Review Article

Treatment Options of Spontaneous Pneumothorax

Abdullah Al-Qudah

Division of Thoracic and Cardiovascular Surgery, Department of General Surgery, Jordan University Hospital
and Faculty of Medicine, Amman, Jordan

ABSTRACT

Penumothorax is a benign condition with high morbidity and high recurrence rate; and remains a significant clinical problem
worldwide. The exact underlying pathogenesis is probably multifocal and is still unclear. The initial approach to the
management of spontaneous pneumothorax differs from country to country and it is very difficult to establish an
international standard protocol. Needless to say, that the safest and most cost-effective treatment protocol for a particular
center should be used. However, first episode of primary spontaneous pneumothorax can be managed conservatively and
there is no consensus on optimal treatment of patients presenting with spontaneous pneumothorax specially those with first
event. On the contrary, there is some consensus that some treatment is mandatory with second or recurrent spontaneous
pneumothorax. Regardless of the chosen therapeutic modality, the treatment goals of spontaneous pneumothorax consist of
elimination of the pleural air and also prevention of future recurrence. Therapeutic options include bed rest, oxygen
supplementation, manual aspiration, chest tube drainage, thoracoscopic and surgical interventions. Till present, there are no
prospective, randomised comparative studies between various treatment strategies but only few between various therapeutic
techniques are available. [Indian J Chest Dis Allied Sci 2006; 48: 191-200]

Key words: Spontaneous pneumothorax, Thoracoscopic surgery, Pleurodesis, Talcage, Chest drainage.

