Wikipedia:Featured article candidates/Pneumothorax/archive1

The following is an archived discussion of a featured article nomination. Please do not modify it. Subsequent comments should be made on the article's talk page or in Wikipedia talk:Featured article candidates. No further edits should be made to this page.

The article was not promoted by SandyGeorgia 16:37, 24 January 2012 [1].

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Pneumothorax

Pneumothorax (edit | talk | history | protect | delete | links | watch | logs | views)

• Featured article candidates/Pneumothorax/archive1

Nominator(s): JFW | T@lk 10:16, 1 January 2012 (UTC)

I am nominating this for featured article because I believe it is a pretty comprehensive take on a condition that is fairly well understood and affects a wide range of people in an even wider range of situations. It has been stable for quite some time, after I expanded it last summer, and had the benefit of a thorough GA review (with some useful expansion) by Doc James around that time. I'm hopeful that I have covered the current evidence base as good as possible. Thanks to everyone in advance for your comments. JFW | T@lk 10:16, 1 January 2012 (UTC)

• Comments by Axl:

  • Thanks for your thorough review Axl, as well as for corrections and improvements already made. I will be responding to each comment in turn but not necessarily in order. I will review the sources where necessary. I hope you don't mind that I've formatted the points & responses here with bullet points etc. JFW | T@lk 13:50, 4 January 2012 (UTC)

