Top ten list in pleural disease.

This supplement contains six sections addressing many aspects of pleural disease. After an introductory section describing the methods to develop the guidelines and a summarization of key points, there is a section each on the investigation of a unilateral pleural effusion in adults and on guidelines for the insertion of a chest drain. Management sections address pleural infection, malignant pleural effusions, and spontaneous pneumothorax. These guidelines are complementary to, and at times divergent from, earlier American College of Chest Physicians (ACCP) guidelines on spontaneous pneumothorax1 and parapneumonic effusions,2 and the American Thoracic Society statement on malignant pleural effusions.3 The rigor of the British Thoracic Society (BTS) grading system assessing the primary literature is potentially concerning. Grade Ia and Ib literature included meta-analyses of randomized trials and randomized controlled trials, respectively. Other guidelines1,4 subjected randomized controlled trials to more rigorous scrutiny, subdividing them into those without important limitations and those with limitations including small sample size with moderate to high risk of false-positive and/or false-negative errors. Perhaps grading of some recommendations made by the BTS would differ utilizing a more rigorous system. Lastly, the guidelines represent “a blend of published evidence and clinical experience” without providing a clear outline of how expert opinion was gleaned in a bias-free fashion. Regardless, the BTS guidelines represent an excellent compendium of evidence-based information related to commonly encountered clinical pleural problems.