INTRODUCTION been estimated that primary SPTx represents 70% to

Pneumothorax is defined as accumulation of air in the
pleural space with secondary lung collapse.
Pneumothoraces can be classified according to their
cause and clinical presentation. They can either be
spontaneous, traumatic, or iatrogenic. A primary
spontaneous pneumothorax occurs in individuals with
no known underlying pulmonary disease, while a
secondary pneumothorax develops in patients with
known clinical and/or radiographic lung disease.
Chronic obstructive pulmonary disease (COPD) is the
most common underlying disorder, although
pulmonany infections due to acquired immuno-
deficiency syndrome and mycobacterial infections also
are often responsible.
Spontaneous pneumothorax (SPTx) commonly
occurs in young, tall, thin adults without any apparent
underlying disease and in elderly patients with chronic
lung disease1. Primary SPTx is a relatively uncommon
disease with an estimated incidence of 5 to 10 per
100,000; a male to female ratio of 6:1 and a peak
prevalence in the 16 to 24 years age group2. Recurrent
SPTx occurs in 4.3:100,000 patients per year with a male
to female ratio of 5:13. Reported mortality rates were
0.62 per million per year for women and 1.26 per
million per year for men between 1991 to 19964. It has
[Received: February 24, 2005; accepted after revision: June 3, 2005]
Correspondence and reprint requests: Abdullah Al-Qudah, P.O. Box 13255 Amman 11942, Jordan; Tele.: 962 6 515 0669,
Fax: 962 6 515 0669, E-mail: al_qudah_as@hotmail.com.
80% while secondary SP represents only 20% to 30%5,6.
Unlike primary SPTx, which has no clear precipitating
factor, secondary SPTx usually occurs as a complication
of lung disease.
The treatment of a primary or secondary SPTx
remains controversial. The optimal treatment for a first
episode of pneumothorax remains to be evaluated.
Current management options include observation,
aspiration, thoracic drainage, thoracoscopic
interventions and surgery7.
PATHOPHYSIOLOGY
The pleural space normally contains only a very small
volume of fluid that allows the parietal and visceral
pleura to move smoothly over each other. The chest
wall and lung are both elastic in nature, with the lung
tending to recoil inwards and the chest wall to spring
outwards, these two opposing forces produce a
negative sub-atmospheric pressure in the pleural space.
The weight of the lung tends to make this pressure less
negative in the dependent areas of the lungs. If the
pleural space is opened to the atmosphere, the sub-
atmospheric pressure will suck air into the pleural
space; the lung will then recoil away from the chest wall
and a pneumothorax will be produced8.
192 Spontaneous Pneumothorax: Treatment Options
Controversy still exists regarding the pathogenesis of
pneumothorax. Numerous large series from around the
world suggest that in patients with primary SPTx
without apparent lung disease, the incidence of
subpleural bullae is in the range of 76% to 100% during
video-assisted thoracoscopic surgery (VATS) 9-12 and
bullae have been found in virtually all patients during
thoracotomy. Subpleural bullae in the the contralateral
lung have been found in 79% to 96% patients with
pneumothorax who underwent sternotomy. Computed
tomography of the chest revealed ipsilateral bullae in
89% of patients with primary SPTx, as compared to 20%
of controls13-18.
The mechanism of cyst or bulla rupture in secondary
SPTx also appears to be multifactorial. Local airway
obstruction caused by pneumonia, mucous plugs, or
bronchoconstriction may be important. Bullae
formation may be enhanced by the fact that, in taller
individuals, the pressure gradient from the lung base to
the lung apex is greater, leading to a greater mean
distending pressure of the alveoli at the lung apex.
Other predisposing factors include genetic pre-
disposition to emphysema and presence of bronchial
abnormalities19-21.
DIAGNOSIS
The clinical diagnosis of pneumothorax is suggested by
history, physical examination and where possible, by
