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Consensus Statements

Consensus Panel on the Management
of Spontaneous Pneumothorax

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Background

Spontaneous pneumothorax that occurs in the absence of thoracic trauma is classified as primary or secondary:

Primary pneumothorax occurs in patients who have no clinically apparent lung disorder.

Secondary pneumothorax occurs in patients with an underlying pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD).

Primary and secondary pneumothorax occurs in more than 20,000 patients annually in the United States.

Extensive and critical review of literature revealed that (1) observational studies demonstrate extensive variation in the clinical management of spontaneous pneumothorax, and (2) there are no generally accepted and methodologically sound guidelines for pneumothorax management. In the absence of sufficient data from randomized trials to develop an evidence-based guideline, a consensus statement of expert opinion was developed using the Delphi technique of controlled feedback to rigorously drawn questions and statistical group response. The degree of consensus increased or remained stable during the Delphi process for most questionnaire items (68%).

Table 1—Expert Opinion Ratings
Likert scale Definitions
9 Extremely Appropriate: Treatment of choice
7-8 Appropriate: A first-line treatment you would often use
4-6 Equivocal: A second-line treatment you would sometimes use (eg, after first-line treatment failed)
2-3 Usually Inappropriate: A third-line treatment would rarely use
1 Extremely Inappropriate: A treatment you would never use
Table 2—Consensus Definitions*
Perfect Consensus All respondents agree on an answer.
Very Good Consensus Median and middle 50% (interquartile range) of respondents are found at one integer (eg, median and interquartile range are both at 8) or 80% of respondents are within one integer of the median (eg, median is 8, 80% of respondents are from 7 to 9).
Good Consensus 50% of respondents are within one integer of the median (eg, median is 8, 50% of respondents are from 7 to 9); or 80% of the respondents are within 2 integers of the median (eg, median is 7, 80% of respondents are from 5 to 9).
Some Consensus 50% of respondents are within 2 integers of the median (eg, median is 7, 50% of respondents are from 5 to 9); or 80% of respondents are within 3 integers of the median (eg, median is 6, 80% of respondents are from 3 to 9).
No Consensus All other responses.

 

Table 3—Clinical Definitions
Pneumothorax size

Determined by distance from the lung apex to the ipsilateral thoracic cupola at the parietal surface as determined by upright standard radiograph.

Small pneumothorax: < 3 cm apex-to-cupola distance
Large pneumothorax: > 3 cm apex-to cupola distance

Stable patient

 All of the following present: respiratory rate <24/min, heart rate >60/min or <120 min, normal blood pressure. Room air O2 saturation >90%, and patient can speak in whole sentences between breaths.
Unstable patient Any patient not fulfilling the definition of stable.

 

 

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