  • From the lead section, paragraph 3: "In larger pneumothoraces or when there are severe symptoms, the air may be aspirated with a syringe." I'm not sure that general readers will understand what "aspirated" means in this context. Axl ¤ [Talk] 12:02, 1 January 2012 (UTC)
    • Done. Already changed to "extracted", I believe by Snowmanradio. JFW | T@lk 13:50, 4 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 1: "It is exceedingly uncommon for PSP to cause tension pneumothorax." Why not say "It is rare for PSP to cause tension pneumothorax"? Axl ¤ [Talk] 12:13, 1 January 2012 (UTC)
    • Done. Agree that "exceedingly" may be too much hyperbole. JFW | T@lk 13:50, 4 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 1: "Tall males, especially smokers, have a higher risk of PSP." The reference (Tschopp) does not state that being tall is a risk factor. Nor does it explicitly state that being male is a risk factor, though this could be inferred by comparing the incidence in males against the incidence in females. Bearing in mind that males tend to be taller than females, it certainly doesn't state that tall males have a higher incidence than (equally) tall females. Axl ¤ [Talk] 12:36, 3 January 2012 (UTC)
    • Done. I have removed it, as the same information is also covered in the PSP subsection under "causes". The height issue is covered in BTS (2010), but the references don't really support it. One is from 1964 (which I cannot access), but the second reference only discusses recurrence. PMID 7300447 is an older Mayo Clinic study that stated that the difference between men and women is mainly a function of their height. JFW | T@lk 00:18, 8 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 1: "It has been found that PSP occurs more commonly during changes in atmospheric pressure and during exposure to loud music." I don't see any need for the first part of the sentence: "It has been found that ...". However this would create repetition of "PSP" with the preceding sentence. Axl ¤ [Talk] 12:17, 1 January 2012 (UTC)
    • Done. Removed redundant text while avoiding duplication of "PSP" in serial sentences. JFW | T@lk 13:50, 4 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 3: "It has been found to occur in half of all cases of injury to the chest". Why not say "It occurs in half of all cases of chest injuries"? Axl ¤ [Talk] 13:59, 1 January 2012 (UTC)
    • Actually the reference (Noppen) states "Pneumothorax [occurs] in up to 50% of chest trauma victims", which isn't the same as "it occurs in half of all cases of injury to the chest". Axl ¤ [Talk] 18:59, 1 January 2012 (UTC)
    • Done. Noppen says "Pneumothorax ranks second to rib fracture as the most common sign of chest trauma, occurring in up to 50% of chest trauma victims". I have rephrased "injuries to the chest" to "chest trauma" to align it closer to the original. JFW | T@lk 00:18, 8 January 2012 (UTC)
      • "Up to 50%" is not the same as "occurs in half". Axl ¤ [Talk] 15:34, 9 January 2012 (UTC)
        • Done. Changed. JFW | T@lk 20:29, 9 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 2: "the unaffected lung is generally not capable of replacing the loss of function from the affected side. Hypoxemia (decreased blood oxygen levels) is usually present". These statements are not supported by the reference (Tschopp). Axl ¤ [Talk] 13:25, 3 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 3: "coming second after rib fracture in the complications after chest trauma." Rib fracture is not a "complication" of chest trauma. The source (Noppen) did not state that. Axl ¤ [Talk] 11:11, 2 January 2012 (UTC)
    • Done. Rephrased. JFW | T@lk 00:18, 8 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 3: "The pneumothorax can be small (occult) in half of these cases." Does "occult" simply mean "small" in this context? The reference (Noppen) does not define "occult". Axl ¤ [Talk] 20:45, 2 January 2012 (UTC)
    • I have removed the word "occult" because it adds nothing to the meaning of the sentence. Whether occult or not, small pneumothoraces are risky if positive pressure ventilation is planned. JFW | T@lk 13:50, 4 January 2012 (UTC)
      • I am uncomfortable with using the word "small". The reference uses the word "occult", not "small". Ths BTS guideline defines "small" as a rim of air less than 2 cm around, which is not the intent here. Axl ¤ [Talk] 20:10, 4 January 2012 (UTC)
    • Done. That's the trouble with the use of the word "small". I have changed it back, using the word "occult". I have however used the description "(not readily apparent)" because most people will not understand the word "occult" without a clarification. JFW | T@lk 00:18, 8 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 3: "It is also often encountered in those already receiving mechanical ventilation." I am not convinced. Neither reference (Noppen & Leigh-Smith) supports that statement. Axl ¤ [Talk] 21:28, 2 January 2012 (UTC)
    • Done. Noppen says that 7% of iatrogenic pneumothoraces are the result of positive pressure ventilation. Leigh-Smith says that in 5.4% cases of tension pneumothorax in major trauma victims, 64% of cases were in ventilated patients. I agree that Leigh-Smith does not make a causal connection, and Noppen does not say that tension is common. I have made changes to reflect this. JFW | T@lk 00:18, 8 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Clinical subtypes", paragraph 4: "Tension pneumothorax is defined differently by different sources, but is generally said to exist when there is severe hypoxia despite administration of oxygen, falling blood pressure or confusion." Leigh-Smith does not support that statement. It indicates that low SpO₂ occurs in fewer than 25% of cases. Axl ¤ [Talk] 22:13, 2 January 2012 (UTC)
    • Done. I see what you mean. Leigh-Smith provides a definition ("significant respiratory or haemodynamic compromise (the latter especially in ventilated patients) that reverses on decompression alone") but also a list of symptoms aggregated from case reports and case series. I have now changed the section to mention both the definition (tension = respiratory or haemodynamic compromise) and the list of symptoms. I hope that this is clearer. JFW | T@lk 22:33, 8 January 2012 (UTC)
      • "Tension pneumothorax ... is generally said to exist when there is significant impairment of respiration or blood circulation." Presumably this is when it is due to pneumothorax? How about "Tension pneumothorax ... is generally said to exist when pneumothorax significantly impairs respiration or blood circulation."? Axl ¤ [Talk] 16:03, 9 January 2012 (UTC)
        • Done. Agree, although for a clinician it may be difficult to state with absolute confidence whether clinical deterioration is attributable to a pneumothorax unless there is improvement with treatment. (E.g. hypotension due to splenic laceration etc.) JFW | T@lk 20:29, 9 January 2012 (UTC)
          • Indeed. There are many reasons for trauma patients to develop respiratory failure or circulatory shock. Thanks for clarifying this. Axl ¤ [Talk] 21:06, 9 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Physical examination", paragraph 2: "In very severe cases, the respiratory rate falls sharply, with shock and coma." The reference (Leigh-Smith) does not indicate the presence of shock. Box 12 in the reference includes "hypotension" as a pre-terminal feature. However hypotension is not the same as circulatory shock. Axl ¤ [Talk] 23:11, 3 January 2012 (UTC)
    • Done. I have rephrased this extensively on re-reading; I have moved all tension-related content to a subsection, because it is a distinct clinical scenario that can emerge (theoretically) in any patient with a pneumothorax. I agree that hypotension does not equate shock and I have changed this around. JFW | T@lk 22:33, 8 January 2012 (UTC)
  • From "Signs and symptoms", subsection "Physical examination", paragraph 2: "Particular clinical signs may also be less useful in the recognition of tension pneumothorax, such as the deviation of the trachea (windpipe) to one side and the presence of raised jugular venous pressure (distended neck veins)." Those signs were not previously mentioned as helpful in the diagnosis of (tension) pneumothorax. Also, the phrase "such as" implies that there are more signs that could be listed. Axl ¤ [Talk] 11:56, 3 January 2012 (UTC)
    • Done. Rephrased: Leigh-Smith and Harris are concerned that these signs are taught as being characteristic in tension, and attempt to set the record straight. Let me know if you agree with the new version. JFW | T@lk 22:33, 8 January 2012 (UTC)
  • In "Cause", subsection "Secondary spontaneous", I think that the list of associated lung diseases would be better presented as a table. similar to the various sources. Tschopp has a nice table that we could duplicate. Axl ¤ [Talk] 15:46, 3 January 2012 (UTC)
    • Done. Indeed, the current list of causes is almost entirely from Tschopp, with catamenial pneumothorax taken from Noppen. I have turned it into a nice table. JFW | T@lk 00:33, 9 January 2012 (UTC)
  • In "Cause", subsection "Secondary spontaneous", there is extensive discussion of Birt–Hogg–Dubé syndrome. This is a rare syndrome, and a rare cause of pneumothorax. The article's text constitutes undue weight. One of the references used is "Birt–Hogg–Dubé syndrome: diagnosis and management". This is not a relevant source for the article on "Pneumothorax". Axl ¤ [Talk] 15:51, 3 January 2012 (UTC)
    • I don't think I agree with the assessment of WP:UNDUE. The Robinson source (pneumothorax in kids) certainly mentions familial pneumothorax due to FLCN mutations, and the fact that Birt-Hogg-Dubé syndrome - although rare - is associated with pneumothorax, FLCN mutations, and a number of other problems. While rare in absolute terms, I believe we need to discuss familial pneumothorax and its associated syndrome. I used the Lancet Oncology reference to provide a little bit more information about BHD, which I believe is not unreasonable, especially with Robinson providing the necessary context. JFW | T@lk 13:50, 4 January 2012 (UTC)
      • Fishman's Pulmonary Diseases and Disorders does not mention Birt–Hogg–Dubé syndrome. However Fishman does state "Genetic risk factors that have been associated to [sic] PSP include the HLA haplotype A₂B₄₀, the α1-antitrypsin phenotypes M₁M₂, and the FBN1 gene mutations." In my opinion, that's a good indicator of the relative importance of Birt–Hogg–Dubé syndrome.
      • Light's Pleural Diseases does actually have a paragraph on Birt–Hogg–Dubé syndrome and the other FLCN mutation syndrome, as well as mentioning HLA A₂B₄₀.
      • Cystic fibrosis is also familial and much more common than Birt–Hogg–Dubé syndrome. However you aren't advocating an extended discussion of CF's clinical features in this article.
      • In my opinion, Birt–Hogg–Dubé syndrome deserves two sentences in this article. I also recommend a mention of HLA A₂B₄₀, and possibly α1-antitrypsin M₁M₂ and FBN1. Axl ¤ [Talk] 21:36, 4 January 2012 (UTC)
        • I have no direct access to Light's. Could I persuade you to add a line about HLA A₂B₄₀? Is there a proposed mechanism for this association?
        • I did not provide details on CF because in the majority of cases the patient will already have received a diagnosis of CF prior to their first pneumothorax. The emphasis on Birt-Hogg-Dubé is mainly because it ties in with the FLCN mutations. JFW | T@lk 20:20, 5 January 2012 (UTC)
          • I have added a statement about HLA A₂B₄₀. The references do not propose a mechanism.
          • I agree that Birt–Hogg–Dubé syndrome carries a higher risk of pneumothorax than CF does. However this review states that 24–38% of Birt–Hogg–Dubé patients have a history of spontaneous pneumothorax. Therefore in the majority of Birt–Hogg–Dubé cases, the patient will already have a diagnosis of Birt–Hogg–Dubé syndrome prior to their first pneumothorax. In any case, that isn't my main point. It is the rarity of the syndrome that should guide the weight given to it in this generic article about "Pneumothorax". What proportion of "new" pneumothoraces are due to a new diagnosis of Birt–Hogg–Dubé syndrome? Of course no-one really knows because the syndrome is so rare. Axl ¤ [Talk] 16:20, 6 January 2012 (UTC)
            • Done. I have found a lovely reference (doi:10.1097/01.mcp.0000230630.73139.f0) that discusses all causes of familial pneumothorax. I have ditched Menko in favour of this reference because it is actually better for the purposes of this article. This source (from Curr Opin Pulm Med) also discusses α₁-antitrypsin deficiency and homocystinuria as well as Marfan's, Ehlers-Danlos and Birt-Hogg-Dubé, and talks about the FLCN mutations in people with familial pneumothorax who have no other stigmata of BHD. I do hope this is better. The one thing I still need a solution for is adding α₁/homocystinuria and BHD to the "secondary causes" table. Whaddaya think? JFW | T@lk 00:33, 9 January 2012 (UTC)
              • Thanks, that's a reasonable compromise. I don't think that there is any value in shoehorning α1AT deficiency, homocystinuria or BHD into the main table. They aren't in the main reference's table (Tschopp). I accept catamenial pneumothorax because it is mentioned in Tschopp, although not in the table. Axl ¤ [Talk] 14:56, 10 January 2012 (UTC)
  • From "Cause", subsection "Traumatic": "Medical procedures of the chest (iatrogenic), such as the taking of biopsy samples from lung tissue, inserting a central venous catheter into one of the chest veins, may lead to injury to the lung and resultant pneumothorax." The grammar of this sentence is faulty. "Iatrogenic" does not mean "medical procedures of the chest". Biopsy sampling of lung tissue always leads to injury of the lung. (Well, I suppose that it depends of your definition of "injury".) Yet the overwhelming majority of lung biopsies do not lead to pneumothorax. Is it really "injury to the lung" that leads to the pneumothorax? Actually lung biopsies are taken by one of two broad routes: either radiologically-guided (typically CT-guided) or via bronchoscopy. Bronchoscopic lung biopsy rarely leads to pneumothorax, especially as CT-guided biopsy has become widely preferred for peripheral lesions. Axl ¤ [Talk] 16:07, 3 January 2012 (UTC)
    • Done. I have tightened up on the phrasing. I agree that lung injury is not required for pneumothorax. An air tract (e.g. a jugular venous catheter or a Trucut needle) is sufficient and breach of the parietal pleura by definition. JFW | T@lk 00:33, 9 January 2012 (UTC)
      • Thanks, although the grammar is still incorrect. Axl ¤ [Talk] 15:06, 10 January 2012 (UTC)
        • I'm not sure how the grammar could be improved. Please advise. JFW | T@lk 22:52, 14 January 2012 (UTC)
          • Someone has now fixed the grammar. Axl ¤ [Talk] 22:39, 15 January 2012 (UTC)
  • From "Mechanism", paragraph 1: "The lungs are physically connected at the hila, where the airways and blood vessels enter the lung." This implies that the lungs are connected to each other at the hila. Axl ¤ [Talk] 16:09, 3 January 2012 (UTC)
    • Done. Of course you and I know exactly what is intended, and the lungs are in a sense connected at the hila through the large vessels and the airways. But I struggled to make this sentence logically comprehensible, and decided to see what would happen if I removed it. JFW | T@lk 00:33, 9 January 2012 (UTC)
  • From "Mechanism", paragraph 1: "They remain inflated inside the thoracic cavity because the pressure inside the pleural space (the potential space between the chest wall and the lung) is almost consistently negative throughout the respiratory cycle, effectively sucking the lung to the chest wall." That's a rather simplistic explanation, and not supported by the reference (Noppen). Noppen actually gives a good explanation for the lack of gas flow into the pleural space during normal function. The other reason why the lungs remain inflated is because the pressure inside the airways is higher than that of the pleural space, for which there are two further reasons. I suppose that the full explanation is beyond the scope of the general article on "Pneumothorax". Axl ¤ [Talk] 22:05, 3 January 2012 (UTC)
    • When I wrote it, I decided to cite almost verbatim from Noppen (because it sounded very straightforward). Please advise whether I should retain this or rephrase it in some way or another. I do agree that extensive discussion of respiratory physiology might be out of proportion. JFW | T@lk 00:33, 9 January 2012 (UTC)
      • How about "The thoracic cavity is the space inside the chest that contains the lungs, heart and major blood vessels of the chest. On each side of the cavity, a pleural membrane covers the surface of lung (visceral pleura) and also lines the inside of the chest wall (parietal pleura). Normally, the two layers are separated only by a small amount of lubricating serous fluid. The lungs are fully inflated within the cavity because the pressure inside the airways is higher than the pressure inside the pleural space. Despite the low pressure in the pleural space, air does not enter it because there are no natural connections to an air-containing passage, and the pressure of gases in the bloodstream is too low for them to be released into the pleural space. Pneumothorax can therefore only develop if air is allowed to enter, either through damage in the chest wall, or damage to the lung itself, or occasionally because microorganisms in the space produce gas." Axl ¤ [Talk] 20:00, 10 January 2012 (UTC)
        • Done. This sounds quite a lot clearer. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Mechanism", paragraph 2: "Various lines of evidence suggest that this hypothesis may not be correct, such as the fact that pneumothorax may recur even after surgical treatment of blebs, and that blebs occur in 15% of healthy people. It has therefore been suggested that PSP is instead caused by areas of disruption (porosity) in the pleural layer, which are prone to rupture." Neither Noppen nor Tschopp deny the possibility that bleb rupture can lead to pneumothorax. Rather, they suggest that some pneumothoraces are caused by pleural porosity. Axl ¤ [Talk] 22:17, 3 January 2012 (UTC)
    • Done. I might have been misled by Noppen's statement that "although alternative explanations are available" and some comments by Tschopp that could also be interpreted as such. I have modified the section accordingly. JFW | T@lk 00:33, 9 January 2012 (UTC)
  • From "Mechanism", paragraph 2: "Once air has stopped entering the pleural cavity, it is gradually resorbed spontaneously. Estimated rates of resorption are between 1.25% and 2.2% the volume of the cavity per day. This would mean that even a completely collapsed lung would spontaneously reinflate over a period of about 6 weeks." I'm not convinced that this is relevant to the "Mechanism" section. Perhaps move it to the "Prognosis" section? Wait, there is no "Prognosis" section? Axl ¤ [Talk] 22:22, 3 January 2012 (UTC)
    • I bunched this together as it seemed to be part of the natural history of the condition. I think it might be very appropriate in the subsection on conservative management, but I will await such a move until I've heard your views. A prognosis section might be relevant to discuss the risk of recurrence etc., but I hope you might agree that the prognosis of an individual episode of pneumothorax might be more suitable for the "management" section. JFW | T@lk 00:33, 9 January 2012 (UTC)
      • I'm not sure what you mean by "the prognosis of an individual episode of pneumothorax". Fishman includes mortality rates for PSP, COPD, CF & AIDS. These certainly could be included in a "Prognosis" section. Light's Pleural Diseases has details on the success rate of needle aspiration and chest tube in PSP. Light also includes recurrence rates for men vs women & smokers vs non-smokers. I am reluctant to include the somewhat speculative time estimate for re-inflation of a completely collapsed lung, because no doctor would treat that with conservative management. Light estimates 12 days for a 15% pneumothorax.