radiological investigations. In general, the clinical
symptoms associated with secondary pneumothoraces
are more severe than those associated with primary
pneumothoraces, and most patients with a secondary
pneumothorax complain of breathlessness which is out
of proportion to the size of pneumothorax 22 .
Radiological diagnosis is best confirmed by the
identification of thin, visceral line (<1 mm in width) that
is found to be displaced from the chest wall on an erect
postero-anterior and lateral chest radiographs.
Expiratory postero-anterior chest radiography may
also be useful to demonstrate a small apical
pneumothorax not seen on a standard film but it is not
recommended for the routine diagnosis of
pneumothorax 23. However, lateral decubitus view is
better to confirm the presence of a pneumothorax and
the routine use of expiratory chest films does not
improve the diagnostic yield24.
Quantitation of the size of a pneumothorax is always
useful, but unfortunately the method for this
quantitation varies greatly and lacks uniformity. With a
standard chest radiograph, estimation of the size of a
pneumothorax is often inaccurate 25,26 . The clinical
history is not a reliable indicator of the size of the
pneumothorax. Computed tomographic scan (CT scan)
of the chest is recommended to differentiate
pneumothorax from complex bullous lung disease,
when aberrant tube placement is suspected, and when
Abdullah Al-Qudah
the plain chest radiograph is obscured by surgical
emphysema. The size of a pneumothorax is categorised
as small or large depending on the presence of a
visible rim of less than 2 cm or greater than or equal to
2 cm between the lung margin and the chest wall27. In
1990, Light et al28, suggested the measurement of the
average diameter of the collapsed lung and the
involved hemithorax, with the cubing of these
diameters to estimate the percentage of collapsed lung.
For example, if the diameter of a hemithorax is 10 cm
and the diameter of the collapsed lung is 6 cm, the size
of the pneumothorax is estimated by the formula:
(10363)/103 or 78 percent.
THERAPEUTIC OPTIONS
Primary Spontaneous Pneumothorax
The treatment of a primary or secondary SPTx remains
controversial and many treatment options exist.
Controversy also exists regarding the most appropriate
choice of management in a given clinical situation.
There is no consensus about treatment of the first
episode of SPTx. Treatment goals of SPTx therapy
include elimatation of air from the pleural space and
prevention of future recurrences. The treatment of
choice for a first episode of primary SPTx depends upon
the clinical presentation, the size of the pneumothorax,
the risk of recurrence; the patients activities, preference
and economical considerations and the presence and
extent of emphysema like changes29.
Five main principles and concepts taken into
consideration for the management of spontaneous
pneumothorax30 are:
1. The presence of intrapleural air is not in itself
necessarily an indication for intervention.
2. Management should depend more on the clinical
symptoms than the size of the pneumothorax.
Younger patients tolerate pneumothorax much
better than older patients with chronic lung disease
and diminished respiratory reserves. A young and
fit patient with a large pneumothorax without
significant symptoms (dyspnoea) can be observed
as out-patient.
3. Complete collapse can be treated effectively by
simple aspiration.
4. Tension pneumothorax developing from primary
spontaneous pneumothorax is extremely rare. It
occurs mainly with secondary pneumothorax and
pneumothorax caused by positive pressure
ventilation.
5. When drainage of air is required, simple aspiration
should always be attempted first. This applies even
to patients with chronic lung disease.
Management strategies ranged from simple
observation, bed rest with supplemental oxygen, tube
thoracostomy with or without instillation of a sclerosing
2006; Vol. 48 The Indian Journal of Chest Diseases & Allied Sciences 193

