What are the American Thoracic Society (ATS) guidelines for managing pneumothorax?

Management of Spontaneous Pneumothorax: ATS/ACCP Guidelines

The American College of Chest Physicians (ACCP) published pneumothorax management guidelines in 2001 using the Delphi consensus method, which differ notably from British Thoracic Society guidelines by rarely recommending simple aspiration and instead favoring chest tube drainage for most symptomatic cases. 1

Key Differences Between ACCP and BTS Approaches

The ACCP guideline consensus process found simple aspiration to be appropriate rarely in any clinical circumstance, with only two panel members arguing that simple aspiration is usually effective for stable patients. 1 This contrasts sharply with BTS guidelines that emphasize simple aspiration as initial treatment for most pneumothoraces. 1

ACCP Management Principles

Initial Assessment

• Base treatment decisions on severity of symptoms and degree of lung collapse as determined by chest radiographs 1
• 90% of ACCP panel members did not incorporate patient age into management decisions 1

Chest Tube Management

• For patients with persistent air leaks who are not operative candidates, chemical pleurodesis through chest tube is appropriate management 1
• Doxycycline (good consensus) and talc (very good consensus) are the preferred sclerosing agents 1

Chest Tube Removal Protocol

• 41% of panel members would never clamp a chest tube to detect air leak presence after lung reexpansion 1
• Remaining members would clamp the tube 5-12 hours after last evidence of air leak 1
• Repeat chest radiograph 13-23 hours after last evidence of air leak (63% of members) to ensure pneumothorax has not recurred before tube removal 1
• Other timing preferences: 4 hours (4%), 5-12 hours (18%), or 24 hours (15%) 1

Role of CT Scanning (ACCP Recommendations)

The ACCP panel could not develop firm recommendations for CT use after first pneumothorax occurrence. 1 However, CT scanning was considered acceptable for:

• Pneumothorax recurrence (good consensus) 1
• Management of persistent air leak (some consensus) 1
• Planning surgical intervention (some consensus) 1
• Especially useful if lung volume reduction surgery is being considered as adjunctive procedure 1

Important Caveats

Comparison with BTS Guidelines

The BTS guidelines emphasize a stepwise approach: observation for minimal symptoms, simple aspiration as initial intervention, and chest tube only for aspiration failures. 1 The ACCP approach is more aggressive, favoring chest tube drainage earlier in the treatment algorithm. 1

Clinical Application

While the ACCP guidelines represent American consensus, the BTS guidelines (2003) have been more widely adopted internationally and demonstrate that adherence to conservative management can prevent approximately 7,000 unnecessary chest drain insertions annually in the UK alone. 1

Specific Populations

For secondary pneumothorax patients, both guidelines agree on more aggressive management due to underlying lung disease and poor pulmonary reserve. 1 For cystic fibrosis patients, early aggressive treatment with consideration of surgical intervention after first episode is recommended. 1

Discharge and Follow-up

• Patients should avoid air travel until chest radiograph confirms complete resolution 1, 2
• Diving should be permanently avoided unless bilateral surgical pleurectomy has been performed 1, 2
• Secondary pneumothorax patients successfully treated with aspiration should be admitted for 24 hours before discharge 1