- Email: [email protected]
Initial management of spontaneous pneumothorax
Correspondence
Improving the prevention and management of respiratory diseases in China: the crucial role of primary care Respiratory disorders are among the leading causes of mortality in China, with an estimated 3·25 million deaths per year; chronic obstructive pulmonary disease (COPD), lung cancer, and pneumonia are the most common causes.1 Respiratory disorders were also responsible for an estimated 36·6 million disability adjusted lifeyears (DALYs) in 2010.2 This figure will continue to increase, driven by changing demographics, the high prevalence of smoking, and the effects of air pollution. The importance of primary care services and research in reducing this substantial disease burden was shown in the launch of the Chinese Thoracic Society’s Chinese Alliance for Respiratory Diseases in Primary Care in Guiyang in September, 2015. The alliance brings together key individuals from general practice, academic respiratory medicine, and primary care organisations from across China. Its launch marked an important milestone that will help to put increased emphasis on prevention and communitybased management of both noncommunicable and communicable respiratory disorders. Currently, health care is heavily concentrated in hospitals and primary care is very under developed. Key priorities for the alliance are to improve the description, understanding, and recording of the changing profile and burden of respiratory disorders in both urban and rural China. There is an urgent need to increase the numbers of family doctors in rural areas and train them for the task of managing common respiratory disorders. Development of online
teaching resources aimed specifically at the primary care workforce will be helpful. It is also crucial that essential equipment (eg, spirometers) and medicines (eg, inhaled corticosteroids and long-acting bronchodilators) are made available to frontline staff across China. Working in close conjunction with hospital specialists, there is a need to develop complete care pathways. The alliance has begun working with stakeholders. Over the long-term, we hope to align closely with and learn from similar primary care respiratory organisations in other parts of the world. We would like, particularly, to gain insights into how to challenge the tobacco industry’s strategy, in view of the huge and increasing burden from active and passive smoking in China.3,4 The alliance will also work closely with the government to develop a national roadmap for reducing the high burden of respiratory disorders in China. This development sets an example of vital partnership between hospital specialists and general practitioners. Such collaborations will be crucial in China’s effort to strengthen primary care. CW’s research is supported by the National Key Technology Research and Development Program of the Ministry of Science and Technology of China during the 12th Five-Year Plan (2012BAI05B02). CC, MY, and KKC report grants from Pfizer China, outside of the submitted work. CW reports grants from Ministry of Science and Technology, China, during the conduct of the study, and grants from AstraZeneca China, outside of the submitted work. AS declares no competing interests.
Chunhua Chi, Aziz Sheikh, Mi Yao, Kar Keung Cheng, *Chen Wang [email protected] Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China (CC); Department of General Practice, Peking University Health Science Center, Beijing, China (CC, MY, KKC); Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK (AS); Beijing Xicheng District Xinjiekou Community Health Service Center, Beijing, China (MY); Institute of Applied Health Research, University of Birmingham, Birmingham, UK (KKC); Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital Beijing, China (CW); Department of Respiratory Medicine, Capital Medical University Beijing, China (CW); and National Clinical Research Centre for Respiratory Diseases, Beijing, China (CW)
www.thelancet.com/respiratory Vol 3 November 2015
1
2
3
4
National Health and Family Planning Commission of the People’s Republic of China. China Health Statistics Yearbook 2014. Beijing: Peking Union Medical College Press, 2014. Yang G, Wang Y, Zeng Y, et al. Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2013; 381: 1987–2015. Ministry of Health. Health report on smoking in China 2012. Beijing: People’s Medical Publishing House, 2012. Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet 2014; 383: 1549–60.