      • I would be happy to write a "Prognosis" section along these lines if you think that it would be helpful. Axl ¤ [Talk] 21:33, 10 January 2012 (UTC)
        • The BTS guideline uses the 6 weeks example to illustrate the "tincture of time" effect in PSP. By extension, a smaller pneumothorax would take less long (but they are not saying that). The word "even" is used to indicate this. I have moved the relevant sentence to the "Management/conservative" section where it is most relevant. I agree that we need a "prognosis" section, but I was hoping to reserve that for the rates of recurrence rather than the natural history of individual episodes. JFW | T@lk 22:52, 14 January 2012 (UTC)
          • "By extension, a smaller pneumothorax would take less long (but they are not saying that)." Actually it's the other way round. Small/medium pneumothoraces resolve at the quoted rate. By extension, a full pneumothorax might resolve in six weeks. The BTS guideline states "Thus, a complete pneumothorax might be expected to take up to 6 weeks to resolve spontaneously and, conceivably, in the presence of a persistent air leak, even longer." So it might take six weeks, less than six weeks, or more than six weeks. In my opinion, this speculation is unhelpful. Axl ¤ [Talk] 22:09, 17 January 2012 (UTC)
  • From "Mechanism", paragraph 3: "A previously uttered theory that the collapsed lung compresses large blood vessels such as the aorta is probably incorrect." The reference (Leigh-Smith) does not state that. Leigh-Smith states that the dog models that demonstrated early hypotension from great vessel obstruction probably aren't directly applicable to humans. Leigh-Smith goes on to say that in awake humans, hypotension is rare, at least in the absence of other significant pathology. In this group, there was no evidence of great vessel obstruction. However in ventilated patients, "the decreased cardiac output ... is probably attributable to a combination of hypoxaemia, diminished blood flow through the collapsed lung, reduced venous return, and possibly great vessel/ventricular compression." Axl ¤ [Talk] 23:47, 3 January 2012 (UTC)
    • Done. Rephrased and restructured. I have avoided citing the dog models, but used the clinical descriptions that generally point at a primary respiratory deterioration and respiratory arrest following a period of compensation. I have omitted the circulatory features, as they are clearly less common. JFW | T@lk 00:33, 9 January 2012 (UTC)
  • From "Diagnosis", subsection "Chest X-ray", paragraph 1: "It is not unusual for the mediastinum (the structure between the lungs that contains the heart and several other organs) to be shifted away from the affected lung due to pressure." "Several other organs"? Axl ¤ [Talk] 00:06, 4 January 2012 (UTC)
    • Done. Agree that "several other organs" is redundant, especially because the thymus is not really relevant here and retrosternal goitre is rare. Changed to "heart and great blood vessels". JFW | T@lk 13:50, 4 January 2012 (UTC)
  • From "Diagnosis", subsection "Chest X-ray", paragraph 2: "The size of the pneumothorax, i.e. the amount of space in the chest taken up by free air rather than air-containing lung." Wht not say "the volume of air in the pleural space"? Axl ¤ [Talk] 00:11, 4 January 2012 (UTC)
    • Done. Agree, sounds altogether less clumsy. JFW | T@lk 13:50, 4 January 2012 (UTC)
  • From "Diagnosis", subsection "Chest X-ray", paragraph 2: "An air rim of 2 cm means that the pneumothorax occupies about 50% of the pleural cavity." I think that it should be 50% of the hemi-thorax. Oddly though, the BTS guideline is unclear about this. It only states "a 2 cm radiographic pneumothorax approximates to 50% pneumothorax by volume." Axl ¤ [Talk] 10:02, 4 January 2012 (UTC)
    • Done. Agree; changed. JFW | T@lk 13:50, 4 January 2012 (UTC)
      • It is debatable whether the volume referred to is the hemi-thorax or the volume of the fully inflated lung. However given the inherent error of the estimate, it probably doesn't matter. Axl ¤ [Talk] 12:21, 11 January 2012 (UTC)
  • From "Diagnosis", subsection "Ultrasound", "Four particular features on ultrasonography of the chest can be used to confirm or exclude the diagnosis." Either include the list of these four features, or delete the sentence. Axl ¤ [Talk] 16:03, 4 January 2012 (UTC)
    • Done. I have replaced "four" with "several", because Volpicelli quite clearly lists the features that a sonographer can use to diagnose or exclude pneumothorax. JFW | T@lk 00:33, 9 January 2012 (UTC)
      • Okay. Axl ¤ [Talk] 12:25, 11 January 2012 (UTC)
  • In "Treatment", the picture of the man with a chest drain isn't quite right. The drain is placed too far anteriorly. There is no slack between the "omental tag" attached to the side of the abdomen and the entry point on the chest wall. Axl ¤ [Talk] 09:40, 5 January 2012 (UTC)
    • I also thought that the drain should be in the mid-axillary line, especially for a "text-book" illustration. I did not notice that there was no slack between the fixing, but your comment sounds logical. I suppose the image should be removed, because it is misleading. Snowman (talk) 13:58, 5 January 2012 (UTC)
    • The image also does not reflect my personal practice (it was drawn by User:Robertolyra), but I do not agree that it is completely wrong. The drain is still in the "safe triangle" as outlined in the BTS guideline, and the use of omental tags and leaving slack between the drain site and the tag seems to depend on personal practice. JFW | T@lk 20:44, 5 January 2012 (UTC)
      • Many doctors do not know where/how to insert a chest drain correctly, or how to affix it. The picture is incorrect and misleading. It should be deleted from Wikimedia Commons. Axl ¤ [Talk] 10:19, 6 January 2012 (UTC)
        • The drain is placed anteriorly, but it is still in the safe triangle. Should we therefore not use it? And why should there be slack between the entry point and the omental tag? Surely the more slack the higher the risk of it getting caught on something? Please clarify. Feel free to nominate it for deletion on commons. It would be a shame because it is otherwise a good image. I have moved it to the talk page for specific discussion, and will try to find a better image. JFW | T@lk 11:33, 8 January 2012 (UTC)
          • I do not believe that the drain is placed in the safe triangle. From the BTS guideline on chest drain insertion: "An omental tag of tape has been described which allows the tube to lie a little away from the chest wall to prevent tube kinking and tension at the insertion site." There needs to be some slack between the omental tag and the entry point through the chest, so that tension on the distal part of the tubing/bottle does not pull the drain out of the chest. Rather, such tension would tend to pull on the omental tag, which can be more easily replaced than the drain itself. (By the way, the diagram that supposedly shows the safe triangle, Figure 3, is incorrect.)
          • I already have asked for its deletion. However, given my lack of success in trying to engage with Wikimedia Commons participants in the past with other erroneous images, I don't expect anyone will even notice, let alone take any action. Axl ¤ [Talk] 16:23, 11 January 2012 (UTC)
            • Because you have removed the picture, I am striking this point. Axl ¤ [Talk] 15:14, 17 January 2012 (UTC)
              • I have made a formal request for this image to be deleted from commons. Snowman (talk) 11:24, 20 January 2012 (UTC)
  • From "Treatment", paragraph 1: "In spontaneous pneumothorax, air travel is discouraged until it has completely resolved." That's not really a treatment. Rather it is secondary prevention. Axl ¤ [Talk] 16:07, 4 January 2012 (UTC)
    • I believe it is most appropriate to discuss the safety of air travel in the context of the management of an episode of pneumothorax. The content of secondary prevention mainly discussion prevention of further episodes. JFW | T@lk 11:33, 8 January 2012 (UTC)
      • Okay, fair enough. How about creating a new subsection (perhaps "Aftercare"?) at the end of the "Treatment" section to discuss air travel, diving and smoking advice? By the way, the BTS guideline also suggests that air travel should be avoided for at least one week after resolution of the pneumothorax. Axl ¤ [Talk] 22:38, 11 January 2012 (UTC)
        • Done. I have followed your advice and grouped all this into a single section. I have also included the anticipated time off work from an occupational medicine textbook. JFW | T@lk 23:43, 19 January 2012 (UTC)
  • From "Treatment", paragraph 2: "In traumatic pneumothorax, chest tubes are usually inserted (unless iatrogenic, see below)." I don't think that the caveat ("unless iatrogenic") is required. In traumatic pneumothorax, chest tubes usually are inserted. Axl ¤ [Talk] 10:04, 5 January 2012 (UTC)
    • This is because Noppen states that iatrogenic pneumothoraces can be aspirated. I agree that it is distracting and I have removed it. JFW | T@lk 11:33, 8 January 2012 (UTC)
  • From "Treatment", paragraph 2: "It is not yet clear if there is a subgroup of people with small pneumothoraces who do not require tube treatment and could be managed conservatively." I don't think that this sentence adds anything. Perhaps delete it? Axl ¤ [Talk] 10:51, 5 January 2012 (UTC)
    • Done. It's mainly based on Noppen. I agree that until there is consensus we cannot really discuss this. JFW | T@lk 13:08, 8 January 2012 (UTC)
  • From "Treatment", paragraph 2: "If mechanical ventilation is required, the insertion of a chest tube is mandatory as it would increase the risk of tension pneumothorax." Mechanical ventilation increases the risk of tension pneumothorax; insertion of a chest tube does not increase the risk of tension pneumothorax. Axl ¤ [Talk] 16:10, 4 January 2012 (UTC)
    • Done. I agree that was confusing. JFW | T@lk 11:33, 8 January 2012 (UTC)
  • From "Treatment", paragraph 3: "Any open chest wound is covered, as it carries a high risk of leading to tension pneumothorax." Is this specific to chest injury? Perhaps move it to a new paragraph? Axl ¤ [Talk] 17:39, 5 January 2012 (UTC)
    • Done. I've moved this to the paragraph on traumatic pneumothorax as it is not only pertinent to tension (although its intention is of course to prevent tension). JFW | T@lk 13:08, 8 January 2012 (UTC)
  • From "Treatment", subsection "Conservative": "This approach is most appropriate if the estimated size of the pneumothorax is small (e.g. <50%)." Should this be "i.e. <50%"? Axl ¤ [Talk] 11:33, 6 January 2012 (UTC)
    • Done. Agree. Replaced with "(defined as <50%)". JFW | T@lk 13:08, 8 January 2012 (UTC)
      • How about "(defined as less than 50% of the volume of the hemi-thorax)"? Axl ¤ [Talk] 12:06, 12 January 2012 (UTC)
        • Done. Followed your advice there. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Treatment", subsection "Chest tube", paragraph 1: "In spontaneous pneumothorax, small-bore (smaller than 14 FG, 4.7 mm diameter) tubes may be inserted.... In traumatic pneumothorax, larger tubes (28 FG, 9.3 mm) are used." I haven't seen the abbreviation "FG". The BTS guideline uses the abbreviation "F". Most drain packets use either "F", "Fr" or "Ch". Axl ¤ [Talk] 18:44, 6 January 2012 (UTC)
    • Done. Quite right. While we use "French gauge" in conversation, "F" or "Fr" or "C(h)" seems to be the written convention. This is also pointed out on French catheter scale. Changed. JFW | T@lk 13:08, 8 January 2012 (UTC)
  • From "Treatment", subsection "Chest tube", paragraph 3: "In SSP, surgery may be required earlier." How about "Failing this, surgery may be required, especially in SSP." Axl ¤ [Talk] 21:50, 10 January 2012 (UTC)
    • Done. Agree that this works better. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Prevention", paragraph 1: "the decision depends largely on the suspected risk of recurrence. They however are often recommended after a second pneumothorax." The reason that pleurodesis is often recommended after the second pneumothorax is because the risk of further recurrence is much higher. Therefore the word "however" isn't really appropriate. Axl ¤ [Talk] 12:17, 12 January 2012 (UTC)
    • Done. Agree. I've removed the word. JFW | T@lk 22:52, 14 January 2012 (UTC)
      • Thanks. I have adjusted the sentence. Axl ¤ [Talk] 12:34, 16 January 2012 (UTC)
  • From "Prevention", paragraph 1: "An exception applies in those who engage in diving; diving is considered unsafe unless permanent treatment has been applied; professional guidelines suggest that pleurectomy is performed on both lungs (see below) and that lung function tests and CT scan must be normal before diving is resumed." Can this long sentence be split? Axl ¤ [Talk] 12:20, 12 January 2012 (UTC)
    • Done. Wasn't hard. Agree that there was an overdose of semicolons in that one. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Prevention", paragraph 2: "The best results, with a recurrence rate less than 1%, are achieved with a thoracotomy." The BTS guideline quotes a rate of "approximately 1%". Axl ¤ [Talk] 22:36, 12 January 2012 (UTC)
    • Done. Thanks. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Prevention", paragraph 2: "The best results, with a recurrence rate less than 1%, are achieved with a thoracotomy (surgical opening of the chest) with identification of any clear air leak." What does "clear" mean in this context? Axl ¤ [Talk] 12:24, 12 January 2012 (UTC)
    • Done. I imagine the thoracic surgeon can't always see the site of the air leak. If it is evident ("clear") it can be addressed directly. It works fine in a clearer, rephrased form though. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Prevention", paragraph 2: "Thoracotomy is always performed under a general anesthetic." I'm not sure why that needs to be mentioned. Axl ¤ [Talk] 12:25, 12 January 2012 (UTC)
    • Done. I added it because Tschopp mentions it. At the same time, I agree that people probably understand that operations are done under an anaesthetic these days. Hence removed. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Prevention", paragraph 3: "A less invasive approach is thoracoscopy, usually in the form of a procedure called video-assisted thoracoscopic surgery. This also involves a general anesthetic but the lung is approached through small incisions between the ribs." It is not clear if "general anesthetic" refers to VATS specifically or thoracoscopy in general. Medical thoracoscopy is performed under sedation, without general anaesthesia. However medical thoracoscopy is infrequently used to achieve pleurodesis following pneumothorax because VATS has better success. Interestingly, Fishman's Pulmonary Diseases and Disorders states "Those patients who are high risk (elderly or significant underlying lung disease) can undergo this procedure [VATS] under local and epidural anesthesia." The BTS guideline states "[VATS] can be undertaken without general anaesthesia." However I have not heard of VATS being performed without general anaesthesia in my region. In any case, I don't think that the comment about "general anesthetic" is very helpful. Perhaps delete it? Axl ¤ [Talk] 21:34, 12 January 2012 (UTC)
    • Done. In contrast to thoracotomy, this may not be common knowledge because quite a few vague similar procedures (e.g. OGD) are done under sedation only. At the same time, because the section mentions both direct and video-assisted thoracoscopy I agree that we cannot comment too extensively on it. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • From "Prevention", paragraph 3: "The results from VATS-based pleural abrasion are slightly worse than those achieved by thoracotomy, but achieved with smaller scars in the skin." In the absence of any other statement, this implies that the only benefit of VATS (vs thoracotomy) is cosmetic. Arguably VATS may be preferable due to better tolerance from the patient, less pain, shorter post-operative recuperation, and lower cost. Axl ¤ [Talk] 22:44, 12 January 2012 (UTC)
    • Done. Have added some advantages from BTS. Cost is not mentioned there. JFW | T@lk 22:52, 14 January 2012 (UTC)
      • The BTS guideline includes the statement "A complicated meta-analysis of three retrospective studies and one prospective study comparing the cost of open thoracotomy versus VATS (not exclusively for pneumothoraces) concluded that the total economic cost of VATS was lower". Fishman states "While the risks associated with general anesthesia remain, overall costs [of VATS] are generally less than thoracotomy owing to a decreased postoperative period." Axl ¤ [Talk] 15:56, 17 January 2012 (UTC)
  • From "Prevention", paragraph 4: "Not everyone may be prepared to undergo surgery." While that is true, it is rarely the reason why individual patients do not have surgery. Usually it it because the patient is unfit for surgery/general anaesthesia. Axl ¤ [Talk] 11:45, 13 January 2012 (UTC)
    • Done. I have removed the sentence, which was mainly intended to clarify why anyone would need medical pleurodesis. I think the paragraph works without this sentence. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • The "Epidemiology" section could be expanded. There is more information available in Light's Pleural Diseases and Fishman's Pulmonary Diseases and Disorders. I would be happy to add this extra information. Axl ¤ [Talk] 13:52, 3 January 2012 (UTC)
    • Would be much appreciated, Axl. JFW | T@lk 13:50, 4 January 2012 (UTC)
  • From "Epidemiology": "The annual incidence of PSP is 18–28 per 100,000 in males." I accept that Tschopp states this incidence. However both Light and Fishman quote a Minnesota study, with an age-adjusted incidence of 7.4 per 100,000 per year for males. Tschopp refers to the BTS guideline. Ironically, the BTS guideline refers to the same study in Minnesota: Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Axl ¤ [Talk] 14:05, 3 January 2012 (UTC)
    • Many sources cite the limited epidemiological data for the UK and USA, with higher rates reported in the UK, based on pretty ancient data. I am secretly hoping that your additions based on Light may resolve this. JFW | T@lk 00:33, 9 January 2012 (UTC)
      • I have changed the figures to those used by Light, Fishman and Melton. Axl ¤ [Talk] 21:00, 19 January 2012 (UTC)
  • From "Epidemiology", paragraph 1: "The incidence in children ... is estimated to occur at an incidence of 5 to 10 per 100,000." Is that per year? Axl ¤ [Talk] 11:55, 13 January 2012 (UTC)
    • Done. Was presuming that incidence without modifier was annual, but have clarified. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • The "History" section seems a little brief. I'll see if I can dig up some more info. Axl ¤ [Talk] 11:57, 13 January 2012 (UTC)
    • Thanks. This is probably better covered in the textbooks. JFW | T@lk 22:52, 14 January 2012 (UTC)
      • I think that the history section could include diagnosis and mortality rates prior to X-ray. Snowman (talk) 19:35, 16 January 2012 (UTC)
  • In "References", some journal abbreviations have full stops (periods) while others do not. Axl ¤ [Talk] 11:53, 16 January 2012 (UTC)
    • Done. I have simply expanded the names of the journals, which I think is kinder to the lay reader while taking up very little extra space. JFW | T@lk 20:06, 16 January 2012 (UTC)
  • Reference 12 (Scalea, "Focused Assessment with Sonography for Trauma (FAST)") has a long list of authors while other references (11: Baumann, 17: Neumar) use et al. Reference 10 (Wolf) has five authors. Axl ¤ [Talk] 11:58, 16 January 2012 (UTC)
    • Done. All papers with over four authors now have three authors followed by et al. JFW | T@lk 20:06, 16 January 2012 (UTC)
  • From "In other animals": "Tension pneumothorax ... [is] followed by insertion of a chest tube and closure of the incision." How do you close the incision while a chest tube is going through? Axl ¤ [Talk] 16:19, 20 January 2012 (UTC)
    • I imagine that the drain is not actually inserted through the incision, which is only made to relieve the tension. I will try to rephrase this to avoid confusion. It's straight from Merck. JFW | T@lk 22:11, 21 January 2012 (UTC)