agent, thoracoscopy, and open thoracotomy 31. Despite
the presence of the wide range of options, the
therapeutic goals are to expand the lung and to prevent
recurrence. Algorithms for the management of
spontaneous primary and secondary pneumothorax are
shown in figures 1 and 2.
Simple observation
Absorption of air from the pleural cavity is slow and is
estimated to be 1.8% per day. Therefore, McEwen 32
suggests conservative treatment for a small
penumothorax (<15%) if the patient is relatively
asymptomatic, reliable and fit. One hundred percent
oxygen may be administered to hasten absorption of
intrapleural air. The patient should be observed by six
hours. If repeat chest radiograph at that time shows no
increase in pneumothorax size, the patient may be
discharged with appropriate advice, and reviewed
again in 24 hours for repeat chest radiograph. The
patient should be followed-up weekly with chest
radiographs until resolution occurs. The British Thoracic
Society (BTS) guidelines 33,34 emphasises the utility of
observation without pleural drainage as initial
management for patients without significant dyspnoea
who have: (i) small or moderately sized primary
pneumothoraces, or (ii) small secondary pneumo-
thoraces. Observation with or without supplemental
oxygen is the conservative approach in patients with
first episodes of primary SPTx who are asymptomatic
and have small (<20%, or a small rim of air/distance of
cupula to lung apex <3 cm) pneumothoraces and small
secondary pneumothoraces33. A high flow (10 L/min)

Primary Spontaneous Pneumothorax

Stable patients +
Stable patients + Unstable patients +
n PSPTx > 20%
n PSPTx < 20% Large PSPTx
n Chronic lung
n No significant
disease
dyspnoea
n Age>50 years
n Recurrent PSPTx
n Pleural effusion

Observation
Aspiration

YES REPEAT CXR NO

Significant dyspnoea Discharge

n PSPTx > 20% CXR next day
n 2.5 l aspirated air

Intercoastal tube
Drainage suction NO
YES

Follow-up
one week

YES

Hospitalisation n Pleurodesis: Medical thoracoscopy for unfit patients or

patient refusing surgery and VATS/surgery for fit
patients
Figure 1. Algorithm for management of primary spontaneous pneumothorax
[PSPTx=primary spontaneous pneumothorax; VATS=video-assisted thoracoscopic surgery; CXR=chest radiograph.]
194 Spontaneous Pneumothorax: Treatment Options Abdullah Al-Qudah

Secondary Spontaneous Pneumothorax

Intercostal tube Aspiration for :

Hospitalisation
drainage suction n Stable patients with
for unstable mild lung disease
patients

NO NO

YES
YES

Pleurodesis
n Medical thoracoscopy
Unfit patients
Patients refusing surgery Discharge
Discharge n VATS or surgery for fit patients

