportunities to convince their colleagues of the virtues of simple aspiration.After completion of the year-long consensus process, however, the majority of experts remained unconvinced and favored observation for small primary spontaneous pneumothoraces in stable patients and insertion of a small-bore chest catheter in symptomatic patients who required an intervention to reexpand the lung. The panel did state that simple aspiration may be indicated for clinically stable patients with small pneumothoraces that progress with observation.This consensus opinion is not surprising considering the lack of investigative data favoring simple aspiration over catheter drainage. Drs. Miller and Harvey refer to a prospective randomized study performed by Harvey and Prescott2Harvey J Prescott RJ Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs.BMJ. 1994; 309: 1338-1339Crossref PubMed Scopus (149) Google Scholar in support of simple aspiration as primary therapy. This article was distributed to the panel members, but it was not considered sufficiently high grade to support simple aspiration. The study sample was small (n = 73) and important design elements were not described, including methods for randomization, allocation concealment, definition of outcomes, and techniques of chest tube insertion. Also, methods for selecting patients for pleurectomy as a measured (and obsolete) outcome were not described. And finally, more patients with complete pneumothoraces were assigned to the chest tube (n = 18) as compared to the simple aspiration group (n = 10). Other methodologic flaws of this study and related concerns have been described elsewhere.3Currie DC Simple aspiration for spontaneous pneumothorax may not reduce the need for pleurectomy [letter].BMJ. 1995; 310: 256Crossref Scopus (2) Google Scholar4Grant IWB Simple aspiration for spontaneous pneumothorax.BMJ. 1995; 310: 468-469Crossref PubMed Google Scholar These major weaknesses in design did not convince the consensus panel to accept this article as level II evidence in support of a grade C recommendation for simple aspiration.Drs. Miller and Harvey also cite the study by Andrivet and colleagues in support of simple aspiration stating that this treatment has a similar success rate (approximately 70%), as compared with chest tube drainage.5Andrivet P Djedaini K Teboul JL et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-339Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar In actual fact, this small study (which was distributed to panel members and tallied in Table 7 of the published statement) reported a higher success rate with chest tube drainage (93%, n = 28) as compared with simple aspiration (67%, n = 33). A subsequent group of patients (n = 35) in an uncontrolled phase of this study had only a 68.5% success rate with simple aspiration. Andrivet and colleagues concluded that thoracic drainage “via a chest tube was significantly more effective in the treatment of pneumothorax” than simple aspiration.5Andrivet P Djedaini K Teboul JL et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-339Abstract Full Text Full Text PDF PubMed Scopus (161) Google ScholarOur consensus panel was also aware of the unpublished British Thoracic Society (BTS) survey that Drs. Miller and Harvey mention in their letter. We did not believe, however, that approbation, noted in this survey, by British practitioners of the 1993 BTS pneumothorax guideline recommendations6Miller AC Harvey JE Guidelines for the management of spontaneous pneumothorax.BMJ. 1993; 307: 114-116Crossref PubMed Google Scholar for simple aspiration could substitute for investigative data. Moreover, two recent publications report that the majority of UK physicians do not conform to the 1993 BTS guidelines in managing patients with spontaneous pneumothorax.7Soulsby T British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work?.J Accid Emerg Med. 1998; 15: 317-321Crossref PubMed Scopus (56) Google Scholar8Courtney P McKane W Audit of the management of spontaneous pneumothorax.Ulster Med J. 1998; 67: 41-43PubMed Google ScholarWe regret the description of the ACCP document as “biased.” The 32 members of the expert panel were selected through an explicit methodology described in the statement and represent the leading published experts in this field. Also, the entire Delphi consensus panel, the ACCP Health and Science Policy Committee, and the Executive Committee of the ACCP Board of Regents reviewed, revised, and approved the statement before its publication. The writing committee responded to the minority concerns of Drs. Miller and Harvey by referring to the BTS guidelines in the published statement and by stating that “two panel members argued that simple aspiration is usually effective for stable patients.” The consensus document could not do more to represent the opinions of a small minority of the expert panel without unjustifiably altering the majority consensus.We recognize that extensive practice variation exists in the management of spontaneous pneumothorax. Indeed, reports of this practice variation prompted the design of the ACCP Delphi study.9Baumann MH Strange C The clinician's perspective on pneumothorax management.Chest. 1997; 112: 822-828Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar A critical analysis of the literature demonstrates that insufficient high-grade data exist to support the development of an evidence-based guideline on pneumothorax management. To its credit, the ACCP proposed that a statement necessarily based on expert consensus in the absence of high-grade outcome data should use an explicit consensus methodology and quantify the degree of consensus for each of its recommendations. We believe that the Delphi pneumothorax statement ably fulfilled this charge. But more importantly, we had hoped that the ACCP recommendations—limited as they are being based on consensus—would promote a broader dialogue on this important topic and stimulate needed, well-designed clinical studies. The letter by Drs. Miller and Harvey represents the first of what we hope to be an ongoing and vigorous discussion of pneumothorax care and the initiation of appropriately designed outcomes research. We appreciate the opportunity to respond in print to the concerns of Drs. Miller and Harvey regarding the grading by the American College of Chest Physicians (ACCP) expert panel1Baumann MH Strange C Heffner JE et al.Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.Chest. 