**6. Hazards of non-compliance with pneumothorax guidelines**

Despite the availability of published guidelines, there has been a recording in the English literature of non-compliance or deviation from the guidelines, which has occasionally resulted in inconsistency or patient harm in management of spontaneous pneumothorax. We have previously published our experience in a large UK tertiary centre [35] where the median time to referral from chest physicians to thoracic surgeons after the 2003 BTS guideline publication was 10 days for a persistent pneumothorax which is longer than any time suggested by all guidelines. This has resulted in a higher incidence of developing empyema and the more frequent need of a thoracotomy rather than VATS treatment for patients with delayed referral. Delayed referral is one of the most common areas of deviation from published pneumothorax guidelines.

When assessing a pneumothorax, the size will determine the initial step of management, ranging from conservative treatment, needle aspiration up to chest tube drainage in larger pneumothoraces. There is discrepancy in size calculations of pneumothorax between different guidelines, and this has resulted in inconsistency in management. Kelly and Clooney have noticed this with management of 234 patients managed in Australia [36], and patients with a large pneumothorax were treated conservatively. Yoon et al. have studied size calculation of PSP in 87 patients in a tertiary UK centre and found significant discrepancy between the size calculation suggested in the BTS guidelines (resulting in only 70% compliance) and the ACCP guidelines (resulting in only 32% compliance) with consequent inconsistent management [37]. Sole blame on physicians and surgeons applying the guidelines can be unfair as there is obvious inconsistency in size calculation between different pneumothorax guidelines [38], and estimation of the size using only a chest X-ray can yield variable results [39].

The BTS guidelines [8] suggest explicitly inserting a chest drain for simple spontaneous pneumothorax in the 'safe triangle of chest'. We have previously published that knowledge of the guidelines regarding this site of insertion is deficient in surgeons and physicians involved in insertion of chest drains [40]. This resulted in more than 50% of drains inserted being outside the 'safe triangle' exposing patients to an unnecessary risk of higher morbidity associated with this common everyday procedure.