Figure 2. Algorithm for management of secondary spontaneous pneumothorax. [VATS=video-assisted thoracoscopic surgery]

oxygen should be administered with appropriate
caution in patients with COPD who may be sensitive to
higher concentrations of oxygen. Those patients should
also be considered for discharge with early out-patient
review. Patients may be admitted for observation if they
live distant from emergency services or follow-up care
is considered unreliable. Therefore, simple observation
may best reserved for SPTx patients with
contraindications for more definitive interventions.
Simple aspiration
Simple aspiration is a simple and safe procedure. It
should be the initial treatment for patients with normal
lungs who present with a SPTx, irrespective of its size.
Simple aspiration is less likely to succeed in secondary
pneumothoraces and on this regard, is only
recommended as an initial treatment in small
pneumothoraces in minimally breathless patients under
the age of 50 years. This therapeutic modality is less
painful than intercostal tube drainage, leads to a shorter
admission, reduces the need for pleurectomy with no
increase in recurrence rate at one year and can by
performed in the majority of patients as an out-patient
procedure34,35. Morbidity of manual aspiration is very
low and the procedure is very well tolerated. However,
the success rate of simple aspiration ranges from only
58% to 80 percent36-39. Consequently, this therapeutic
modality is regarded as the treatment of choice for the
first episode of an uncomplicated primary SPTx due to
its minimal morbidity, out-patient based
implementation, supported efficacy as compared with
chest tube drainage and low cost40. If the aspiration is
not successful, a small-bore catheter or a chest tube is
inserted and the patient is hospitalised. In all
circumstances, patients with secondary pneumo-
thoraces treated successfully with simple aspiration
should be admitted to hospital and observed for at least
24 hours before discharge. Aspiration is to discontinued
if more than 2.5 liters are aspirated. Some authors
disagreed with the use of observation and simple
drainage as they had concerns about the safety of out-
patient observation41. Factors significantly associated
with success of aspiration are as follows37: (i) age below
50 years, (ii) absence of underlying chronic lung disease,
(iii) pneumothorax size not more than 50%, (iv) volume
of aspirated air not exceeding 2.5 liters, and (v) no
previous history of pneumothorax.
2006; Vol. 48 The Indian Journal of Chest Diseases & Allied Sciences
Simple aspiration is contraindicated if the patient has
significant lung disease or concurrent medical
problems, haemothorax, pleural effusion, or bilateral
pneumothorax and should be replaced by intercostal
tube drainage. After aspiration, chest radiography is
performed and significant residual pneumothorax can
be re-aspirated once. The patient is discharged if there is
no significant dyspnoea after six hours of observation
and a repeat chest radiograph at that time shows no
recurrence of pneumothorax. The patient is to return
immediately if significant dyspnoea occurs, and to
return in 24 hours for follow-up and further repeat chest
radiography. The recent American College of Chest
Physicians (ACCP) guidelines consensus process found
simple aspiration to be rarely appropriate in any clinical
circumstances33.
Intercostal drainage
An intercostal drainage is indicated if aspiration is
unsuccessful. The catheter can be attached to a one-way
Heimlich valve, which allows ambulation or to a water-
seal device29,38,39,42. Routine application of suction has not
been shown to improve the outcome43. Suction should
be directly applied after chest tube insertion at it has not
been shown to be associated with an increased success
rate38. Suction may be tried if there is a persistent air
leak or the lung fails to expand quickly 44. However, if
the suction is applied, the chest tube time is shorter in
comparison with a simple underwater seal 45 . If
intercostal drains are removed too soon, there is a
chance of lung collapse. The BTS guidelines recommend
that chest drains should be removed 24 hours after they
have stopped bubbling. The practice of clamping is still
widespread, but the new trend is to discourage the
practice of clamping33.
Regardless of whether the chest tube is or not
clamped, most authors would repeat a chest radiograph
24 hours after the last evidence of air leak to insure the
absence of pneumothorax recurrence and the patient
should not leave the specialist ward area. The Research
Committee study of the BTS has found that manual
aspiration and chest tube drainage were reported to be
equally successful in first and recurrent episodes of
Table 1. Recurrence rate in patients with primary spontaneous pneumothorax, treated with bed rest, needle aspiration or tube drainage.
Author Year Patients No. of Patients
47
Hyde 1963 200
Gobel48 1963 110
Ruckley49 1966 175
Sermetis1 1970 154
ORourke50 1989 148
Almind51 1989 34
Lippert52 1991 122
BTSRC44 1993 65
Harvey34 1994 65
Andrivet40 1995 61
BR=bed rest, NA=needle aspiration, TD=tube drainage, BTSRC=British Thoracic Society Research Committee.
195
primary SPTx, with manual aspiration being less
painful, leading to less admission rates, was associated
with a reduction in the need for pleurectomy, and
without increase in recurrence rate at one year. The
recent ACCP guidelines consensus process 32 found
simple aspiration to be appropriate rarely in any clinical
circumstances in spite of simple aspiration is being
effective for stable patients. Approximately 20% to 40%
will experience recurrence after a first episode. If the
second episode is treated conservatively, the probability
of a third recurrence is about 60 percent. Surgery will be
necessary in about 20% of patients usually because of
recurrence. Finally, complications of chest tube drainage
include pain, pleural infection, incorrect placement of
the tube, haemorrhage, hypotension, and pulmonary
oedema due to lung re-expansion. Spontaneous
pneumothorax recurs after chest drainage treatment of
the first episode in 20% to 25% of patients28, 46.
Table 1 summarises the recurrence rates in patients
with primary SPTx, treated with bed rest, needle
aspiartion or tube drainage.
Medical thoracoscopy
A well-accepted routine technique performed
worldwide for many decades as treatment of SPTx is
pleurodesis using talc or other sclerosing agents. It can
be done by chest physicians or surgeons under local or
general anesthesia 53. It is less expensive than VATS.
Medical thoracoscopy with talc poudrage is well
tolerated with no major perioperative complications but
it underestimates the presence of visceral pleural
abnormalities and does not deal with existing blebs or
bullae which may require coagulation, stapling, or over
suturing54.
Experimental and clinical studies showed that talc is
the best chemical agent to use for pleurodesis. However
talc has been experimentally incriminated be Werebe et
al 55 to be responsible for development of acute
respiratory distress syndrome (ARDS). This
complication as well as the development of empyema
are rare. Curiously these results strongly contrast with
the European experiences of usage of talc without any
serious side effects29. These results have been confirmed
Treatment Recurrence Rate (%) Follow-up Years
BR, NA, TD 27
BR, NA, TD 52 6
BR, NA, TD 16 1-4
BR, TD 41 >2
BR, TD 25 6.3
TD 31 4.6
TD 29 10
NA, TD 23 1
NA, TD 23 1
NA, TD 21 0.25
196 Spontaneous Pneumothorax: Treatment Options Abdullah Al-Qudah

