title: Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis.
abstract: BACKGROUND
  Although health care providers utilize classically described signs and symptoms to diagnose tension pneumothorax, available literature sources differ in their descriptions of its clinical manifestations. Moreover, while the clinical manifestations of tension pneumothorax have been suggested to differ among subjects of varying respiratory status, it remains unknown if these differences are supported by clinical evidence. Thus, the primary objective of this study is to systematically describe and contrast the clinical manifestations of tension pneumothorax among patients receiving positive pressure ventilation versus those who are breathing unassisted.
  
  
  METHODS
  We will search electronic bibliographic databases (MEDLINE, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews) and clinical trial registries from their first available date as well as personal files, identified review articles, and included article bibliographies. Two investigators will independently screen identified article titles and abstracts and select observational (cohort, case-control, and cross-sectional) studies and case reports and series that report original data on clinical manifestations of tension pneumothorax. These investigators will also independently assess risk of bias and extract data. Identified data on the clinical manifestations of tension pneumothorax will be stratified according to whether adult or pediatric study patients were receiving positive pressure ventilation or were breathing unassisted, as well as whether the two investigators independently agreed that the clinical condition of the study patient(s) aligned with a previously published tension pneumothorax working definition. These data will then be summarized using a formal narrative synthesis alongside a meta-analysis of observational studies and then case reports and series where possible. Pooled or combined estimates of the occurrence rate of clinical manifestations will be calculated using random effects models (for observational studies) and generalized estimating equations adjusted for reported potential confounding factors (for case reports and series).
  
  
  CONCLUSIONS
  This study will compile the world literature on tension pneumothorax and provide the first systematic description of the clinical manifestations of the disorder according to presenting patient respiratory status. It will also demonstrate a series of methods that may be used to address difficulties likely to be encountered during the conduct of a meta-analysis of data contained in published case reports and series. PROSPERO registration number: CRD42013005826.
authors.affiliation: Department of Surgery, University of Calgary and the Foothills Medical Centre, 1403-29th Street NW, T2N 2T9, Calgary, Alberta, Canada. Derek.Roberts01@gmail.com.
authors.forename: Derek J
authors.initials: DJ
authors.lastname: Roberts
authors.forename: Simon
authors.initials: S
authors.lastname: Leigh-Smith
authors.forename: Peter D
authors.initials: PD
authors.lastname: Faris
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.forename: Helen Lee
authors.initials: HL
authors.lastname: Robertson
authors.forename: Christopher
authors.initials: C
authors.lastname: Blackmore
authors.forename: Elijah
authors.initials: E
authors.lastname: Dixon
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
authors.forename: John B
authors.initials: JB
authors.lastname: Kortbeek
authors.forename: Henry Thomas
authors.initials: HT
authors.lastname: Stelfox
mesh_terms: D006801:Humans; D011030:Pneumothorax / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology; D011175:Positive-Pressure Respiration / Q000009:adverse effects; D012143:Respiratory Physiological Phenomena; D000078202:Systematic Reviews as Topic; D015201:Meta-Analysis as Topic