Provide explicit expert-based consensus recommendations for the management of adults with primary and secondary spontaneous pneumothoraces in an emergency department and inpatient hospital setting. The use of opinion was made explicit by employing a structured questionnaire, appropriateness scores, and consensus scores with a Delphi technique. The guideline was designed to be relevant to physicians who make management decisions for the care of patients with pneumothorax.

The strength of any recommendation depends on two factors: the trade-off between benefits and risks, and the strength of the methodology that leads us to estimates of the treatment effect. The framework that we used for this conference captures these factors. We grade the trade-off between benefits and risks in two categories: (1) the trade-off is clear enough that most patients, despite differences in values, would make the same choice; and (2) the trade-off is less clear, and each patient's values will likely lead to different choices. We grade methodologic strength in three categories: (1) randomized trials, ideally summarized in a meta-analysis, that show consistent results; (2) randomized trials with inconsistent results; and (3)observational studies. The framework summarized in Table 1 therefore generates recommendations from the very strong (1A: benefit/risk clear, methods strong) to the very weak (2C: benefit/risk questionable, methods weak). Whatever the grade of recommendation, clinicians must bring their judgment considering local and individual patient circumstances, and patient values, to bear in making individual decisions. In general, however, they should place progressively greater weight on expert recommendations as they move from 2C to 1A.

A panel was convened by the Health and Science Policy Committee of the American College of Chest Physicians to develop a clinical practice guideline on the medical and surgical treatment of parapneumonic effusions (PPE) using evidence-based methods.

The Infectious Diseases Society of America (IDSA) has published guidelines for the treatment of community-acquired pneumonia (CAP). Although Streptococcus pneumoniae remains the most common etiologic agent, Chlamydia pneumoniae and Legionella pneumophila are also important causes. For all suspected CAP patients, particularly those requiring hospitalization, chest radiographs are strongly recommended to confirm the diagnosis. The IDSA guidelines, in contrast to those published by the American Thoracic Society, emphasize the use of sputum Gram's stain and culture in all patients, whenever possible, to establish etiology. This information can be used not only to guide therapy but also to track trends in the etiologic pathogens for CAP and their antibiotic susceptibility. In light of the better outcomes with the earliest possible interventions, the IDSA recommends initial empiric antimicrobial therapy until laboratory results can be obtained to guide more specific therapy. Macrolides, doxycycline, and fluoroquinolones are suggested for primary empiric therapy, since each has activity against common bacterial pathogens and atypical agents. Detailed antibiotic recommendations are made for various pathogens. For inpatients, attempts should be made to cover Legionella and other common pathogenic bacteria. Alternative antibiotics are recommended for patients with structural diseases of the lung, penicillin allergy, or suspected aspiration pneumonia. Switch to an appropriate oral antibiotic is recommended as soon as the patient's condition is stable and he or she can tolerate oral therapy, often within 72 h.

In 1997, the National Heart, Lung, and Blood Institute released the Second Expert Panel Report on the Guidelines for the Diagnosis and Management of Asthma as a follow-up to the first report issued in 1991. Implementation of the recommendations from this report could have a potentially huge impact on care and treatment of asthma in the United States. Even though the Guidelines are expansive, there are some areas related to the pharmacologic component that warrant further discussion and clarification. These are: (1) safety and efficacy of available asthma medications, (2) clinical efficacy comparisons of inhaled corticosteroids, (3) comparative risks among inhaled corticosteroids, and (4) expectations of different delivery systems used with inhaled corticosteroids.

Guidelines for the use of nebulizers outside of the hospital were developed at the request of the Health Care Financing Administration (HCFA) to assist in the preparation of Medicare criteria for reimbursement. The National Association for Medical Direction of Respiratory Care (NAMDRC) convened a consensus conference in Leesburg, Va, with physician representatives from the major medical organizations involved in adult and pediatric respiratory care. Members of the health-care industry also were invited to participate. After review of the pertinent references, members of the faculty were preassigned topics for presentations during the first day of the meeting. Three workshops were organized to address segments of the consensus statement and to develop written reports. Each report was reviewed by the entire group and then finalized. The Consensus Conference recommends that a metered-dose inhaler (MDI) with reservoir chamber is the preferred mode of aerosol therapy for patients outside of the hospital. The circumstances under which a small-volume nebulizer (SVN) may be appropriate are described. The medications that may be administered by SVN are identified with recommendations as to the usual doses to be prescribed. A cost analysis of the various modes of aerosol therapy is presented. These guidelines should be of value to physicians who are prescribing aerosol therapy in the home and also to policy makers who are developing guidelines for reimbursement.