• Regarding "plural pneumothoraces": this is illogical as each person has only one thorax unless, perhaps one is speaking of pneumothorax occurring in multiple people. Pneumothorax may be unilateral or bilateral. --24.84.113.11 (talk) 06:41, 3 January 2012 (UTC)
  • Yes, it probably could be explained better and include the unilateral and bilateral possibilities. Snowman (talk) 12:21, 4 January 2012 (UTC)
  • I found the comment above stuck on to the top of the FAC, which had removed the title page from the FAC list. I hope I've corrected it now, but please review the page history to make sure all is in order. SandyGeorgia (Talk) 02:54, 4 January 2012 (UTC)
  • Response: the convention seems to be to discuss terminology upfront. I agree that in biology the word "thorax" refers to the entire upper body, but a pneumothorax is said to involve only one hemithorax. Because the plural of "pneumothorax" is non-standard, I think it is entirely reasonable to clarify that "pneumothoraces" is the plural form. In clinical practice, someone with a pneumothorax in both lungs is said to have "bilateral pneumothoraces", while someone who has repeated episodes is said to have "recurrent pneumothoraces". With regards to Snowmanradio's comment, I think the opening sentence is not the place to discuss the distinction between unilateral pneumothorax and bilateral pneumothoraces. JFW | T@lk 13:50, 4 January 2012 (UTC)
    • Perhaps, not in the introduction, but "bilateral" is not used anywhere in the article. Snowman (talk) 14:05, 4 January 2012 (UTC)
      • I will ensure the point is covered somewhere in the article. JFW | T@lk 19:48, 4 January 2012 (UTC)

