Talk:Pneumothorax/GA1

GA Review

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Reviewer: Doc James (talk · contribs · email) 04:46, 16 August 2010 (UTC)[reply]

Definitely a GA article with a few adjustments

Will list them below:

~~The ACCP ref is not working?~~
A little unsure about this text "Even in cases of tension pneumothorax an X-ray is sometimes required if there is doubt about the location of the pneumothorax (which is possible)" If one truly has a tension the person should have needles placed immediately.
~~I am not sure about comments within the text that recommend "see below"~~
~~I have never pursued preventative measures. Wondering if we should describe who this is appropriate for?~~
I assume here you mean that if one wishes to continue diving they would need a pleurectomy? "An exception is diving, which requires pleurectomy (see below) as well as investigations to confirm normal lung function before it can be regarded as safe." I have always seen a previous pneumo as a contraindication. But I see the ref says "Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively. (C)"
~~Never heard of a "Asherman chest seal". We should probably describe it as Wikipedia does not have a page. Google has a bunch of images [1]~~
~~The "safe triangle" is mentioned but not described.~~

My favorite device call a pigtail catheters is not mentioned? [2]

Trying to figure out how to improve the causes section. Trauma is not mentioned. Neither is iatrogenic. I remember reading somewhere that the most common cause of a pneumothorax is positive pressure ventilation and it usually occurs on the rights side as if the ET tube goes down to fair into the primary bronchus you can end up ventilation one lung when you thing you are ventilation two. It think this was from the ATLS book. Will look when I get home.

Should we comment a little on prognosis? We have this ref saying one should not fly for two week after resolution. PMID: 10597066

Uptodate says "A primary spontaneous pneumothorax (PSP) is a pneumothorax that occurs without a precipitating event in a person who does not have known lung disease. In actuality, most individuals with PSP have unrecognized lung disease, with the pneumothorax resulting from rupture of a subpleural bleb". I guess this is why some of the cause redirects to the mechanism section.

Rosen's says suction is fine as long as the pneumothorax has been present for 3 days or less. Seem like there is slight disagreement between the two sides of the pond? :-) These sort of details however would only be needed once it gets to FA.

~~A second ref Rosen's says that Marfan's syndrome is a cause of PSP I guess implying that there is an absence of known lung disease.~~

Doc James (talk · contribs · email) 23:33, 12 August 2010 (UTC)[reply]

Nominated. I will do some more tidying up today. JFW | T@lk 07:46, 13 August 2010 (UTC)[reply]

To respond to comments:

Done ACCP reference: I got the name of the reference wrong. It was ye olde ACCP consensus guideline.
The source (Leigh-Smith) is very clear that a chest X-ray is not verboten in tension unless the patient is truly in extremis
Yes I guess it depends on how exactly one defines tension. Some restrict it to extremis. Have seen texts say that one should never see a tension pneumo on X ray as it should have already been decompressed.
I use "see below" where there is a concept that will be defined later on in the article in the right context rather than clarifying it on the spot. It has not previously been a problem, but I agree that I've had to resort to this a few times to keep the article flowing.
The sources are quite vague about who should actually be offered prevantative measures. That's why I phrased it in that way - a diver would much prefer intervention, while a young non-smoker with PSP might defer unless a further episode occurs.
Done I'll rephrase the statement about diving.
Done I hadn't heard of Asherman seals until I saw it in the source. I'll expand on it.
Done Safe triangle now clarified
The sources don't readily describe the various devices available. All I felt was necessary was to distinguish between small and large caliber tubes, and even then this is difficult to source.
These are all mentioned in the text (mostly sourced to Noppen and Leigh-Smith), but I didn't make a separate section in the "causes" section. Will do that later on today.
I didn't want to give specific time frames for flying because of the controversy. As UpToDate says, the actual evidence on which these recommendations are based is flimsier than flimsy.
All recent reviews (Noppen, Tschopp, BTS) cast doubt on the role of blebs. PSP causes no other symptoms of lung disease either. I have therefore discussed this in the context of "mechanism".
I left suction vague because various sources are indeed in disagreement (ACCP vs BTS) in the absence of real evidence.
I don't think you can answer that question. Everyone always screams "Marfan's!" whenever a tall chap comes in with a pneumothorax, and everyone always makes an effort to point at the slightly high-arched palate, the possible arachnodactyly and the increased arm span. In reality, I can't remember any one them where they were formally evaluated for Marfan's with genetics and echocardiography. Have you got evidence that pneumothorax can be the the first presentation of otherwise clinically silent Marfan's?