2001; 119: 590-602Abstract Full Text Full Text PDF PubMed Scopus (857) Google Scholar of simple pneumothorax aspiration as being less desirable as compared with short-term catheter drainage. Drs. Miller and Harvey were two of the six esteemed panel members from the United Kingdom who participated in the ACCP consensus group along with 26 other worldwide experts. We had multiple communications with Drs. Miller and Harvey about their faith in simple aspiration both during the Delphi process and after each distribution of the article drafts to them and other panel members. The reiterative distribution of panel members’ opinions among the expert consensus group through the Delphi technique provided them with extensive opportunities to convince their colleagues of the virtues of simple aspiration. After completion of the year-long consensus process, however, the majority of experts remained unconvinced and favored observation for small primary spontaneous pneumothoraces in stable patients and insertion of a small-bore chest catheter in symptomatic patients who required an intervention to reexpand the lung. The panel did state that simple aspiration may be indicated for clinically stable patients with small pneumothoraces that progress with observation. This consensus opinion is not surprising considering the lack of investigative data favoring simple aspiration over catheter drainage. Drs. Miller and Harvey refer to a prospective randomized study performed by Harvey and Prescott2Harvey J Prescott RJ Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs.BMJ. 1994; 309: 1338-1339Crossref PubMed Scopus (149) Google Scholar in support of simple aspiration as primary therapy. This article was distributed to the panel members, but it was not considered sufficiently high grade to support simple aspiration. The study sample was small (n = 73) and important design elements were not described, including methods for randomization, allocation concealment, definition of outcomes, and techniques of chest tube insertion. Also, methods for selecting patients for pleurectomy as a measured (and obsolete) outcome were not described. And finally, more patients with complete pneumothoraces were assigned to the chest tube (n = 18) as compared to the simple aspiration group (n = 10). Other methodologic flaws of this study and related concerns have been described elsewhere.3Currie DC Simple aspiration for spontaneous pneumothorax may not reduce the need for pleurectomy [letter].BMJ. 1995; 310: 256Crossref Scopus (2) Google Scholar4Grant IWB Simple aspiration for spontaneous pneumothorax.BMJ. 1995; 310: 468-469Crossref PubMed Google Scholar These major weaknesses in design did not convince the consensus panel to accept this article as level II evidence in support of a grade C recommendation for simple aspiration. Drs. Miller and Harvey also cite the study by Andrivet and colleagues in support of simple aspiration stating that this treatment has a similar success rate (approximately 70%), as compared with chest tube drainage.5Andrivet P Djedaini K Teboul JL et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-339Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar In actual fact, this small study (which was distributed to panel members and tallied in Table 7 of the published statement) reported a higher success rate with chest tube drainage (93%, n = 28) as compared with simple aspiration (67%, n = 33). A subsequent group of patients (n = 35) in an uncontrolled phase of this study had only a 68.5% success rate with simple aspiration. Andrivet and colleagues concluded that thoracic drainage “via a chest tube was significantly more effective in the treatment of pneumothorax” than simple aspiration.5Andrivet P Djedaini K Teboul JL et al.Spontaneous pneumothorax: comparison of thoracic drainage vs immediate or delayed needle aspiration.Chest. 1995; 108: 335-339Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar Our consensus panel was also aware of the unpublished British Thoracic Society (BTS) survey that Drs. Miller and Harvey mention in their letter. We did not believe, however, that approbation, noted in this survey, by British practitioners of the 1993 BTS pneumothorax guideline recommendations6Miller AC Harvey JE Guidelines for the management of spontaneous pneumothorax.BMJ. 1993; 307: 114-116Crossref PubMed Google Scholar for simple aspiration could substitute for investigative data. Moreover, two recent publications report that the majority of UK physicians do not conform to the 1993 BTS guidelines in managing patients with spontaneous pneumothorax.7Soulsby T British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work?.J Accid Emerg Med. 1998; 15: 317-321Crossref PubMed Scopus (56) Google Scholar8Courtney P McKane W Audit of the management of spontaneous pneumothorax.Ulster Med J. 1998; 67: 41-43PubMed Google Scholar We regret the description of the ACCP document as “biased.” The 32 members of the expert panel were selected through an explicit methodology described in the statement and represent the leading published experts in this field. Also, the entire Delphi consensus panel, the ACCP Health and Science Policy Committee, and the Executive Committee of the ACCP Board of Regents reviewed, revised, and approved the statement before its publication. The writing committee responded to the minority concerns of Drs. Miller and Harvey by referring to the BTS guidelines in the published statement and by stating that “two panel members argued that simple aspiration is usually effective for stable patients.” The consensus document could not do more to represent the opinions of a small minority of the expert panel without unjustifiably altering the majority consensus. We recognize that extensive practice variation exists in the management of spontaneous pneumothorax. Indeed, reports of this practice variation prompted the design of the ACCP Delphi study.9Baumann MH Strange C The clinician's perspective on pneumothorax management.Chest. 1997; 112: 822-828Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar A critical analysis of the literature demonstrates that insufficient high-grade data exist to support the development of an evidence-based guideline on pneumothorax management. To its credit, the ACCP proposed that a statement necessarily based on expert consensus in the absence of high-grade outcome data should use an explicit consensus methodology and quantify the degree of consensus for each of its recommendations. We believe that the Delphi pneumothorax statement ably fulfilled this charge. But more importantly, we had hoped that the ACCP recommendations—limited as they are being based on consensus—would promote a broader dialogue on this important topic and stimulate needed, well-designed clinical studies. The letter by Drs. Miller and Harvey represents the first of what we hope to be an ongoing and vigorous discussion of pneumothorax care and the initiation of appropriately designed outcomes research. Pneumothorax: What’s Wrong With Simple Aspiration?CHESTVol. 120Issue 3PreviewAs two of the British panel members for the Delphi consensus statement on pneumothorax,1 we were dismayed to see that, in spite of our strong representations, the article included the statement “The present ACCP [American College of Chest Physicians] guideline consensus process found simple aspiration to be appropriate rarely in any clinical circumstance,” even though this is the first intervention recommended by the British Thoracic Society (BTS) in 1993.2 Full-Text PDF" @default.
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