Initial management of spontaneous pneumothorax
If you would like to respond to an article published in The Lancet Respiratory Medicine, please submit your correspondence online at: http:// ees.elsevier.com/thelancetrm
We read with interest the Article by Oliver J Bintcliffe and colleagues, who drew attention to controversial issues in the management of spontaneous pneumothorax. 1 We agree with the investigators’ statement that “Clinicians have rarely questioned how expansion of the lung aids healing of the leak”.1 If chest tube drainage is not absolutely necessary for recovery from respiratory insufficiency2 and avoidance of critical complications,3,4 and the next step in management can be selected, then the question that needs to be addressed is whether chest tube drainage or conservative observation is most effective at stopping an air leak. On the one hand, chest tube drainage is done to achieve full lung expansion, bringing wounded visceral and intact parietal pleura together. This pleural contact causes adhesion over the pleural defect, which can seal the air leak.5 On the other hand, conservative observation can keep the lung collapsed, allowing apposition of the visceral wound for healing.1,2 We presumed and, therefore, agreed with the notion that visceral leakage sites are more likely to heal if the lung remains collapsed.1 To the best of our knowledge, this idea has been proposed by some clinicians,2 but we were unable to confirm this from published research. Which methods e35
Correspondence
are most effective for stopping the air leak and preventing recurrence is a question related to the management of spontaneous pneumothorax and needs to be addressed. In cases without drainage, elucidation of whether there is an air leak is not straightforward, but is crucial for optimum initial management. In the absence of drainage, three approaches are available to elucidate whether there is an airleak: suspicion based on findings from the clinical examination, such as symptoms and oxygenation; change in the lung collapse over time; and measurement of intrapleural pressure. According to the guidelines of the American College of Chest Physicians,6 clinically stable patients with small pneumothoraxes should be observed in the emergency department for 3–6 h, and be discharged home if a repeat chest radiograph excludes progression of the pneumothorax. The collapse of the lung at a single point in time is not a simple indication of whether an air leak is ongoing. Based on our clinical experience, stronger symptoms in the patients are not directly associated with the degree of lung collapse, but might be associated with a larger change in intrapleural pressure. Once the collapsed lung has become stable, which presumably indicates that the air leak has been stopped, intrapleural pressure becomes stable, and the patient’s symptoms resolve thereafter. This is clinically well known, has not been reported, and might require further investigation. We agree with Bintcliffe and colleagues’ comments that management of primary spontaneous pneumothorax is “an exciting area of research.”1 In drawing up an adequate study design for a clinical study, we believe that it is crucial to focus on the treatment objective,3 which should guide the selection of the appropriate arm for comparison. Further research, with suitable study design, will lead to appropriate initial management of spontaneous pneumothorax. e36
We declare no competing interests.
*Hiroyuki Kaneda, Tomohiro Murakawa [email protected] Department of Thoracic and Cardiovascular Surgery, Kansai Medical University 2-5-1 Shinmachi, Hirakatashi, Osaka, 573-1010 Japan (HK, TM) 1
2
3
4
5
6
Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med 2015; 3: 578–88. Miller AC. Management of spontaneous pneumothorax: back to the future. Eur Respir J 1996; 9: 1773–74. Kaneda H, Nakano T, Taniguchi Y, Saito T, Konobu T, Saito Y. Three-step management of pneumothorax: time for a re-think on initial management. Interact Cardiovasc Thorac Surg 2013; 16: 186–92. Stradling P, Poole G. Conservative management of spontaneous pneumothorax. Thorax 1966; 21: 145–49. O’Rourke JP, Yee ES. Civilian spontaneous pneumothorax. Treatment options and long-term results. Chest 1989; 96: 1302–06. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119: 590–602.
Authors’ reply We thank Kaneda and Murakawa for their comments and share their views on the need for well designed randomised trials in patients with spontaneous pneumothorax. Existing international guidelines rely on the evidence in published reports to formulate strategies for the management of pneumothorax; the evidence is generally of poor quality, outdated, and often from nonrandomised and retrospective studies. Investigators have also tended to focus on radiological rather than patientcentred outcomes. Kaneda’s and Murakawa’s thoughts on intrapleural pressure changes correlating with symptoms are certainly thought provoking and we agree that this would be an interesting area to focus on in future research. The fact that we remain uncertain as to whether resolution of an air leak is hastened or delayed by lung re-expansion draws attention to our incomplete collective understanding of the pathophysiological processes involved. One possible reason why we are still unable to answer to this
question might be because of the variability in the resolution. Some patients might benefit from a partly collapsed lung to help seal the leak, which then allows gradual lung expansion, whereas others need pleural apposition to seal the ongoing leak. This difference might also explain why some patients benefit from chest tube suction, whereas others seem to clinically deteriorate if this is added. We do not agree that chest tube drainage is crucial in all cases of spontaneous pneumothorax to guide optimum initial management. Not only is there unequivocal evidence that some patients can be safely treated conservatively, but also admitting all patients to hospital for chest drainage is not without iatrogenic risks. We believe chest drain insertion is a somewhat ineffective means of triaging patients who need surgery for an ongoing air leak, from those who will resolve spontaneously over time. The authors’ competing interests remain the same as those declared in the original article.