• Comments from RexxS: I'm aware that I promised to add some material relating to pneumothorax in scuba diving, before FAC, and I apologise for my failure to do so. It is fortunately a rare enough occurrence that its present omission should not be sufficient to cause concern over the comprehensiveness of this article.
  • The images would benefit from alt text. --RexxS (talk) 19:28, 4 January 2012 (UTC)
    • Done. JFW | T@lk 21:21, 15 January 2012 (UTC)
  • I'm disappointed at the amount of jargon that has crept back into this article since the GAN, and I'm particularly concerned at the WP:jargon in the lead. Comparing this version (28 December 2011) with today's version (4 January 2011) shows a significant loss of readability for the general audience. In particular: --RexxS (talk) 19:28, 4 January 2012 (UTC)
  • "in the chest between the layers of the pleura, which are normally closely applied". This makes little sense to anyone not trained in medical jargon and requires a click-through a link to discover what pleura are (and that requires a high level of reading comprehension in itself - serous membrane indeed!). We actually need a Google search to find out what "normally closely applied" might mean. The previous text was "in the pleural cavity of the chest between the lung and the chest wall" and may have been less exact, but at least gave us an idea of what we are talking about, without having to follow two depths of click-through to accomplish the same result. --RexxS (talk) 19:28, 4 January 2012 (UTC)
    • How can you misunderstand; "normally closely applied"? Note the "plural cavity" is a misnomer and I think it is easily misunderstood. In health "plural cavity" is a potential space. I expect a reader would need to be trained in medical jargon to understand "plural cavity", and "plural cavity" has the extra layer of difficulty being a misnomer. In the comment above, I do not understand; "and that requires a high level of reading comprehension in itself - serous membrane indeed!". I really think that we should not be happy about text that is "less exact". I agree that the anatomy of the pleura is easier to visualise than to describe in a few words, but I think that introduction would benefit from having the word "pleura", and a simple explanation of what pleura are. Pleura is wikilinked, so I do not think that a reader would necessarily need to do web-searches to understand any part of the introduction. Snowman (talk) 12:45, 5 January 2012 (UTC)
      • First of all "normally closely applied" is two adverbs and a past particle which taken together make no sense at all in everyday use. applied: 1. having a practical purpose or use; derived from or involved with actual phenomena ( distinguished from theoretical, opposed to pure): applied mathematics; applied science. 2. of or pertaining to those arts or crafts that have a primarily utilitarian function, or to the designs and decorations used in these arts. Now how do you qualify that with the adverb "closely" and make any sense of "normally closely applied"? Is my inability to comprehend clear enough for you now? I had to do a Google search to find examples of how the phrase is used in medicine for it make some sense, and I'd be willing to bet that I'm not the only reader who would have to do that.
      • We need not worry here about the fine distinction of potential spaces in the term "pleural cavity". That's an issue for the Pleural cavity article, not for the lead of Pneumothorax (where the space is very real, of course). My complaint is that you feel it is sufficient to wiki-link a piece of jargon, and remove the words "that separates the lung from the chest wall" which went a long way to explaining the pleural cavity to the lay reader. In fact when you click-through to Pleural cavity, you are greeted with a further layer of jargon, thus: "The pleura is a serous membrane", which requires another click-through for most readers. Where does it end? and hence my contempt for the practice of assuming readers are going to interrupt their reading every few lines to attempt to make sense of another word that they have never encountered before.
      • I understand that we should not be happy about text that is "less exact", but we should not pursue that goal at the expense of text that is incomprehensible to the majority of readers. We can always explore inexactitudes in the body of the article, and I reject any suggestion that we should sacrifice readability for absolute precision in the lead of any article. I believe that the appropriate advice is expressed in WP:JARGON: Avoid excessive wikilinking (linking within Wikipedia) as a substitute for parenthetic explanations such as the one in this sentence. Do not introduce new and specialized words simply to teach them to the reader, when more common alternatives will do. --RexxS (talk) 16:44, 5 January 2012 (UTC)
        • The relevant definition is probably lower on the page you cite, "to be placed or remain in contact". The phrase may be more typical in British English.
        • The series of adverbs is perfectly acceptable. "These structures are normally closely applied" is grammatically no more complicated than "In this doctor's office, the wait time is normally very extended." WhatamIdoing (talk) 15:59, 6 January 2012 (UTC)
          • Except that definition 14 at Dictionary.com has only an example of applying paint, where the sense is the action of application, not of position as it is used in the medical context. I am British and have been speaking the language since the 1950s, yet I have not previously encountered the past participle/adjective "applied" used in the sense of "near to" before. Please understand that my lack of experience with medical jargon does not imply that I am unable to parse English grammar, but the issue is not of grammatical complexity but of writing text where an ordinary English word (applied) is deployed in a manner found nowhere else in common speech. You might as well be writing "In this doctor's office, the appointment times are normally closely applied." and expect readers to divine a meaning. Plain English, please. http://www.youtube.com/watch?v=m_mDTLphIVY --RexxS (talk) 16:31, 6 January 2012 (UTC)
            • I think that you are doing a good job in helping us to rephrase "every-day medical language" on Wiki medical articles. I would be interested to know your opinion on the heading "Signs and symptoms". The MEDMOS guidelines suggest "Characteristics" as an alternative. "Signs" used in this contex has a very precise meaning in medicine and I guess it could easily cause difficulty to non-medcial readers. Snowman (talk) 10:58, 7 January 2012 (UTC)
              • Yes, "signs" has a precise meaning here, such that the lay reader almost certainly would not appreciate the distinction between a sign and a symptom, and I suspect that most readers would lump them together in their minds as symptoms. Nevertheless, when taken together as a heading, I don't think that anyone would be surprised or confused by the content that follows in that section. From my point of view, I associate "characteristics" with a property of something (perhaps an unique or defining property), for example: "In England post boxes are characteristically red". So, in the medical context, "characteristics", having the meaning of signs or symptoms, is also being used in a narrower sense. In everyday speech I might say "A long recovery time is characteristic of Rheumatic fever", but I'm not sure that a long recovery time would qualify as a sign or symptom? Anyway, what I'm trying to convey is my slight preference for Signs and symptoms as a lay-friendly section header, but that represents only my own opinion. Hope that helps. --RexxS (talk) 16:10, 7 January 2012 (UTC)
  • Do we have to say "compromise respiration" when "make breathing difficult" or something similar is far easier to comprehend? --RexxS (talk) 19:28, 4 January 2012 (UTC)
    • Done. I have rephrased this. JFW | T@lk 00:33, 9 January 2012 (UTC)
    • I think that this part of your feed back has been helpful. I now see how to improve the introduction, but it is not in the way you have suggested. Excuse me, I do not always predict how lay people will misunderstand the text. Using technical words become a way-of-life. I think that most people would use "breathing" for the muscular actions of breathing. In pneumothorax (unilateral small and moderate perhaps) the external appearances of breathing are not significantly affected. The compromised elements are not the muscular actions of breathing. Inflation and deflation of the lung during breathing is what is compromised. The problem is that a lung that is partly surrounded by a pneumothorax is not fully ventilated. It is somewhat more accurate to say "respiration is compromised", but I see that you did not see why I chose these words. I have copy edited the introduction keeping it simple to help people understand the abnormality better. Please re-read the introduction and I hope that you will be able to understand the abnormality better, and feed-back would be welcome. Snowman (talk) 13:47, 5 January 2012 (UTC)
  • "the internal mid-line chest structures" – would it be bad to actually tell the reader what these are? --RexxS (talk) 19:28, 4 January 2012 (UTC)
    • I have added what the big ones are. However, is misses out masses of lymphatic vessels, lymph glands and nerves, the pericardium, the thymus, and loads more. I think that "the internal mid-line chest structures" is more accurate and I would have guessed that most people would have some inkling of what it meant? It is a narrow path between accuracy and over-simplification. Snowman (talk) 14:51, 5 January 2012 (UTC)
    • Done. Rephrased. JFW | T@lk 00:33, 9 January 2012 (UTC)
  • There are other less severe examples in the lead and many more examples throughout the text. While I know that some degree of jargon is unavoidable in medical articles, I don't accept that it is inevitable in the lead in this case, and I'd urge contributors to consider why they chose to employ a particular specialised word when a more generally understandable construction may be available. Words such as 'iatrogenic' and 'mediastinum', when found in image captions are examples of where a concise term is useful (takes less space), but the opportunity has been missed to link them to their definitions. --RexxS (talk) 19:28, 4 January 2012 (UTC)
    • The decision to rewrite the lead was not mine. There were also references that disappeared (I like at least a few references in the lead section). I will address the stylistic issues that you pointed out in an upcoming edit. JFW | T@lk 19:48, 4 January 2012 (UTC)
      • I know you were not responsible for that rewrite and perhaps you will take my comments as an endorsement for your earlier version which I feel was much more readable. I understand the tension that occurs in medical FACs between a concise medical term and an often more wordy or less precise construction that is immediately comprehensible to a broader audience. We had recent confirmation in the Signpost of the quality of our medical articles, but we were criticised for being the least readable of the online sources. It is a distinct failing of the Wikipedia:Featured article criteria that they do not directly address the issue of readability, but that should not stop us from aspiring to do the best we can for content that is to be recognised as Wikipedia's very best. --RexxS (talk) 00:12, 5 January 2012 (UTC)
        • Please report all the difficult jargon that you find. Jargon can be usually easily copy-edited by someone that understands the subject. My edits have already been copy-edited and I expect further enhancements can be made. There is no need for references in the introduction. Snowman (talk) 12:51, 5 January 2012 (UTC)
          • This might be slightly more meta than what is sought, but unfortunately as drafted currently the article requires someone to have come via the Collapsed lung redirect for it to become clear that a pneumothorax is in fact one of the most common conditions, all of which can be known as a collapsed lung. Clearly the medical term is the most accurate, however it does not promote the best understanding of the article to refuse to address the fact that if a person says "collapsed lung" they are almost certainly referring to a pneumothorax. I did try to have a discussion on the talk page but it doesn't appear there has been any significant response thusfar. BigHairRef | Talk 22:35, 6 January 2012 (UTC)
        • In view of recent comment in edit history (see this edit), I reinterate that there is not need for in-line references in the introduction. I think that in-line references tend to stiffle copy-editing and should not be added back. Snowman (talk) 11:42, 7 January 2012 (UTC)
• Thanks for all the efforts to meet the concerns that I raised. I am able to strike all of the specific ones. Although jargon is always the bug-bear of technical articles, I'm happy with the readability of the article now, and I'd urge contributors to do their best to maintain that in future. Accessibility is good: the use of text, images, tables, and colours meets or exceeds our guidelines at WP:ACCESS and the W3C recommendations at WCAG AAA level. From those two perspectives, I'd support the promotion of this article. --RexxS (talk) 22:45, 15 January 2012 (UTC)

