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Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

Steven Walker, Robert Hallifax, Sara Ricciardi, Deirdre Fitzgerald, Marlies Keijzers, Olivia Lauk, Jesper Petersen, Luca Bertolaccini, Uffe Bodtger, Amelia Clive, Stefano Elia, Marios Froudarakis, Julius Janssen, Y.C. Gary Lee, Peter Licht, Gilbert Massard, Blin Nagavci, Jens Neudecker, Eric Roessner, Paul Van Schil, David Waller, Thorsten Walles, Giuseppe Cardillo, Nick Maskell, Najib Rahman

European Respiratory Journal 21 May 2024

Background: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

背景：自发性气胸(SP)的最佳治疗仍然存在争议，有各种建议的方法。这份来自ERS、EACTS和EST协会的联合临床实践指南为SP的管理提供了循证建议。

METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

方法：这个多学科特别工作组使用ERS方法制定指南，解决了气胸管理的12个关键临床问题。系统检索MEDLINE和Embase。证据是通过进行荟萃分析来合成的，如果可能的话，或者是描述性的。证据的确定性用等级(建议等级、评估等级、发展等级和评价等级)进行评级。用证据到决定框架来决定建议的方向和力度。

RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

结果：专家小组建议对临床稳定的有轻微症状的原发性自发性气胸(PSP)患者进行有条件的保守治疗。我们强烈建议在最初的PSP治疗中采用针吸而不是胸管引流。我们建议对最初的PSP进行有条件的门诊治疗。我们有条件地建议对优先预防复发的PSP患者进行早期手术治疗。专家小组提出了一项有条件的建议，在继发性SP合并持续性空气泄漏(PAL)的患者中使用自体血液补片。该小组无法就其他干预措施提出建议，包括支气管瓣、抽吸、除手术切除外的胸膜固定术或手术胸膜固定术的类型。

CONCLUSION: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

结论：根据这一国际指南，ERS、EACTS和EST协会为SP管理提供了临床实践建议。我们强调了PAL的管理和复发预防的证据差距，并提出了研究建议。

目录

1. INTRODUCTION

2. METHODS

    2.1 Scope and purpose of the document

    2.2 Composition of the Task Force panel

    2.3 Formulation of questions and selection of outcomes

Literature searches and evidence synthesis

Assessment of quality of evidence and strength of the recommendations

Conflict of interest management

3. Results

    3.1 Optimal management of acute presentation of pneumothorax

    3.2 Optimal management of PAL in patients with a pneumothorax deemed not fit for surgery

PICO 5: Should autologous blood patch (ABP)be used for management of persistent air leak(PAL)in spontaneous pneumothorax(compared to chest drain alone)?

PICO 6: Should bronchial valves be used for management of persistent air leak in spontaneous pneumothorax (compared to chest drain alone)?

PICO 7: Should suction be used for management of persistent air leak in spontaneous pneumothorax (compared to chest drain alone)?

    3.3 Optimal recurrence prevention in SP

PICO 8: Should treatment with pulmonary intervention (VATS)alone be used for recurrence prevention in spontaneous pneumothorax (compared with pulmonary intervention (VATS)plus pleurodesis)?

PICO 9: Should surgical pleurectomy be used for recurrence prevention in spontaneous pneumothorax (compared to chemical pleurodesis,delivered surgically or medically)?

    3.4 Narrative questions

Narrative question 1: What are the optimal methods for predicting initial clinical course and recurrence?

Narrative question 2: What factors influence determination of fitness for surgery and timing of surgical intervention for persistent air leak?

4. Discussion

— 图表汇总—

1. INTRODUCTION

Figure 1. Approach for management of spontaneous pneumothorax.

This figure is a combination of the recommendations made in this guideline and a description of the Task Force members’ usual practice in situations where there was not enough evidence to warrant a recommendation or for questions for which a systematic review of the literature was not undertaken. Note that the information depicted as usual practice is not intended as a recommendation for clinical practice. PICO: Patient, Intervention, Comparison, Outcome; CXR: chest X-ray; ABP: autologous blood patch; VATS: video-assisted thoracic surgery.

Figure 2. Decision aid for initial management pathways for primary spontaneous pneumothorax.

2. METHODS

    2.3 Formulation of questions and selection of outcomes

Literature searches and evidence synthesis (supplementary material)

Assessment of quality of evidence and strength of the recommendations 

 (supplementary material)

Conflict of interest management

3. Results

Table 1. PICO (Patient, Intervention, Comparison, Outcome) questions and recommendations

Table 2.Narrative questions and recommendations

OUTCOMES CONSIDERED AND THEIR IMPORTANCE

ERS guideline protocols 

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