Oliver Bintcliffe, Nick Maskell, *Najib Rahman [email protected] Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK (OB, NM); and Oxford Centre for Respiratory Medicine and Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford OX3 7LE, UK (NR)
Air travel in chronic conditions The report by Kathryn Senior1 on the medical challenges of flight has prompted us to report a new facility established specifically to assist patients wishing to travel by air. Among the 3·1 billion passengers who travel by air every year2 are some with severe illnesses for whom flight poses particular challenges. Existing guidelines for air travel apply to some discrete illnesses such as COPD or pneumothorax,3,4,5 and may not be as specific for some comorbidities.
www.thelancet.com/respiratory Vol 3 November 2015
Improving the prevention and management of respiratory diseases in China: the crucial role of primary care Respiratory disorders are among the leading causes of mortality in China, with an estimated 3·25 million deaths per year; chronic obstructive pulmonary disease (COPD), lung cancer, and pneumonia are the most common causes.1 Respiratory disorders were also responsible for an estimated 36·6 million disability adjusted lifeyears (DALYs) in 2010.2 This figure will continue to increase, driven by changing demographics, the high prevalence of smoking, and the effects of air pollution. The importance of primary care services and research in reducing this substantial disease burden was shown in the launch of the Chinese Thoracic Society’s Chinese Alliance for Respiratory Diseases in Primary Care in Guiyang in September, 2015. The alliance brings together key individuals from general practice, academic respiratory medicine, and primary care organisations from across China. Its launch marked an important milestone that will help to put increased emphasis on prevention and communitybased management of both noncommunicable and communicable respiratory disorders. Currently, health care is heavily concentrated in hospitals and primary care is very under developed. Key priorities for the alliance are to improve the description, understanding, and recording of the changing profile and burden of respiratory disorders in both urban and rural China. There is an urgent need to increase the numbers of family doctors in rural areas and train them for the task of managing common respiratory disorders. Development of online
teaching resources aimed specifically at the primary care workforce will be helpful. It is also crucial that essential equipment (eg, spirometers) and medicines (eg, inhaled corticosteroids and long-acting bronchodilators) are made available to frontline staff across China. Working in close conjunction with hospital specialists, there is a need to develop complete care pathways. The alliance has begun working with stakeholders. Over the long-term, we hope to align closely with and learn from similar primary care respiratory organisations in other parts of the world. We would like, particularly, to gain insights into how to challenge the tobacco industry’s strategy, in view of the huge and increasing burden from active and passive smoking in China.3,4 The alliance will also work closely with the government to develop a national roadmap for reducing the high burden of respiratory disorders in China. This development sets an example of vital partnership between hospital specialists and general practitioners. Such collaborations will be crucial in China’s effort to strengthen primary care. CW’s research is supported by the National Key Technology Research and Development Program of the Ministry of Science and Technology of China during the 12th Five-Year Plan (2012BAI05B02). CC, MY, and KKC report grants from Pfizer China, outside of the submitted work. CW reports grants from Ministry of Science and Technology, China, during the conduct of the study, and grants from AstraZeneca China, outside of the submitted work. AS declares no competing interests.
Chunhua Chi, Aziz Sheikh, Mi Yao, Kar Keung Cheng, *Chen Wang [email protected] Department of Respiratory and Critical Care Medicine, Peking University First Hospital, Beijing, China (CC); Department of General Practice, Peking University Health Science Center, Beijing, China (CC, MY, KKC); Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK (AS); Beijing Xicheng District Xinjiekou Community Health Service Center, Beijing, China (MY); Institute of Applied Health Research, University of Birmingham, Birmingham, UK (KKC); Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital Beijing, China (CW); Department of Respiratory Medicine, Capital Medical University Beijing, China (CW); and National Clinical Research Centre for Respiratory Diseases, Beijing, China (CW)
www.thelancet.com/respiratory Vol 3 November 2015
1
2
3
4
National Health and Family Planning Commission of the People’s Republic of China. China Health Statistics Yearbook 2014. Beijing: Peking Union Medical College Press, 2014. Yang G, Wang Y, Zeng Y, et al. Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2013; 381: 1987–2015. Ministry of Health. Health report on smoking in China 2012. Beijing: People’s Medical Publishing House, 2012. Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet 2014; 383: 1549–60.
