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Croydon, UK Bristol, UK
Correspondence to: Andrew C. Miller, MD, PhD, FCCP, Mayday Healthcare, Croydon Chest Clinic, Thorton Heath, Surrey, United Kingdom CR7 7YE
To the Editor:
As 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
Unlike the ACCP recommendations, the BTS guidelines were circulated to all BTS members and modified accordingly before publication. It took into account the results of a BTS randomized controlled trial that was subsequently published,3 and so its recommendations on simple aspiration are not "grade E (lowest grade of evidence)." Both in that study and other studies, the success rate of 70% is the same as that of catheter drainage,4 yet only the latter technique is recommended in the ACCP article.
The ACCP has not yet had the opportunity to assess the impact of its recommendations. On the other hand, the BTS surveyed all its members in 1998, with a response rate of 62%; all but 19% follow the 1993 recommendation of simple aspiration in primary spontaneous pneumothorax (98% using the described technique). These unpublished results were made available early in the Delphi process to the authors. Even the most conservative estimate suggests that in the United Kingdom alone, the use of simple aspiration avoids unnecessary large-bore tube drainage in 2,000 patients with primary spontaneous pneumothorax annually. This approach is supported in a recent thorough review.5
We therefore found the authors comments on simple aspiration to be inexplicably dismissive and biased. They are particularly surprising, because one of them is recently on record in a prestigious textbook of medicine, as follows "The initial recommended treatment for primary spontaneous pneumothorax is simple aspiration."6 They will doubtless justify this by saying that they were constrained by the Delphi process, which questions whether this really can produce "methodologically sound guidelines."
This is more serious than a minor difference of emphasis between groups of individuals, because the article is under the auspices of the ACCP, which rightly prides itself on its international representation. Many who log on to the Web site7 will conclude that the ACCP recommends catheter drainage and that simple aspiration is not appropriate. What would be appropriate is a more carefully worded and even-handed correction to the article and modification of that Web site.
References
University of Mississippi Medical Center Jackson, MS Medical University of South Carolina Charleston, SC
Correspondence to: Michael H. Baumann, MD, FCCP, University of Mississippi Medical Center, Department of Medicine, Division of Pulmonary/Critical Care Medicine, 2500 North State St, Jackson, MS 39216-4505; e-mail: mbaumann{at}medicine.umsmed.edu
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 panel1 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 Prescott2 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.3 4 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.5 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.5
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 recommendations6 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.7 8
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.9 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.
References
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