Comparison of different methods of size classification of primary spontaneous pneumothorax
Correspondence / American Journal of Emergency Medicine 36 (2018) 319–338 327
Lee CC, Lin WJ, Shin JI, Wu CJ, Chen PL, Lee HC, et al. Clinical significance of potential contaminants in blood cultures among patients in a medical center. J Microbiol Immunol Infect 2007;40:438-44.
Comparison of different methods of size classification of primary spontaneous
pneumothorax?
In literature there are few guidelines in management of Primary Spon- taneous Pneumothorax (PSP): the British Thoracic Society (BTS) [1], the American College of Chest Physicians (ACCP) [2], the Belgian Society of Pulmonology (BSP) [3] and the Spanish Society of Pulmonology and Tho- racic Surgery (SEPAR) [4] guidelines. In the asymptomatic patients, the de- cision to intervene can be considered on the basis of the size of the PSP. Unfortunately, there is no unique method of measuring the size of a PSP.
We would to compare the classification of PSP into “small” or “large” groups using the four international guidelines. We verified the agree- ment between an ultrasound measuring method (US) and the guide- lines; and between the “ideal” management on the basis of the BTS guideline and the “real life” practice.
A retrospective cohort of adult patients with PSP evaluated in our Emergency Department (annual census 30,000 patients) from January 1, 2011 to December 31, 2016, was considered. Participants were select- ed from the electronic archive of all the patients visited in the consid- ered period. We excluded the patients with traumatic or secondary pneumothorax. Data collected included was shown in Table 1.
BTS guidelines classify a “large” PSP when the Interpleural distance at level of the hilum is N 2 cm; ACCP instead when the apex to cupola distance is N 3 cm; BPS and SEPAR when the separation between the vis- ceral and parietal pleura occurs throughout the Pleural cavity. For US method we used the technique of Volpicelli et al. [5].
We calculated the global and pair-wise agreement using the Cohen’s K coefficient (respectively, Cohen-Fleiss and Cohen). A multiple comparisons analysis through a Tukey’s test (adjusted for Westfall’s correction), using Generalized linear models with binomial distribution, was achieved (p– value <=0.05). To assess the agreement between US and radiographic evalu- ation and the correlation between the "ideal" therapeutic management ac- cording to the BTS guidelines and the current practice, was used the Cohen's K coefficient. All statistical analysis was conducted using R-CRAN project ver. 3.4.0 (packages: "multcomp", "sandwich", and "irr").
In the considered period we studied 39 patients with PSP. See Table 1. The global agreement between the guidelines was discrete (K = 0.47); the pair-wise K for agreement is shown in Table 2. The difference between BTS and ACCP was statistically significant (p = 0.03) (Fig. 1). The agree- ment between the US and the different guidelines were: US vs BTS 0.47, US vs. ACCP 0.67 and US vs. BSP/SEPAR 0.84 (Table 3). The agreement be- tween the “real-life” practice and the BTS guideline was poor (K = 0.27).
The guidelines are sufficiently unanimous in considering the size of PSP
determinant to management: “large” PSP must be managed with an inva- sive approach. However, a univocal method in order to measure the size of PSP does not exist yet. All the guidelines recommend the chest x-ray as initially technique to estimate the size but the methods are different. For BTS guidelines only 7 in 49 PSP are “large”, but for other guidelines as BSP 29 in 49 are so [6]. Furthermore the agreement in the measurement of the size of the PSP through the chest x-ray is very poor, even among experts [7]. The agreement between the different guidelines is globally discrete, but it is very poor between two of the most widely used guidelines as BTS and ACCP. This means that, at least theoretically, very different therapeutic ap- proach could be applied according to which guidelines is followed. If this in- fluences somehow the rate of recurrences or the incidence of complications is currently unknown.
? Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Table 1
Main characteristics of the population. The continuous variables are expressed in median (IQR), nominal and categorical variables are expressed in percentage. yy = years; M = male; dd = days. Dys = dyspnoea; BTS = large according to BTS guidelines; CT: computed tomography
Age (yy; IQR) Gender (% M) |
30 (22 / 50) 74.4 |
|
Symptoms (%) |
Dyspnoea |
5.1 |
Chest pain |
69.2 |
|
Cough |
0 |
|
Dys + chest pain |
12.8 |
|
Cough + chest pain |
2.6 |
|
SpO2 (% in room air; IQR) |
Asymptomatic |
10.3 99 (97 / 100) |
Type |
Spontaneous |
87.2 |
Iatrogenic |
12.8 |
|
Side (% right) |
51.3 |
|
BTS (% large) |
48.7 |
|
Lung point (%) |
Emiclavear line |
5.9 |
Anterior axillary line |
17.6 |
|
Midaxillary line |
11.8 |
|
Posterior axillary line |
5.9 |
|
No lung point |
58.8 |
|
Therapy |
Observation |
15.4 |
Aspiration |
20.5 |
|
Drainage |
64.1 |
|
Chest CT (%) |
20.5 |
|
Hospitalization (%) |
76.9 |
|
Duration of hospitalization (dd; IQR) |
3 (2 / 4) |
|
Follow up (%) |
23.1 |
Table 2
Pair-wise agreement between the four international guidelines (Cohen K coefficient). We considered poor agreement for K values between 0 and 0.4; discrete between 0.4 and 0.6; good between 0.6 and 0.8 and excellent between 0.8 and 1. BTS: British Thoracic Society; ACCP: American College of Chest Physicians; BPS: Belgian Society of Pulmonologists; SEPAR: Spanish Society of Pulmonology and Thoracic Surgery.