Initial management of spontaneous pneumothorax
If you would like to respond to an article published in The Lancet Respiratory Medicine, please submit your correspondence online at: http:// ees.elsevier.com/thelancetrm
We read with interest the Article by Oliver J Bintcliffe and colleagues, who drew attention to controversial issues in the management of spontaneous pneumothorax. 1 We agree with the investigators’ statement that “Clinicians have rarely questioned how expansion of the lung aids healing of the leak”.1 If chest tube drainage is not absolutely necessary for recovery from respiratory insufficiency2 and avoidance of critical complications,3,4 and the next step in management can be selected, then the question that needs to be addressed is whether chest tube drainage or conservative observation is most effective at stopping an air leak. On the one hand, chest tube drainage is done to achieve full lung expansion, bringing wounded visceral and intact parietal pleura together. This pleural contact causes adhesion over the pleural defect, which can seal the air leak.5 On the other hand, conservative observation can keep the lung collapsed, allowing apposition of the visceral wound for healing.1,2 We presumed and, therefore, agreed with the notion that visceral leakage sites are more likely to heal if the lung remains collapsed.1 To the best of our knowledge, this idea has been proposed by some clinicians,2 but we were unable to confirm this from published research. Which methods e35
Correspondence
are most effective for stopping the air leak and preventing recurrence is a question related to the management of spontaneous pneumothorax and needs to be addressed. In cases without drainage, elucidation of whether there is an air leak is not straightforward, but is crucial for optimum initial management. In the absence of drainage, three approaches are available to elucidate whether there is an airleak: suspicion based on findings from the clinical examination, such as symptoms and oxygenation; change in the lung collapse over time; and measurement of intrapleural pressure. According to the guidelines of the American College of Chest Physicians,6 clinically stable patients with small pneumothoraxes should be observed in the emergency department for 3–6 h, and be discharged home if a repeat chest radiograph excludes progression of the pneumothorax. The collapse of the lung at a single point in time is not a simple indication of whether an air leak is ongoing. Based on our clinical experience, stronger symptoms in the patients are not directly associated with the degree of lung collapse, but might be associated with a larger change in intrapleural pressure. Once the collapsed lung has become stable, which presumably indicates that the air leak has been stopped, intrapleural pressure becomes stable, and the patient’s symptoms resolve thereafter. This is clinically well known, has not been reported, and might require further investigation. We agree with Bintcliffe and colleagues’ comments that management of primary spontaneous pneumothorax is “an exciting area of research.”1 In drawing up an adequate study design for a clinical study, we believe that it is crucial to focus on the treatment objective,3 which should guide the selection of the appropriate arm for comparison. Further research, with suitable study design, will lead to appropriate initial management of spontaneous pneumothorax. e36
We declare no competing interests.
*Hiroyuki Kaneda, Tomohiro Murakawa [email protected] Department of Thoracic and Cardiovascular Surgery, Kansai Medical University 2-5-1 Shinmachi, Hirakatashi, Osaka, 573-1010 Japan (HK, TM) 1
2
3
4
5
6
Bintcliffe OJ, Hallifax RJ, Edey A, et al. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med 2015; 3: 578–88. Miller AC. Management of spontaneous pneumothorax: back to the future. Eur Respir J 1996; 9: 1773–74. Kaneda H, Nakano T, Taniguchi Y, Saito T, Konobu T, Saito Y. Three-step management of pneumothorax: time for a re-think on initial management. Interact Cardiovasc Thorac Surg 2013; 16: 186–92. Stradling P, Poole G. Conservative management of spontaneous pneumothorax. Thorax 1966; 21: 145–49. O’Rourke JP, Yee ES. Civilian spontaneous pneumothorax. Treatment options and long-term results. Chest 1989; 96: 1302–06. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119: 590–602.
Authors’ reply We thank Kaneda and Murakawa for their comments and share their views on the need for well designed randomised trials in patients with spontaneous pneumothorax. Existing international guidelines rely on the evidence in published reports to formulate strategies for the management of pneumothorax; the evidence is generally of poor quality, outdated, and often from nonrandomised and retrospective studies. Investigators have also tended to focus on radiological rather than patientcentred outcomes. Kaneda’s and Murakawa’s thoughts on intrapleural pressure changes correlating with symptoms are certainly thought provoking and we agree that this would be an interesting area to focus on in future research. The fact that we remain uncertain as to whether resolution of an air leak is hastened or delayed by lung re-expansion draws attention to our incomplete collective understanding of the pathophysiological processes involved. One possible reason why we are still unable to answer to this
question might be because of the variability in the resolution. Some patients might benefit from a partly collapsed lung to help seal the leak, which then allows gradual lung expansion, whereas others need pleural apposition to seal the ongoing leak. This difference might also explain why some patients benefit from chest tube suction, whereas others seem to clinically deteriorate if this is added. We do not agree that chest tube drainage is crucial in all cases of spontaneous pneumothorax to guide optimum initial management. Not only is there unequivocal evidence that some patients can be safely treated conservatively, but also admitting all patients to hospital for chest drainage is not without iatrogenic risks. We believe chest drain insertion is a somewhat ineffective means of triaging patients who need surgery for an ongoing air leak, from those who will resolve spontaneously over time. The authors’ competing interests remain the same as those declared in the original article.
Oliver Bintcliffe, Nick Maskell, *Najib Rahman [email protected] Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK (OB, NM); and Oxford Centre for Respiratory Medicine and Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford OX3 7LE, UK (NR)
Air travel in chronic conditions The report by Kathryn Senior1 on the medical challenges of flight has prompted us to report a new facility established specifically to assist patients wishing to travel by air. Among the 3·1 billion passengers who travel by air every year2 are some with severe illnesses for whom flight poses particular challenges. Existing guidelines for air travel apply to some discrete illnesses such as COPD or pneumothorax,3,4,5 and may not be as specific for some comorbidities.
www.thelancet.com/respiratory Vol 3 November 2015