Affiliations: Croydon, UK
University of Mississippi Medical Center
Medical University of South Carolina
Correspondence to: Andrew C. Miller, MD, PhD, FCCP, Mayday Healthcare, Croydon Chest Clinic, Thorton Heath, Surrey, United Kingdom CR7 7YE
As two of the British panel members for the Delphi consensus
statement on pneumothorax,1we 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
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,3and 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 These unpublished results were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
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.
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 Prescott2in 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
recommendations6for 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.
Become a CHEST member and receive a FREE subscription as a benefit of membership.
Individuals can purchase this article on ScienceDirect.
Individuals can purchase a subscription to the journal.
Individuals can purchase a subscription to the journal or buy individual articles.
Learn more about membership or Purchase a Full Subscription.
Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 7
Customize your page view by dragging & repositioning the boxes below.
Enter your username and email address. We'll send you a reminder to the email address on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.