Let me know what else needs to be fixed. I will be back online tomorrow night BST. JFW | T@lk 16:10, 13 August 2010 (UTC)[reply]

Should the section title "Prevention" be retitled "Prevention of recurrence" or "Secondary prevention" for clarity?Yobol (talk) 02:25, 14 August 2010 (UTC)[reply]

I'd like to keep the title consistent with WP:MEDMOS. The text is self-explanatory. JFW | T@lk 22:39, 14 August 2010 (UTC)[reply]

We had this same discussion on the gout page during GA. I have no problem with primary and secondary prevention being discussed under prevention. If primary prevent it should go before treatment, if secondary prevention after treatment section IMO.Doc James (talk · contribs · email) 09:20, 15 August 2010 (UTC)[reply]

RexxS

I read through the article and was just about to offer to review it, but James beat me to it! I've a few suggestions for improvement that you may wish to consider anyway:

There are a couple of acronyms ("VATS" and "CT scan") that don't seem to be defined anywhere near where they are used. I'd recommend spelling them out on first use (even if "CT scan" is probably common enough to be recognised by many).
I see that you have made a classification in the Signs and symptoms section – was this a deliberate choice not to include a Classification section?
All medical articles contain jargon, and you've gone a long way to explain many terms either parenthetically or by wikilink, but there may be a few that need a little more explanation ("in emphysema and clusters of endometrial cells in catamenial pneumothorax" struck me in the Mechanism section).
As a scuba diver, the dangers of pneumothorax are strongly emphasised in the training; is "breath-holding during ascent" a cause that is worth mentioning? If so, I'll dig out some refs if you need them.

Hope this is helpful --RexxS (talk) 02:07, 16 August 2010 (UTC)[reply]

Thank you. Some quick responses (will catch up with any corrections tonight):

Done Will sort out the acronym situation
Giving a classification would cause a lot of duplication. There is already a lot of duplication between "signs & symptoms" and "causes".
Done Have simply removed the confusing jargon
This was not mentioned in any of my sources, but let me know if you have a reliable source for this advice. As with flying, much of this is the stuff of anecdote.

Cheers, JFW | T@lk 06:00, 16 August 2010 (UTC)[reply]

Diving-related PTX is a rare occurrence, but is well-documented. The "bible" of diving medicine, Bennett & Elliott, discusses it the context of pulmonary barotrauma:

Brubakk, Alf O; Neuman, Tom S, eds. (2003). Bennett and Elliott's physiology and medicine of diving, 5th Rev ed. United States: Saunders. pp. 561–563. ISBN 0702025712.

The danger of PTX for divers is present even on very shallow dives:

Air embolism with bilateral pneumothorax after a five-meter dive

and it's interesting that treatment consisted of recompression to 3 bar on 100% O2 while the PTX was being drained. The discussion section there gives some insight to the complications likely to arise in the diving setting. Pulmonary overinflation syndrome is a group of related conditions including PTX, since in diving, the insult to the lungs caused by air expansion is almost certain to produce additional conditions (AGE probably being the most serious):

Pulmonary overinflation syndrome in an underwater logger

There are quite a few other sources. Anyway, you may feel that the diving-related area is too specialised to include here; I'll leave that to your judgement. I'll ping Gene Hobbs to ask for the best sources if you do want to include something. Cheers --RexxS (talk) 14:05, 16 August 2010 (UTC)[reply]

Gene has replied with some interesting information, although you'll have to estimate how much you want to include here, see User talk:Gene Hobbs#Pneumothorax --RexxS (talk) 19:03, 16 August 2010 (UTC)[reply]

Could you make an edit on diving practices causing pneumothorax? I think Bennett & Elliott is the only one of the above that qualifies as a WP:MEDRS. JFW | T@lk 20:14, 16 August 2010 (UTC)[reply]

Unless anyone has further comments I see nothing here that would limit this articles promotion to GA.Doc James (talk · contribs · email) 22:12, 20 August 2010 (UTC)[reply]

I know I've promised to add a few words about pneumothorax and diving, but I've just not found a good stretch of time when I can read through the sources Gene has pointed me to, and I have to do that before I can be confident of what I write. In any case, I really think that's sort of a 'niche' issue, and I certainly don't think there's any bar to GA status for the article. I do promise I'll add a bit more about diving-related pneumothorax before it gets to FA :) --RexxS (talk) 23:52, 20 August 2010 (UTC)[reply]