• The article structure is not entirely according to MEDMOS. I suggest conformity with a heading structure indicatad in MEDMOS. (I have also indicated improvements and omissions): Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Classification: May also be placed as a subheading of diagnosis, where there is a "Subtypes" heading in the article. I think that a "Classification" would be better in a section of its own as in the layout here. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Signs and symptoms or Characteristics
  • Causes:
  • Pathophysiology or Mechanism
  • Diagnosis: Differential diagnosis is not included (ie dd of chest pain). I think more should be made of clinical diagnosis (for medium and larger pneumothoraces), as some parts of the world may not have easy access to radiology. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Prevention or Screening (if the section only discusses secondary prevention it should follow the treatment section). Clearly surgery and other treatments here are secondary prevention, so this section is mostly mistaken and its contents should be included in "Management". Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Treatment or Management: This might include any type of currently used treatment, such as diet, exercise, medication, palliative care, physical therapy, psychotherapy, self care, surgery, watchful waiting. Section missing. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Prognosis This section is missing. Could include rates of recurrence. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Epidemiology: factors such as incidence, prevalence, age distribution, and influence of gender.
  • History: Early discoveries, historical figures, and outdated treatments (not patient history). I think that it would be worthwhile and interesting to discuss diagnosis prior to radiology. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Society and culture: There may be some notable cases. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • Research directions: If any. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • In special populations, such as In the elderly or In pregnancy or In children. This section is missing. Snowman (talk) 12:07, 5 January 2012 (UTC)
  • In other animals - section missing. Snowman (talk) 12:07, 5 January 2012 (UTC)
    • Response: thanks for your comments. Firstly, MEDMOS does not demand that certain sections are included. In the case of this article, placing "classification" first would lead to a section that is near enough incomprehensible to the reader, because it would necessitate discussion of concepts that are only defined further down in the article. Therefore, the relevant content is discussed in "causes". I generally do not feel that medical articles should include the differential diagnosis (unless certain conditions have notorious mimics that are emphasised in secondary sources); a list of differentials this depends completely on the clinical presentation. I agree a "prognosis" section could include the risk of recurrence - this is information that could come from elsewhere in the article (e.g. increased recurrence rates in smokers). From my reading of the secondary sources (cited in the article or listed on the talkpage) I have not identified major research directions that we are not already discussing (apical blebs vs pleural porosity, for instance). I will have a look at the major veterinary sources to see if we need to discuss pneumothorax in other species. JFW | T@lk 20:12, 5 January 2012 (UTC)
  • Further explanation of the need for the article to conform to MEDMOS more closely. Of course, MEDMOS guidelines are not demands. However, it seems to me that this article needlessly disregards the guidlines on headings and page orgainisation. I think that Pneumothrorax is a condition that could easily conform to more of the MEDMOS guidelines on headings, than the article currently does. Consistency, is importand on the Wiki and makes the enclopedia easier to read going from article to article. In addition to lack of concordance with MEDMOS, I think that the current page organisation is quite bad for some topics. Examples: Snowman (talk) 10:51, 7 January 2012 (UTC)
  • I think that it would be possible to write a "Clasification" section that is understandable and place it after the introduction as suggested by the MEDMOS guidelines. I would not expect to find "Subtypes" under "Signs and symptoms", and a "Classification" section would replace a "subtypes" section in the "Signs and symtoms" section. Snowman (talk) 10:51, 7 January 2012 (UTC)
    • The classification is strongly dependent on features at presentation. I am not planning to change the order of the sections now. My view is that MEDMOS is generally a useful guideline, but I have never found it logical to place "Classification" at the top before you've even had a chance to describe the condition and possible subtypes in practical terms. Feel free to open a thread on WT:MEDMOS about this. JFW | T@lk 23:33, 7 January 2012 (UTC)
• MEDMOS makes a strong statement about the contents of the "Prevention" section saying; "if the section only discusses secondary prevention it should follow the treatment section". The article completely disregards this. Snowman (talk) 10:51, 7 January 2012 (UTC)
  • In what way does it disregard this completely? All prevention of pneumothorax is secondary prevention. Please clarify. JFW | T@lk 23:33, 7 January 2012 (UTC)
    • As far as I am aware, surgery or an intervention are often done when other treatments have not resolved a pneumothorax. Surgery and other interventions are often a treatment of last resort for unresolved pneumothoraces, which also has the effect of secondary prevention. I do not think surgery can be classifid an secondary prevention and nothing else. Would you call an appendicectomy secondary prevention? Snowman (talk) 16:03, 8 January 2012 (UTC)
      • I am still not clear in what way the current "Prevention" section "completely disregards" WP:MEDMOS. As the article currently states, the same procedures may be used both as a treatment for unremitting pneumothorax and as prophylaxis for further episodes in those deemed high-risk. I have rolled the content together in the same paragraph. JFW | T@lk 18:15, 8 January 2012 (UTC)
        • This is what medmos says; "Treatment or Management: This might include any type of currently used treatment ...". The prevention section includes interventions that are often mainly used as treatment, so I think all of the prevention section should be re-named to something like "Interventions" (or a reader friendly version) and that it should be included at the end of "Treatment" section. Snowman (talk) 22:03, 8 January 2012 (UTC)
          • I will look into this, but I am not completely certain whether these interventions are not primarily preventative. I am not a thoracic surgeon so I cannot say with confidence whether the interventions are more commonly used for treatment or for prevention. JFW | T@lk 01:06, 9 January 2012 (UTC)
            • You need to get this right. As far as I am aware, a surgeon would only operate on a chest with a pneumothorax as a treatment of last resort. Opening a chest would not be used for the sole purpose of secondary prevention of a pneumothorax. Talk insuflation can have complications and would not be used as only secondary prevention. Surgery and talk insufflation are used to treat pneumothoraces that have not resolved with other treatmetns. Snowman (talk) 16:18, 11 January 2012 (UTC)
              • Have you read the guidelines from the British Thoracic Society, cited in the article? Recurrent pneumothorax, even when succesfully treated with intercostal drains, may warrant VATS-based or mini-thoracotomy based pleural abrasion with or without stapling of blebs. The same applies to people who wish to go SCUBA diving and have a history of pneumothorax. Talc insufflation can only be performed once the pneumothorax has fully resolved, as otherwise no pleurodesis will be achieved, and is therefore a form of secondary prevention per excellence. JFW | T@lk 19:52, 11 January 2012 (UTC)
                • I did not know that about talk insufflation, but think that this is not grounds for putting larger thoracotomies in a "Prevention" subheading. Snowman (talk) 20:17, 13 January 2012 (UTC)
                  • If your interpretation of Thorax is the usual clinical practice for mini-penumothorocotomies and talk insuflation, then this section is a mixture of topics, some of which are a combination of secondary prevention and treatment and larger thoracotomies, which are mainly treatment. I think that this section is badly organised. Incidentally, the article does not mention "mini-thoracotomies". Snowman (talk) 12:54, 14 January 2012 (UTC)
                    • Tschopp mentions that "recent reports show that there is a preference for smaller incision", but being a general article I did not think that it would be appropriate to go into the WP:HOWTO of the procedure. I imagine the incision made for "curative" and "preventative" thoracotomy is determined mainly by what the surgeon is planning to do, rather than the reason why the operation is performed. This depends on the results of imaging (e.g. presence of emphysematous bullae). JFW | T@lk 22:52, 14 January 2012 (UTC)
                      • I note that sections have been substantially re-organised for the better by User Jfdwolff; see this edit. Snowman (talk) 11:51, 20 January 2012 (UTC)
  • In the article currently, the "Causes", "Mechanism", and the "Subtypes" sections have a lot of repetition and this could be addressed with consideration of headings and the overall page reorganisation. Snowman (talk) 11:36, 7 January 2012 (UTC)
    • That is the price we're paying for having one comprehensive article about various subtypes of pneumothorax. I'd prefer to have a degree of repetition as opposed to confusing the reader. Do you have specific examples? JFW | T@lk 23:33, 7 January 2012 (UTC)
      • I think that the repetition can be minimised with better page organisation. Snowman (talk) 16:21, 11 January 2012 (UTC)
        • See my response on the next point. A small amount of repetition is inherent in every reasonably well-organised article. JFW | T@lk 19:52, 11 January 2012 (UTC)
  • Despite being rare tension pneumothorax has a high profile, because urgent treatment can be life saving. Aspects of this medical emergency are separated over several headings all over the article, and I think that explaining this contidion better can be considered with page re-organistion. Snowman (talk) 11:53, 7 January 2012 (UTC)
    • Again, this is the price we are paying for treating all forms of pneumothorax in one comprehensive article. I am extremely wary of moving all content relating to tension pneumothorax into one section. After all, all forms of pneumothorax can precipitate an episode of tension. JFW | T@lk 23:33, 7 January 2012 (UTC)
      • Again, this is an example of poor page organisation. Snowman (talk) 16:21, 11 January 2012 (UTC)
        • I have now moved all the clinical information on tension pneumothorax (history and physical examination) into one subsection. Given that every kind of pneumothorax could theoretically lead to tension, I do not want to isolate this content any further. I know you have a perspective on the organisation of the page, but unless you can come up with a suggestion that is in harmony with the current guidelines in WP:MEDMOS I think I prefer the current arrangement. JFW | T@lk 19:52, 11 January 2012 (UTC)
  • Omission: pneumothorax and flying; see Thorax 2003 (a more up-to-date reference will be needed for the article). Snowman (talk) 11:31, 7 January 2012 (UTC)
    • The 2010 guideline also mentions this. I agree that we should mention this, together with the content on scuba diving that RexxS has proposed on Talk:Pneumothorax. JFW | T@lk 23:33, 7 January 2012 (UTC)
    • In truth, we allude to this in the opening paragraph of "Treatment", and therefore no omission occurred. Axl has suggested that this be discussed in "Prevention". I am reviewing this. JFW | T@lk 13:23, 8 January 2012 (UTC)
      • I think that the article should also say that both underwater diving professionals and pilots flying aircraft are indications for surgery. There is nothing about surgery in pilots in the article. Snowman (talk) 01:23, 20 January 2012 (UTC)
        • Diving can be unsafe whether done professionally or not. I have added (under "aftercare") the point about pilots being considered for surgery. More diving-related content has been prepared on the talkpage, and will soon be added to the article. JFW | T@lk 02:25, 20 January 2012 (UTC)
  • Possible omission: Air and a fluid both present; air and blood (Hemopneumothorax), air and empyaema, or and a watery fluid (hydropneumothorax), Snowman (talk) 12:00, 7 January 2012 (UTC)
    • We are mentioning haemopneumothorax (diagnosis, 3rd paragraph), but I would need to find a reference to cover hydro & pyopneumothorax. JFW | T@lk 23:33, 7 January 2012 (UTC)
  • Possible omission: Pneumothorax caused by loud music; see "Loud music lung collapse warning" on BBC. Snowman (talk) 16:10, 7 January 2012 (UTC)
    • We are covering this already (signs and symptoms, 1st paragraph). I would not want to use BBC as a source. JFW | T@lk 23:33, 7 January 2012 (UTC)
  • Possible omission: President-elect of Argentina, Fernando de la Rua had a pneumothorax; see "World: Americas: Argentine president-elect discharged from hospital" on BBC. Snowman (talk) 16:13, 7 January 2012 (UTC)
    • This happened 12 years ago and clearly has not made a lasting impact on the popular perception of the condition. I think that it should not be first of a list of famous people who once had a pneumothorax. JFW | T@lk 23:33, 7 January 2012 (UTC)
      • You may not be looking at this from the perspective of a person from South America. Actually, the BBC is an extreamly realiable source and the BBC is (or has been) the single RS most often used on the Wiki. I think that it is useful so have some examples of famous people, who have had the condition and how it affected them. Of course, there may be other famous people affected. Snowman (talk) 16:27, 11 January 2012 (UTC)
        • Can you demonstrate that De la Rua's pneumothorax has had a lasting impact on the public perception of the disease, in the same way Michael J. Fox's Parkinson's disease has had an impact of the popular perception of that illness? The BBC might be a useful source to demonstrate that, but the current source doesn't. JFW | T@lk 19:52, 11 January 2012 (UTC)
          • I think that what is important to readers here is the cause of the illness in a famous person, in this case a typical episode. I do not see why a lasting impact on a nation is the only criteria here. Snowman (talk) 12:54, 14 January 2012 (UTC)
            • WP:MEDMOS (under "notable cases") has some guidance on this. If we agree to mention this one case we oblige ourselves to mention all other notable people who have once suffered a pneumothorax. This tends to snowball as people of less renown are added ad infinitum. JFW | T@lk 22:52, 14 January 2012 (UTC)
  • Possible omission: Pneumothorax and medical certification for the boxing sport; see Army Boxing Association (Army BA) Aade Memoire. Snowman (talk) 19:32, 16 January 2012 (UTC)
    • Not mentioned in secondary sources, unless you're aware of one. JFW | T@lk 19:51, 16 January 2012 (UTC)
      • I would be amazed if this is not included in sports medicine text books or review articles. Scuba diving is included in the article and to me it seems illogical to exclude other sports and activities. Snowman (talk) 20:03, 16 January 2012 (UTC)
        • I have provided a link to boxing on the RAF website, so I think I have conclusively indicated a possible omission. Please try a systematic literature search. Snowman (talk) 23:41, 16 January 2012 (UTC)
          • See comments to the next two points. JFW | T@lk 23:43, 19 January 2012 (UTC)
  • Possible omission: Pneumothorax and fitness to fly military and civil aircraft and fitness for space flight (NASA); see Spontaneous Pneumothorax and its Effects on Aircrews and Australian authority book. Snowman (talk) 19:32, 16 January 2012 (UTC)
    • Not discussed in secondary sources. See my next response. JFW | T@lk 19:51, 16 January 2012 (UTC)
      • I would be amazed if this is not included in occupational health text books or review articles. Snowman (talk) 20:03, 16 January 2012 (UTC)
        • Just a sampling: ISBN 0-63204-832-8 does not contain "pneumothorax" as a text word, and ISBN 0-70218-674-0 mentions it as an aside on one occasion. Are you aware of any sources? JFW | T@lk 20:26, 16 January 2012 (UTC)
          • The two external websites that I have linked show that the article has a possible omission, so I expect that there are reliable sources somewhere. Snowman (talk) 23:41, 16 January 2012 (UTC)
            • This is a very detailed and specialised subject that would be WP:WEIGHT if discussed in a general encyclopedia article. See also my comments below on occupational health perspectives. JFW | T@lk 23:43, 19 January 2012 (UTC)
  • Possible omission: A section on occupational medicine (fitness to do certain types of work). Snowman (talk) 19:49, 16 January 2012 (UTC)
    • Not discussed in secondary sources. I will have a look and see if there is a paper on occupational medicine and pneumothorax, but I'm not particularly hopeful. JFW | T@lk 19:51, 16 January 2012 (UTC)
      • I would be amazed aspects of pneumothorax are not included in occupational health text books or review articles. Snowman (talk) 20:03, 16 January 2012 (UTC)
        • See my previous comment. JFW | T@lk 20:26, 16 January 2012 (UTC)
          • May I suggest that you do a systematic search of the literature. Snowman (talk) 23:41, 16 January 2012 (UTC)
            • Doing so would generate content based on primary sources. I have found a (short) paragraph in an occupational medicine handbook that distinguishes coarsely between light and heavy manual work, and I have indeed added this content to a new subsection called "aftercare". It does not discuss specific occupations, and I get the impression that there is insufficient data to make a hard recommendation about particular situations. A specialist occupational physician will probably end up making a risk assessment based on perceived exposure and risk. This is not something we can do in a general purpose encyclopedia article. JFW | T@lk 23:43, 19 January 2012 (UTC)
  • Possible omission: Pneumothorax as a sports injury. Snowman (talk) 19:32, 16 January 2012 (UTC)
    • Why is this different from any other injury? JFW | T@lk 19:51, 16 January 2012 (UTC)
      • Incidence in various sports could be added. Snowman (talk) 20:03, 16 January 2012 (UTC)
        • On the basis of which secondary source? JFW | T@lk 20:26, 16 January 2012 (UTC)
          • I have suggested a possible omission and I really think that it is not up to me to provide references for the article. Snowman (talk) 23:41, 16 January 2012 (UTC)
            • It certainly is when the general references for this article do not elaborate on the subject of pneumothorax specifically as a sports injury. For the purposes of a general encyclopedia article this might to quite granular and not relevant for the majority of readers. I am very happy to reconsider if you think there is a solid source that meets all the criteria from WP:MEDRS and gives a general overview of pneumothorax as a sport injury, but I believes it does an injustice to the many other traumatic cirumstances under which one could sustain a pneumothorax, such as road traffic accidents or being trampled by wildebeest. JFW | T@lk 23:43, 19 January 2012 (UTC)
              • Actually, sports medicine is a respected sub-speciality. Snowman (talk) 00:47, 20 January 2012 (UTC)
                • I don't think that materially alters the validity of my response. JFW | T@lk 00:58, 20 January 2012 (UTC)
                  • I think that your comment about "being trampled by wildebeest" does not materially alter the validity of my response. Snowman (talk) 02:01, 20 January 2012 (UTC)
                    • Ah, tu quoque. It was not intended to invalidate your response. I rest my case. JFW | T@lk 02:14, 20 January 2012 (UTC)
  • Inconsistency: The image description on Commons for File:Pneumothorax CXR.jpg indicates that the X-ray is a tension pneumothorax; however, any mention of this diagnosis is missing from the caption in the article. I would suggest that the overall shape of the lung on the affected side is somewhat irregular and this needs some explaining in the caption as well. Snowman (talk) 00:21, 17 January 2012 (UTC)
    • The description on commons is wrong. The definition of tension pneumothorax is based on clinical parameters and not on the size of the pneumothorax or the presence of mediastinal shift (see the Noppen reference). JFW | T@lk 00:59, 17 January 2012 (UTC)
      • I think that this sort of inconsistency should sorted out. May I suggest that you clarify the diagnosis suggested in the image description on Commons of this X-ray by the author or the editor who uploaded of the image. Snowman (talk) 23:42, 17 January 2012 (UTC)
        • I will do, but I don't believe it has bearing on the suitability for this article to achieve FA. JFW | T@lk 23:43, 19 January 2012 (UTC)
          • I think that good and consistent image documentation is important. I think that the inconsistency seen in the caption on the page and the image description on Commons is not satisfactory for any medical article. Snowman (talk) 00:44, 20 January 2012 (UTC)
            • Well, you'll be pleased to hear that I modified the caption on Commons. I hope this settles the matter. JFW | T@lk 00:58, 20 January 2012 (UTC)
              • I think that your modification of the image description on Commons might have the tendency to muddy the waters. I think that your modification of the image description on Commons does not help. I have asked User Kauczuk on Commons to clarify the diagnosis of the person, who was X-rayed. How do you know that the diagnosis was not a clinical diagnosis? I would recommend that you revert your edit and await for the author to reply. He might know a lot more about the X-ray than is apparent at the moment. This matter has not been resolved. Snowman (talk) 01:57, 20 January 2012 (UTC)
                • I disagree. The X-ray shows a pneumothorax. Whether the patient was clinically in tension at the time of the X-ray is of no relevance to this article. I have simply removed the assertion that the X-ray shows "tension", because this is not a diagnosis that is made on an X-ray image. I wish we could move on from this. JFW | T@lk 02:14, 20 January 2012 (UTC)
                • The image is related to the following case history on the "Clinical Cases Blog": Tension pneumothorax. The case history mentions a blood pressure of 78/61. The history is therefore consistent with tension. But it is not an X-ray diagnosis. JFW | T@lk 02:30, 20 January 2012 (UTC)
                  • I have put back some clinical information in the image description on Commons. I think that it is important to get this right. I think that the main point here is that the X-ray would give suspicion of a tension pneumothorax or is consistent with a tension pneumothorax. I maintain that it is somewhat misleading to present this as a typical X-ray for a left pneumothorax, as seems apparent in the image caption in the article. I am fairly sure that the possibility of a tension pneumothorax would have been mentioned in the X-ray report for an X-ray like this. I think that the caption in the article needs rephrasing. Snowman (talk) 11:00, 20 January 2012 (UTC)
                    • I have made a simple amendment to the caption, which I think now has the correct emphasis. Snowman (talk) 11:07, 20 January 2012 (UTC)
                      • You have added "consistent with a clinical history of tension pneumothorax". This is exactly what you cannot conclude from the X-ray. Mediastinal shift is often seen in pneumothorax, even with the patient being completely stable (see Noppen). It is not equivalent to clinical tension. To suggest that this X-ray is "consistent with a clinical history of tension pneumothorax" perpetuates a myth. JFW | T@lk 22:11, 21 January 2012 (UTC)
                        • This is exactly why the phrase is "consistent with tension pneumothorax" is appropriate, because it is not saying that there is not another cause of a shifted mediastinum. This is the correct way of highlighting a particular significant possible diagnosis that might be one diagnosis in a list of several possibilities. Snowman (talk) 11:33, 22 January 2012 (UTC)
                          • The image caption is not the right place to highlight the distinction between compensated and tension pneumothorax. This distinction is made in the text. JFW | T@lk 11:51, 22 January 2012 (UTC)
                            • Unstable caption: I note that the caption has been reverted again; see this edit. This part of the article appears to be unstable to me. I think that the caption needs to give some indication that this sort of X-ray appearance can occur in clinical tension pneumothorax. This can be written into the caption in many different ways. On the WP Medicine talk page, I have invited editors for their opinion about this caption. Snowman (talk) 14:33, 22 January 2012 (UTC)