by Tschopp et al56, who reported that thoracoscopic talc
pleurodesis under local anesthesia is superior to
conservative treatment by chest tube drainage in cases
of primary SPTx where simple aspiration failed,
provided that there is efficient control of pain by
opioids. However, randomised studies comparing
recurrence rates of pneumothorax after simple talc
pleurodesis alone by thoracoscopy versus pleurodesis
and bullectomy by VATS in patients with blebs and
bullae are still needed.
Surgical interventions
Conventional surgical interventions consists of
thoracotomy (postero-lateral or limited axillary type)
with bullectomy and partial and/or complete
pleurectomy. The goals of surgical intervention are two
folds: the first is to resect the blebs and the second is to
create a pleural symphysis to prevent recurrences. The
results of parietal pleurectomy are excellent and apical
pleurectomy and with blebs excision is now considered
the operation of choice for the definitive control of
recurrence. The recurrence rate is less than 0.5 percent58.
Success rates with chemical pleurodesis are only 78% to
91% compared to success rates of 95% to 100% with
surgical intervention 57. Many techniques have been
described for resecting blebs or bullae. They include
endoscopic stapler, loop technique, electrocoagulation,
laser coagulation or a combination of both. In 1941,
pleural abrasion was used by Tyson et al58 as a treatment
for pneumothorax while in 1956, pleurectomy was
introduced by Gaensler 59 for treating recurrent
pneumothorax. Combined pleurectomy and bullectomy
showed an average recurrence rate of two percent.
Traditionally, surgery is indicated for controlling
persistent air leaks and prevention of recurrence. VATS
seems more widely used and effective than
thoracotomy, as one third of primary SPTx patients and
nearly half of secondary SPTx patients with recurrence
undergo thoracoscopy, as opposed to less than 5% and
less than 12% patients with primary SPTx and
secondary SPTx respectively, underlying thoractomy60.
However, between 2% and 10% of patients with
primary SPTx and up to 29% of patients with secondary
SPTx who undergo VATS require change to
thoracotomy because of technical difficulties 61,62 .
Surgery in the form of open thoracotomy yields the
lowest post-operative recurrence results and is by far
the most successful therapy for SPTx, as measured by
the low recurrence rate (4%), compared to a much
higher recurrence rate with chemical pleurodesis, which
does not address the bullae (8% to 25%) or tube
drainage alone (40%) 63. Open thoracotomy may be
associated with increased post-operative dysfunction
and hospital stay compared with VATS procedures 64.
Consequently, open thoracotomy finds its best
indication in patients with secondary pneumothoraces
who may require extensive pleurectomy, subpleural
bullectomy or pleural effusion65. Accepted indications
for operative intervention are as follows66:
A. First episode
1. Prolonged air leak (7 to 10 days)
2. Failure of re-expansion of the lung
3. Bilateral pneumothoraces
4. Haemopneumothorax
5. Associated single large bulla
6. Tension pneumothorax
7. Occupational hazards (pilots, divers, and
individuals living in remote areas)
B. Second episode
1. Ipsilateral recurrence
2. Contralateral recurrence after a first pneumothorax.
Reports from large series from around the world
indicate that the recurrence rates of primary SPTx
following VATS bullectomy combined with surgical
pleurodesis is in the range of 1.7 percent to five
percent 67 . Morbidity from thoracotomy for
pneumothorax has an overall incidence of 3.7%, mostly

