Reply to Hallifax et al.: From Recommendations to Implementation: Also a Multidisciplinary Matter

From the Authors:

Randomized controlled studies provide the highest level of evidence. The results of these studies, when available, help feed, qualify, and determine the strength of the proposed recommendations of the clinical practice guidelines.

We designed the EXPRED (exsufflation of primary spontaneous pneumothorax versus chest tube drainage) study with this aim, and to date, this study represents the largest randomized study comparing simple aspiration versus standard thoracic drainage in first-line treatment of patients with first episodes of complete, primary pneumothorax (1). These results help inform and guide good practice recommendations for primary spontaneous pneumothorax. The study was performed in 31 emergency departments in France. During study conception, and during the course of the management and follow-up of the patients, we had to make a trade-off between rigor and flexibility: rigor because the study was randomized and controlled, and its inclusion criteria were strictly defined, and flexibility because the inclusion of patients in emergency departments remains a challenge, the overcrowded conditions making it difficult to conduct randomized controlled trials, sometimes contrary to the habits of care. Thus, the decision to keep patients for a longer or shorter time in the hospital after their inclusion in the EXPRED study was left to the discretion of the team at each center. This may explain the relatively high length of hospitalization in the aspiration arm. Moreover, a study of practice in France by Kepka and colleagues revealed that even in the absence of any procedure to evacuate intrapleural air, almost all patients remain under hospital surveillance (2).

One of the current and future difficulties is the application of the recommendations at the patient’s bedside. Many obstacles exist; the most frequently identified are awareness, familiarity, agreement, self-efficacy, outcome expectancy, ability to overcome the inertia of previous practice, and absence of external barriers to enacting recommendations (3). In the design and conduct of the EXPRED study, pulmonologists, surgeons, and emergency physicians were associated and involved. We visited the eligible centers before formal inclusion to identify the preferential management pathway that existed after the emergency visit, either pneumological or surgical. These pathways were respected in the follow-up of the patients in the EXPRED study.

The first French recommendations concerning spontaneous pneumothorax are in press (4). These recommendations are based on consensus among French societies of pneumologists, surgeons, intensivists, and emergency physicians. They define a common reference that will probably contribute to the harmonization of the management of this benign pathology and will lead to privileging ambulatory management by means of minimally invasive suction devices, allowing quick return to patients’ homes.

If standard chest drainage continues to be used at many centers, it is also because the patient’s point of view is not always the top priority. Indeed, it may seem simpler and less risky at 3 a.m. to set up a chest tube drainage and hospitalize a patient than to use an ambulatory management pathway, especially if the procedure is not well formalized.

The production of national and international recommendations is essential. They must be adopted (and probably partially adapted) at each center by all the specialists involved—pulmonologists, emergency physicians, and surgeons—to guarantee 24/7 compliance with the management algorithms inspired by the recommendations. Setting up this kind of ambulatory management is therefore a multidisciplinary affair and is the sine qua non for their effective implementation at the bedside.