                            • Please note the pneumothorax web-page of e-medicine shows an X-ray, which is consistent with clinical pneumothroax. The caption on emedicine says; "This chest radiograph has 2 abnormalities: (1) tension pneumothorax and (2) potentially life-saving intervention delayed while waiting for x-ray results. Tension pneumothorax is a clinical diagnosis requiring emergent needle decompression, and therapy should never be delayed for x-ray confirmation." Perhaps, their caption could be improved by saying "consistent with tension pneumothorax", but I think that it is better to have mentioned tension pneumothrax than not have done. Snowman (talk) 15:36, 22 January 2012 (UTC)
                              • The caption is only unstable because you insist on changing it in a way that cannot be justified. As I have explained repeatedly, this X-ray does not show unequivocally whether the patient is unwell or not. That is something that requires a clinical assessment. I am surprised that you cannot seem to accept my point. As for Emedicine, it directly contradicts observation by Noppen & De Keukeleire that mediastinal displacement is a feature commonly encountered on X-rays of people with pneumothorax, whether stable or clinically in tension. JFW | T@lk 01:25, 23 January 2012 (UTC)
                                • My change to the caption are entirely justifiable. This caption is being discussed on the WP Medicine talk page, where Doc Smith says that he thinks the expression "abc changes are consistent with a diagnosis of xyz" is a commonly used expression. The caption is about a situation where there is mediastial deviation, and is not about how common it is in this condition, so I find you quote from e-medicine is irrelevant. I would also like to reiterate that the image description on Commons originally said that the X-ray was one of a tension pneumothroax. I can not understand why anyone would want to leave out any mention of the clinical diagnosis or clinical findings (in this case as far as can be determined from the image description on Commons and from the original source) of such an important condition as tension pneumothroax. Snowman (talk) 14:25, 23 January 2012 (UTC)
                                  • I have several concerns about the Commons text, which I have described on WT:MED. In my opinion, these issues call into question the validity of the text. [By the way, his name is "Doc James".] Axl ¤ [Talk] 14:49, 23 January 2012 (UTC)
                                    • The image description on Commons may need to be rewritten carefully. The image is from clinical cases. The websites disclaimer says; "There are no real life patient data on this website." Snowman (talk) 16:56, 23 January 2012 (UTC)
                                      • The image description on Commons has no direct bearing on this article. The reader should not need to navigate to Commons to understand the image. At the moment, all we know is that the X-ray shows a pneumothorax. If we have to believe the text on the Clinical Cases blog, the clinical history may well be fictional. JFW | T@lk 20:50, 23 January 2012 (UTC)
                                        • The X-ray shows a lot of air between the lung and the rib cage on one side. I expect that emedicine used this X-ray for a reason to illustrate a fictional case of a tension pneumothorax. The reason being that the X-ray appearances of this X-ray are consistent with a tension pneumothroax. The X-ray is not rotated (sternoclavicular joints are symmetrical) and there is no fibrosis in the expanded lung. It shows deviation of the trachea and this can be a late sign of tension pneumothroax. Snowman (talk) 22:27, 23 January 2012 (UTC)
                                          • "a lot of air between the lung and the rib cage on one side" is not a particularly good sign for tension pneumothorax. In my personal practice I have seen a number of cases where the lung was entirely collapsed, yet the patient was entirely stable and only reported chest discomfort, with peripheral oxygen saturations of 99%! Deviation of the trachea on a chest X-ray is not the same as tracheal deviation on physical examination. You cannot conclude that just because the trachea is displaced on the CXR, the patient must therefore be in tension. JFW | T@lk 22:48, 23 January 2012 (UTC)
                                            • I think that this discussion has been advanced further at Wikipedia talk:WikiProject Medicine#Image caption in pneumothorax, probably because there has been more contributors to the discussion there. Snowman (talk) 23:19, 23 January 2012 (UTC)
                                              • All we have achieved there is the observation that chest X-rays of people suspected clinically of tension pneumothorax can delay appropriate management and should not be performed. I am personally of the opinion that we should not change the image caption any further, and I am not intending to restate my views again. JFW | T@lk 23:41, 23 January 2012 (UTC)
  • "Deviation of the trachea (windpipe) to one side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as clinical signs, despite being taught as characteristic for tension pneumothorax.[4]". I think that the article it is not clear and contradictory on why a deviated trachea is not a reliable clinical sign and why it is thought that is is a characteristic feature. I think that many people would tend to trust ivory towers of training. My assumption would be that the presence of a deviated trachea with chest pain and breathlessness would be very significant. Snowman (talk) 00:21, 17 January 2012 (UTC)
    • To clarify: they are too rare to be useful, because their absence does not exclude tension pneumothorax. I will try to make the sentence clearer, but I am somewhat bound by the way Leigh-Smith has phrased it. JFW | T@lk 00:59, 17 January 2012 (UTC)
      • I think that you may need to clarify the sensitivity and specificity of the clinical sign of a deviated trachea. Snowman (talk) 23:35, 17 January 2012 (UTC)
        • Again, when assessing someone who is critically unwell, spending time to assess tracheal position may not be time well spent because if it is not deviated you have not excluded a tension pneumothorax. This is the point that Leigh-Smith makes, and I will ensure that the text faithfully represents this. Giving exact percentages is hard, especially because Leigh-Smith does not pronounce on the specificity of the sign (which is probably unknown). JFW | T@lk 23:16, 19 January 2012 (UTC)
          • ... how long does it take to check the position of the trachea? Snowman (talk) 00:31, 20 January 2012 (UTC)
            • If you do it properly, about 10-15 seconds. Which can make all the difference in someone with SpO₂ 60% and a systolic blood pressure of 45 mmHg. With regards to specificity, any cause of chronic volume loss (lobectomy, fibrosis of the upper lobes) can cause tracheal deviation, and the sign is therefore not specific for tension pneumothorax. JFW | T@lk 01:01, 20 January 2012 (UTC)
              • Yes, I would have thought about about 15 seconds or perhaps 5 seconds if it was marked. It is an interesting topic. Perhaps "... despite being taught as characteristic for tension pneumothorax" is historical now and the worlds top professors teach up-to-date facts about the windpipe. Perhaps, the wording in the article could clarify if this teaching is current or historical. If this teaching is historical, perhaps it could be included in the "history" section to avoid confusion. Snowman (talk) 01:20, 20 January 2012 (UTC)
                • Do you have evidence for that claim? Tracheal position is still taught in ATLS. Unless you can prove that this teaching has been abandoned, I don't think it belongs under "history". JFW | T@lk 02:30, 20 January 2012 (UTC)
                  • Perhaps, this seems to be a case when one reliable source criticises another reliable source. The teaching stance of ATLS is not represented. Wikipedia should not take sides. I am not happy by the way the article deals with deviation of the trachea here. Snowman (talk) 10:47, 20 January 2012 (UTC)
                    • I would need to consult the ATLS manual to see how they discuss this. I don't think the current phrasing constitutes an NPOV violation. JFW | T@lk 22:11, 21 January 2012 (UTC)
                      • The current wording about this in the article is; "Deviation of the trachea (windpipe) to one side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as clinical signs, despite being taught as characteristic for tension pneumothorax.[4]". There is only one in-line reference (reference number 4) for this line, so in the Wiki article one review publication is contradicting the basis of standard teaching. I would have thought that the Wiki should not take sides and only give the point of view of the review here. The article is not explaining the case for standard teaching. Please to ahead and consult the ATLS manual; however, the review publication appears to contradict medical education in general over the significance of the position of the trachea. How important would it be if the position of the trachea changed from the time of the initial examination to the time of a second review examination in the emergency department? The progress of a tension pneumothorax can take minutes or hours, and for the slower progressing types there would be time to test and record the position of the trachea. Snowman (talk) 15:02, 22 January 2012 (UTC)
                      • Emedicine teaches that the deviation of the windpipe is an inconsistent and late sign, and goes on to say that "Although historic emphasis has been placed on tracheal deviation". My initial instinctive impression may be correct that teaching is up-to-date. Nevertheless, I remain unhappy about the way the current article appear to be taking sides. Snowman (talk) 16:21, 22 January 2012 (UTC)
                        • As I said, I will be reviewing the ATLS manual at the closest opportunity, and consider including it as a source. It seems that Emedicine agrees with our current view, namely that absence of tracheal deviation does not exclude tension. JFW | T@lk 01:25, 23 January 2012 (UTC)
                          • I would agree that up-to-date references say that tracheal deviation does not exclude tension pneumothorax. The part of the article that I think should be fixed is where is indicates that teaching is wrong with this; "... despite being taught as characteristic for tension pneumothorax". I do not know exactly what is the current teaching on the position of the trachea in tension pneumothorax, but the article indicates that it is out-of-date universality on the basis of one 2005 review. I think that the article takes sides on this. I expect that the teaching had a good bases when it was (or is still) being taught and this is not presented in the article. I would guess that this teaching in most places on the wind pipe has been revised on the basis of new research. I think that this Wiki article may risk unduly criticising current 2012 standard teaching on the basis on one 2005 review. The in-line reference for this is 2005, which is unsatisfactory for indicating what current teaching is. Snowman (talk) 16:40, 23 January 2012 (UTC)
                            • Fine, you win. I have removed the words "[...] despite being taught as characteristic for tension pneumothorax" because I am not convinced that we should provide loads of sources solely for the purpose of NPOV. The reason I originally added the words in question was because it was not clear why one would expect the trachea to be deviated or the JVP to be raised. JFW | T@lk 20:50, 23 January 2012 (UTC)
                              • Personally speaking, I think that the matter of who wins or looses is not important. The offending phrase was obviously problematic and I think that it would have made this part of the article sound silly to many. The FAC process generally tends to make articles better. It was a long road, but what is important to me here is that a misleading phrase on the Wikipedia has been corrected. I could have corrected it myself days ago, but I guess that the main authors of the page would have reverted my edit. During FACs I often edit pages directly writing explanations in good edit summaries and my edits are reworked, and when I team up with erudite editors I think that this can work well and the amount of discussion necessary in the FAC is reduced. Snowman (talk) 21:55, 23 January 2012 (UTC)
                                • I hope you realise that my "you win" was tongue in cheek. Obviously this is not a contest. It is good that we seem to have come to an agreement here, although there is a small risk that the reader will think "why are they mentioning tracheal shift and raised JVP, only to say that they are not very sensitive signs?" JFW | T@lk 21:58, 23 January 2012 (UTC)
                                  • I think there needs to be a sentence before to say what are the most commonly found and most reliable clinical findings (I think this is reduced breath sounds on the affected side). Snowman (talk) 22:40, 23 January 2012 (UTC)
                                    • I have rephrased one sentence to read "Other findings often include quieter breath sounds on one side of the chest". Leigh-Smith states that this is found in 50-75% of cases, so still not universal. I'd say that is fairly reliable, but I don't think we can say that in so many words because the positive predictive value has not been calculated. JFW | T@lk 22:48, 23 January 2012 (UTC)
                                      • Incidentally, may I suggest minimising "tongue in cheek" comments, just in case they are misunderstood. Further, some readers, perhaps with English as their second language, may find this "figure of speech" difficult to understand. Snowman (talk) 23:19, 23 January 2012 (UTC)
                                        • Okay. JFW | T@lk 23:41, 23 January 2012 (UTC)
  • Page organisation of information on tension pneumonthorax: It seems to me that information of tension pneumothorax is in several sections up and down the page and so I think that is probably difficult for a general reader to find out about this condition in the article. I could not see anywhere in the article to say specifically that oxygen is beneficial in penumothorax nor anything about the sequence of decompression with a cannula and then establishing bubbling in a chest tube. However, I might have missed a sentence or two about tension pneumothorax hidden in one or more sections. Snowman (talk) 00:31, 20 January 2012 (UTC)
    • I have already moved a fair amount of content on tension pneumothorax into a separate subsection under "signs and symptoms". For the remainder of the article, specific treatment for tension pneumothorax is highlighted where relevant. We are mentioning that oxygen is beneficial (under "Treatment#Conservative"). You have indeed missed the discussion about needle decompression followed by a chest tube - this is in the opening paragraphs of "Treatment" - that's hardly "hidden". JFW | T@lk 00:56, 20 January 2012 (UTC)
      • To me this indicates how difficult the information about tension pneumothorax is to find in this fairly long article, and I would recommend a re-think on page organisation of tension pneumothorax. Snowman (talk) 01:05, 20 January 2012 (UTC)
        • How do you propose this should be done within the framework of WP:MEDMOS? As I have stated earlier, tension pneumothorax is a subtype of pneumothorax, and the causes are identical. JFW | T@lk 01:18, 20 January 2012 (UTC)
          • More sub-sections (level 3 headings) dedicated to tension pneumothorax might help. Snowman (talk) 01:26, 20 January 2012 (UTC)
            • As I have been trying to explain, tension is a feature that can occur to any kind of pneumothorax. You are trying to make it sound like it is a distinct clinical entity. It's not. JFW | T@lk 02:04, 20 January 2012 (UTC)
              • I am aware that there are a number of causes for tension pneumothorax. Of course, tension pneumothorax is to the chest as brittle bones is to the limbs. There is already a subsection on tension pneumothorax in the "Signs and symptoms" section and I think that the article could be better organised if there were sub-sections in the treatment and causes sections. Snowman (talk) 11:33, 20 January 2012 (UTC)
                • I don't see a good reason to add a subsection to "causes". As for "treatment", the management of tension pneumothorax is covered by a single paragraph. The Manual of Style explicitly discourages the use of very short sections. That is why I went for the current solution. JFW | T@lk 22:11, 21 January 2012 (UTC)
              • In addition, there is "Surgery is often required" for tension pneumothorax in AIDS, which seems out of place in the "Chest drain" section. Snowman (talk) 15:27, 20 January 2012 (UTC)
                • Surgery is not just required for tension but for PTX in AIDS in general. This is probably the best context to clarify this (rather than redoing the whole thing elsewhere). Also, it is the final paragraph on chest tubes and segues nicely into the section on surgery. JFW | T@lk 22:11, 21 January 2012 (UTC)
                  • This FAC mentions "tension pneumothroax" 62 times at this juncture. I think that this is likely to indicate the the presentation of this topic has problems. A re-think on the presentation of this topic may be indicated. Snowman (talk) 23:19, 23 January 2012 (UTC)
                    • This FAC mentions "tension pneumothorax" mostly in the discussion threads above. I think I have made an effort to organise the presentation of this topic, and we have engaged in a very long and mostly fruitless discussion on four words in an image caption on tension pneumothorax. I don't think the statistics are causally related to a problem with the organisation of the content. JFW | T@lk 23:41, 23 January 2012 (UTC)
  • Omission: Pneumothorax and AIDS. Snowman (talk) 00:36, 20 January 2012 (UTC)
    • We are mentioning pneumothorax secondary to pneumocystis pneumonia (under "causes") which is the main reason by which AIDS could lead to pneumothorax. Is there anything else that we need to cover? The sources don't accord special importance to AIDS. JFW | T@lk 00:56, 20 January 2012 (UTC)
      • There is a section about the importance of pneumothorax in AIDS in Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 BTS guidelines: Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Snowman (talk) 01:05, 20 January 2012 (UTC)
        • Done. Fair point. I will try to cover this somewhere. JFW | T@lk 02:04, 20 January 2012 (UTC)
          • Only partially done. There may be other stuff to add to the article about AIDS. What about incidence of bilateral pneumothoraces in AIDS? Snowman (talk) 12:35, 20 January 2012 (UTC)
            • Mentioned bilateral pneumothorax. Don't think we should discuss the medical management of PCP or AIDS in this context. JFW | T@lk 22:11, 21 January 2012 (UTC)
  • Copy-editing: "Professional guidelines suggest that pleurectomy is performed ...". What are these "professional guidelines"? Is the word "Professional" needed? Snowman (talk) 12:04, 20 January 2012 (UTC)
    • Yes. Anyone can issue a guideline, but it is only useful if accepted by professionals. JFW | T@lk 22:11, 21 January 2012 (UTC)
  • Possible omission: The role of self-help groups in the "After care" section? Snowman (talk) 12:11, 20 January 2012 (UTC)
    • None of the sources mention self-help groups. What kind of self-help would be appropriate for someone who has had an episode of pneumothorax, apart from stopping smoking? JFW | T@lk 22:11, 21 January 2012 (UTC)
  • "A chest tube (or intercostal drain) is the most definitive initial treatment of a pneumothorax."; I think that this is controversial or bias to USA treatment. It may be the practice in USA. A simple cannula is generally the first treatment in the UK. Snowman (talk) 12:31, 20 January 2012 (UTC)
    • You are misreading it. It is not ambiguous. An intercostal drain is the most definitive initial treatment. Aspiration is less definitive, in that it fails in 50% of cases. If definite treatment is needed (e.g. in a patient who is showing clinical signs of deterioration), aspiration might not be the right treatment. JFW | T@lk 22:11, 21 January 2012 (UTC)
  • Correction needed on essential basics: "... inability to hear breath sounds on one side of the chest ..."; this is incorrect as there is not inability to hear breath sounds. If there were no breath sounds on the affected side, then a pneumothorax would be easy to diagnose with a stethoscope. In short, the breath sounds on the affected side are generally slightly quieter. Snowman (talk) 15:18, 20 January 2012 (UTC)
    • (edit conflict) - see [2]. Nevertheless, replacing it with "deceased breath sounds" simply obscures the meaning for 99% of the audience. I've reverted that and would ask why "generally quieter breath sounds" isn't used for the text if that's what is actually observed? I assume this is meant to be referenced to Leigh-Smith? Unfortunately, I can't find anything to support those findings in the article. Perhaps other sources might be definitive on the issue. --RexxS (talk) 15:40, 20 January 2012 (UTC)
      • I have put back my comment, as User RexxS has answered it. See Box 12 in "Review: "Tension pneumothorax—time for a re-think?" S Leigh-Smith, T Harris. It says "Decreased breath sounds" in box 12. This source is the in-line reference for most of this paragraph of the article, so this is also an error of extracting information from the review. I would be grateful if user RexxS would help to amend this section writing in the correct information about breath sounds in good English. Snowman (talk) 15:53, 20 January 2012 (UTC)
        • Thanks, I hadn't looked hard enough in the boxes in Leigh-Smith. I can see what you were trying to do now, but I took your edit of "deceased" breath sounds to some kind of medical jargon for breath sounds that had stopped! and I missed it being an obvious typo for "decreased" - apologies. I'll have a try at editing the text to reflect the source. Please feel free to butcher my efforts mercilessly. --RexxS (talk) 14:53, 21 January 2012 (UTC)
          • I had not realised that my edit that you reverted included a typo. I see how my typo lead to a misunderstanding. Thank you for explaining and fixing it. I welcome your work in rolling out plane English. Snowman (talk) 16:31, 21 January 2012 (UTC)
  • Possible omission of research directions: Some information at Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement Snowman (talk) 21:58, 20 January 2012 (UTC)
    • The section "Priorities for Future Research" doesn't actually discuss any emerging research findings. Rather, it calls for "prospective studies that have adequate sample sizes and follow-up periods to show effects. Study end points should include the relevant clinical outcomes, such as mortality, morbidity, patient perceptions, functional status, and cost." I would not want to base an entire section on this, especially when the main point is going to be that "More research is needed". JFW | T@lk 22:11, 21 January 2012 (UTC)
      • This is a significant source and it is a research direction, so it seems to be what is indicated in MEDMoS. Snowman (talk) 17:29, 23 January 2012 (UTC)
        • I agree that it is a significant source, but the "research directions" section should ideally be reserved for research that is widely thought (by secondary sources) to promising in the diagnosis or treatment of a condition. See dengue fever for some good examples. (COI: I wrote most of that section.) I am less certain that there is any mileage in saying that "the current guidelines are based on flaky data, and we need bigger trials"; no one should be forced to read that in an encyclopedia. JFW | T@lk 20:50, 23 January 2012 (UTC)
          • I disagree, I think that it is important for readers to know that there has been few studies on management guidelines, and this area that has been recommended for further study. Snowman (talk) 23:33, 23 January 2012 (UTC)
            • We can certainly mention the fact that the guidelines are not built on gold-plated evidence, but that is not the purpose of the "research directions" section. JFW | T@lk 23:42, 23 January 2012 (UTC)
  • Omission: Prognosis section; as indicated in MEDMOS. Snowman (talk) 23:19, 23 January 2012 (UTC)
    • MEDMOS does not mandate particular sections. Most of the relevant content is discussed in context in the "Management" and "Epidemiology" sections, and moving it to a separate section doesn't seem useful to me. JFW | T@lk 23:41, 23 January 2012 (UTC)
  • I think that the Management section should have a section called something like "Emergency decompression", which can show more lengthy text on the management of "Tension pneumothroax". I note that my edit starting this presentation has been reverted by this edit. I doubt if I will edit the article or here much in the near future. Snowman (talk) 23:19, 23 January 2012 (UTC)
    • The Manual of Style (see WP:BODY) discourages the use of short sections. This is the only reason I reverted your edit, so there should be no concern with regards to future editing. I had already explained the issue of very short sections here, and I had hoped that this was clear. JFW | T@lk 23:41, 23 January 2012 (UTC)
      • Please focus on my suggestion about more lengthy section on the management of tension pneumothroax. Snowman (talk) 00:05, 24 January 2012 (UTC)