Table 2. Results with conventional surgical treatment in patients with spontaneous pneumothorax
Author Year No. of Patients Treatment Recurrence Rate (%) Follow-up Years
12
Baronofsky 1957 17 B, PP 0 6
Gobel48 1963 31 B, PP 0 5.5
Askew68 1976 100 PP 2.5 ?
Gertz69 1983 40 PA 2.5 10
Weedon57 1988 233 PP 0.4 4.7
Nkere70 1991 60 PA 2 2.6
Elfeldt71 1991 68 B, PP 0 ?
Brekel72 1993 248 B, PP 3 ?
Donahue15 1993 83 B, PD 4 9.1
Krasnik73 1993 97 B, PA 0 0.41
Hazelrigg74 1993 20 B, PA NS NS
Waller64 1994 30 B, PA 3.3 NS
Cole61 1995 43 B, PD 3 NS
Liu75 1996 82 B, PA 0 1.8
Al-Qudah76 1998 50 B, PP 0 6
B=bullectomy, PP=partial pleurectomy, PA=pleural abrasion, PD=pleurodesis, NS : not stated.
2006; Vol. 48 The Indian Journal of Chest Diseases & Allied Sciences 197

in the form of sputum retention51. Table 2 shows the
results of conventional surgery in patients with
spontaneous pneumothorax.
Video-assisted thoracoscopic surgery (VATS)
There is no consensus regarding the ideal method for
pleurodesis once it becomes indicated. Obliteration of
the pleural space is usually accomplished by chemical
pleurodesis, by mechanical abrasion or parietal
pleurectomy. Either of the above procedures can be
performed alone or in association with resection of the
lung at the time of thoracotomy or thoracoscopy.
Pleurodesis is generally attempted to guard against
missed bullae or the future development of more bullae.
The ACCP recommends medical thoracoscopy or
VATS as the primary procedure, and a limited axillary
thoracotomy with pleural abrasion as a secondary
approach. VATS has been advocated as a routine for
first time primary SPTx for the reason of cost-
effectiveness. The BTS recommends open thoracotomy
with repair with VATS reserved for patients who cannot
tolerate an open procedure. Currently, the preferred
surgical approach in patients requiring surgery for SPTx
is thoracoscopy with resection of the apical blebs or
bullae, and abrasion of the pleura producing firm
adhesions between the lung and the chest wall.
Thoracoscopy affords better visualisation of the entire
lung surface, especially the lower lobe that cannot be
seen when traditional axillary approach is used.VATS
constitutes the therapeutic modality of choice for the
treatment of pneumothorax when the surgical decision
is made and in those patients where multiple pleuro-
pulmonary adhesions are not suspected, while
thoracotomy with or without pleurectomy is no longer
the routine approach for the surgical treatment of
bullae61. The current enthusiasm of VATS should not
lead to premature abandonment of successful
throacotomy in these patients. Thoracotomy, including
the axillary approach with partial or total pleurectomy
and excision of bullae in primary SPTx and secondary
SPTx limit recurrence to less than one percent.
Finally, VATS offers significant advantages over open
thoracotomy including a shorter post-operative hospital
stay, less post-operative pain, better post-operative
pulmonary function, and probable overall neutral cost
impact. VATS is functionally superior to open
thoracotomy for pneumothorax surgery and bullous
lung disease and, may allow surgical intervention in
patients with inadequate pulmonary function77. Table 3
summarises the rules of VATS in patients with
spontaneous pneumothorax.
Secondary Spontaneous Pneumothorax
Current practice in managing secondary SPTx is more
homogenous than that in treating primary SPTx.
Treatment of patients with primary or secondary STPx
are quite similar. Patients with secondary SPTx have
concomitant respiratory diseases and thus require
prompt and effective treatment. All patients with
secondary SPTx should be hospitalised, irrespective of
whether they are stable or not. In general, recurrent
SPTx is considered to be an indication for invasive
therapy, such as chemical pleurodesis or even surgery.
Those who are stable and with small pneumothorax
may be observed or treated with a chest tube insertion
depending on the extent of their symptoms and the
course of their pneumothorax. The current trend is to
recommend a more aggressive approach in managing
secondary SPTx as compared with primary SPTx.
Treatment with tube thoracostomy has a high
recurrence rate of 65 percent. Effective treatment should
be performed by chemical or surgical pleurodesis in
combination with effective sealing of the air leak by
stapling, electrocoagulation or laser coagulation1. The
ACCP consensus statement on pneumothorax recom-
mends chest tube insertion for all patients and
pleurodesis with the first episode of a secondary SPTx
to prevent a recurrence33. However, this consensus is
incomplete as 19% of the authors would defer pleuro-
desis until the second pneumothorax. The BTS pneumo-
thorax guidelines36 recommend manual aspiration with
a catheter and syringe for small pneumothoraces in

Table 3. Results of video-assisted thoracoscopic surgery in patients with spontaneous pneumothorax