BTS |
ACCP |
BSP |
SEPAR |
|
BTS |
0.29 |
0.44 |
0.44 |
|
ACCP |
0.29 |
0.38 |
0.38 |
|
BSP |
0.44 |
0.38 |
1 |
|
SEPAR |
0.44 |
0.38 |
1 |
Table 3 Agreement between measurement through thoracic ultrasound and the four international guidelines (Cohen’s K coefficient). We considered poor agreement for K values between 0 and 0.4; discrete between 0.4 and 0.6; good between 0.6 and 0.8 and excellent between
0.8 and 1. US: thoracic ultrasound; BTS: British Thoracic Society; ACCP: American College of Chest Physicians; BPS: Belgian Society of Pulmonologists; SEPAR: Spanish Society of Pulmonology and Thoracic Surgery.
BTS |
ACCP |
BSP |
SEPAR |
|
US |
0.47 |
0.67 |
0.84 |
0.84 |
Some authors have proposed the US as method for measuring of the size of PSP [5-8,9]. Volpicelli and colleagues have shown that a lung point – which is the point in which the pleural sliding reappears – be- hind the anterior axillary line correlates with a collapse of the pulmo- nary parenchyma greater than the 15% [5]. We shown the US classification varies depending on which guideline is taken as a refer- ence: agreement is only discreet for BTS, but excellent for PSP/SEPAR. Further perspective randomized studies should be conducted with the purpose to clarify this aspect that seems to be promising.
The adherence to guidelines in the “real life” practice is very poor. This result seems to be common to other studies of such kind, also con- sidering different guidelines [6,10,11]. We are not able to affirm that this determines a different, neither worse neither best, outcome. We believe that this aspect would deserve to be investigated and clarified, at least with an international consensus.
328 Correspondence / American Journal of Emergency Medicine 36 (2018) 319–338
Clinical evaluation and management of acute corrosive poisoning in adult patients – A ten year experience
To the Editor:
Fig. 1. Pair-wise multiple comparions among confidence Iintervals of the four international guidelines. The comparison between BTS and ACCP is significant (p = 0.03). Bg: Belgian Society of Pulmonologists (BSP); A: American College of Chest Physi- cians (ACCP); Bt: British Thoracic Society (BTS); S: Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).
Giulia Montanari Daniele Orso * Nicola Guglielmo Roberto Copetti
Department of Emergency Medicine, AAS 2 “Bassa Friulana – Isontina“, Hospital of Latisana, via Sabbionera 45, 33053 Latisana, Udine, Italy
*Corresponding author.
E-mail address: [email protected] (D. Orso)
8 July 2017
https://doi.org/10.1016/j.ajem.2017.07.065
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Acute poisonings with corrosive substances cause various chemical injuries along the entire upper gastrointestinal tract and they can be ei- ther superficial or destructive, often leading to serious and fatal complica- tions, such as perforation. The outcome of these intoxications depends on the severity of the injuries, clinical state of the patient and obtainability of adequate medical treatment [1-3]. Unfortunately, acute corrosive poison- ings in adults have high mortality rates and still remain serious medical and social problem. Patients with acute corrosive poisonings can face with serious Acute complications, such as extensive bleeding, perforation or necrosis, during the first 96 h, whereas late post-corrosive complica- tions, such as development of fistulas, stenosis or strictures can be seen during the first 3 weeks. Outcome and prognosis of these poisonings are very uncertain, although today we have contemporary and sophisti- cated management protocols [4,5].
We demonstrate to you the most important results collected from our ten years study, conducted at the University clinic for toxicology and ur- gent internal medicine, in Skopje, Macedonia. In the period between years 2005 and 2017 we had a total of 6716 patients with different kinds of intoxications, from which 747 (11.47%) were patients intoxicated with corrosive agents. All of these patients were hospitalized in the inten- sive care unit for initial and urgent reanimation and in order to perform the urgent Upper endoscopy, during the first 12-24 h in the majority of patients. According to the endoscopic findings, using the Kikendal’s clas- sification, patients were divided in five groups (Table 1).
Every group has its own protocol for evaluation, treatment and clin- ical follow-up.
All of our patients went through a psychological counseling, since the majority of them ingested corrosive Chemical agents with suicidal intention. According to Kikendal’s classification 69 patients (9.33%) were clas- sified as having grade I post-corrosive injuries, 277 (37.08%) with grade IIA, with grade IIB were 215 (28.78%), 150 (20.08%) with grade III and 36 (4.8%) with grade IV injuries. Patients classified with grade I injuries remained hospitalized, immediately put on a liquid diet and closely ob- served during the first 48 h. Patients with grade IIA injuries remained in the intensive care unit and were treated with parenteral antibiotics, antacids and vitamins. All of them received nutritive support as supple- mentary parenteral nutrition. After a hospitalization in duration of 7- 10 days they went through a control upper endoscopy and depending on the findings they remained hospitalized or were discharged and controlled on a follow-up after 3 months. Patients with grade IIB and III injuries also remained in the intensive care unit; they were put on parenteral or enteral nutrition (esophageal rest) until the first endoscopic control (usually after 15-20 days). After this critical period we can liberalize the nutrition, depending on the endoscopic and radiological findings. We performed specialized radiological studies using gastrografin to exclude strictures and stenosis. In patients in whom we had detected initial esophageal stenosis we placed feeding jejunostoma, in collaboration with an abdominal surgeon. This device can be used for an eventual long-term enteral nutritive support, which
Table 1
KIkendal’s classification.
Grade Endoscopic finding
Grade I Mucosal Erythema and edema
Grade IIA Hemorrhage, erosions and superficial damages
Grade IIB Circumferential lesions
Grade III Deep brownish, grey or black ulcers
Grade IV Perforation