• Comments (just the few things I could find that have not already been addressed by others above, I hope I am not repeating):
  • Treatment/prevention: should probably include smoking cessation
  • Diagnosis: possible additions: rib fractures with subcutaneous emphysema on x-ray highly suggestive for pneumothorax; most likely location where small pneumothoraces are seen on x-ray (should probably find a ref for these statements)
  • Relationship with pneumomediastinum; should this be mentioned?
  • "Several particular features on ultrasonography of the chest can be used to confirm or exclude the diagnosis.": which features? --WS (talk) 20:24, 15 January 2012 (UTC)
    • Response: thanks for your comments Wouter.
    • Done. Treatment/prevention: I have added something about smoking cessation in the "prevention" section, as the BTS guideline makes some recommendations in this area.
    • Diagnosis: As for subcutaneous emphysema, none of the sources mentioned this (but they are generally quite thin on traumatic pneumothorax). Perhaps Rosen10 mentions it, or perhaps you could recommend another source?
    • Diagnosis: The source mentions four features that could be beneficial for ultrasonographers. This is not a widely used technique, so I was a bit hesitant to include this. After all, this might be interpreted as canonical while it far from that. Also, the features are somewhat technical: "the lung sliding, the B lines, the lung point, and the lung pulse". We would need to clarify each feature in turn!
    • Hope this is helpful. JFW | T@lk 21:09, 15 January 2012 (UTC)
      • I recommend an "Aftercare" subsection at the end of the "Treatment" section, which would include smoking cessation, flying and diving.
      • Is that really true? In Rosen's Emergency Medicine, I found no support for that, neither in the "Pneumothorax" section, nor in the "Rib fracture" section. Interestingly, in the "Hemothorax" section, there is a CT slice (Figure 42-11) on page 397 with the caption "Multiple rib fractues [sic] with extensive subcutaneous emphysema, with no pneumothorax seen." Oddly, there is of course a large haemothorax, which isn't mentioned in the caption.
      • Rosen's Emergency Medicine contains a single paragraph on spontaneous and secondary (non-traumatic) pneumomediastinum. The paragraph begins "Spontaneous pneumomediastinum is a closely related clinical entity", and goes on to describe several features that are different from pneumothorax. I am not convinced that pneumomediastinum has any place in Wikipedia's article on "Pneumothorax". If you insist, I suppose that a single sentence in the "Mechanism" section would be reasonable.
      • I'll let JFW address the comment about ultrasonographic features. Axl ¤ [Talk] 22:27, 15 January 2012 (UTC)

• Note: the {{Done-t}} templates cause the FAC archives to exceed Wikipedia:Template limits (which is why the FAC instructions asked that they be avoided), creating errors in archives. Could someone please remove them ? Thanks, SandyGeorgia (Talk) 19:53, 16 January 2012 (UTC)
  • {{done-t}} :D --RexxS (talk) 21:00, 16 January 2012 (UTC)
  • I missed that instruction. Sorry, and thanks to RexxS for doing the "search & replace" job on it. JFW | T@lk 21:07, 16 January 2012 (UTC)

Closing note: we are past the three-week mark, with no consensus to promote, and a lengthy review that is likely to discourage other reviewers from engaging. The fastest route to the bronze star under these circumstances is typically a fresh start in a few weeks. Good luck! SandyGeorgia (Talk) 16:30, 24 January 2012 (UTC)

The above discussion is preserved as an archive. Please do not modify it. No further edits should be made to this page.