Author Year No. of Morbidity Mortality Recurrence Rate Follow-up
Patients (%) (%) (%) Months
Linder78 1993 94 8.5 NS 1.1 NS
Hazelrigg9 1993 26 0 0 0 8
Waller64 1994 30 NS 6.7 6.7 NS
Yim79 1995 100 8 NS 3 17 (8-24)
Naunheim80 1995 113 8 NS 4.1 13 (1-34)
Liu75 1996 82 7.3 0 0 22
Cole61 1995 30 7 NS 17 NS
Mouroux81 1996 100 10 0 3 30 (7-49)
Freixinet82 1997 132 6 0 6 36
Al-Qudah83 1999 50 0 0 0 3 (1-6)
Ayed84 2000 72 4.1 0 5.5 42 (36-54)
Hatz85 2000 109 2.7 NS 4.6 53.2
VATS=video-assisted thoracoscpic surgery, NS=not stated.
198 Spontaneous Pneumothorax: Treatment Options
patients with mild underlying lung disease, but submit
that most patients will require chest tube drainage.
Patients should not be referred for thoracoscopy
without prior stabilisation. Unstable patients and
patients who appear to be at risk for large pleural air
leaks because they are subjected to mechanical
ventilation need intermediate chest tube (24F to 28F),
while in stable patients a small bore catheter (14F) may
be acceptable. The BTS recommends removal of the
chest tube after lung re-expansion and resolution of air
leaks, and reserves pleurodesis for patients with an
unresolved air leak or a recurrent pneumothorax. Even
less consensus exits regarding the ideal method for
pleurodesis once it becomes indicated. The ACCP
recommends medical thoracoscopy or VATS as the
primary procedure, and a limited axillary thoracotomy
with pleural abrasion as a secondary approach. Chest
tube placement has been the first-line therapy.
However, it is recognised that observation for small
secondary pneumothoraces is an acceptable alternative
for patients who are clinically stable. The key difference
in the management approaches for small primary and
secondary pneumothoraces is that the latter requires
hospital admission.
Observation is not an option for patients with a large
secondary SPTx or those who are clinically unstable;
chest tube placement and admission are preferred. The
trend is against using the Heimlich valve in these
settings.
Staged approach is recommended for chest tube
attachment and removal in patients with a secondary
SPTx. Once again, this represents a departure from the
current practice. Particularly in the setting of secondary
pneumothorax, suctioning may increase the risk of an
air leak. The key difference from primary SPTx
management is that 13 to 23 hours should elapse
between the last evidence of an air leak and chest tube
removal.
Patients with secondary SPTx are at increased risk
(40%) of recurrence. The indication for VATS in the
treatment of secondary SPTx should be considered with
caution and surgery via limited trans-axillary
thoracotomy is found to be as safe and effective as
VATS. Pleural abrasion and bullectomy stood out as the
most favoured operative procedures.
Prevention of Pneumothorax Recurrence
Currently, it seems that there is a general agreement to
recommend intervention to prevent pneumothorax
recurrence after the first occurrence because of the
potential lethality of secondary pneumothoraces 86-89.
However, some authors still suggest performing an
intervention only after the second episode of SPTx. To
prevent recurrence the diseased site should be resected
and pleural space obliterated. In all circumstances,
patients with recurring pneumothorax should undergo
surgery due to the lower recurrence rates of such
Abdullah Al-Qudah
procedures compared to the instillation of sclerosing
agent through a chest tube 90. De Varies and Wolfe 90
estimated a recurrence rate of 32% with non-operative
methods. In cases with contraindications to surgery,
chemical pleurodesis can be done through a chest tube.
Sclerosing agents used for chemical pleurodesis include
talc slurry, doxycycline, minocycline and bleomycin.
Medical or surgical thoracoscopy is considered as the
treatment of choice for treating recurrence with sparing
muscle thoracotomy being accepted as an alternative
therapeutic modality. Bullectomy is preferably done
with a stapler or during surgery, is the preferred method
of pleural symphysis associated with partial or total
parietal pleurectomy and abrasion of the visceral
pleura76.
CONCLUSIONS
There is lack of universal agreement on the treatment
options for spontaneous pneumothorax. Several
possible methods for the initial treatment of SPTx exist.
The best treatment for the first episode of primary SPTx
is still yet an unanswered question. Management of
pneumothorax should depend primarily upon its
clinical effect rather than its radiographic size. The
choice of treatment of SPTx should depend mainly on
the efficacy of treatment rather than the clinical
presentation of the first episode or its recurrence. Simple
observation should be limited to patients with surgical
contraindications. Pleurodesis by pleurectomy during
VATS shows the best results regarding cost-effectiveness
in the management of primary and secondary SPTx.
Chemical pleurodesis with sclerosing agents is another
accepted treatment option and talcage is regarded as the
best conservative technique in achieving pleurodesis.
Surgery is to be considered when there is a persistent
air-leak or recurrence. The role of VATS after the first
episode of pneumothorax needs to be detemined in
further studies.
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