From the Guidelines
The management of secondary pneumothorax requires prompt intervention, with chest tube insertion being the preferred method for most cases, as recommended by the British Thoracic Society guidelines 1.
Initial Management
Initial management includes supplemental oxygen to aid reabsorption of air and pain control with appropriate analgesics.
- For small, stable pneumothoraces (<2-3 cm) in minimally symptomatic patients, observation with close monitoring may be appropriate, but hospitalization is recommended for these cases 1.
- However, most secondary pneumothoraces require active intervention due to the compromised respiratory reserve in these patients.
Active Intervention
- Needle aspiration can be attempted for smaller collections, but chest tube insertion (typically 12-14 French for small to moderate pneumothoraces, or 16-22 French for larger ones) is often necessary 1.
- The chest tube should be connected to a water seal or digital drainage system with suction at -10 to -20 cm H2O if needed.
- Persistent air leaks beyond 3-5 days may require surgical intervention, typically video-assisted thoracoscopic surgery (VATS) with pleurodesis or pleurectomy to prevent recurrence, as supported by the most recent guidelines 1.
Recurrence Prevention and Underlying Disease Management
- Chemical pleurodesis using agents like talc or doxycycline can be considered in patients who are poor surgical candidates 1.
- The underlying lung disease must be optimized simultaneously, which may include bronchodilators, antibiotics for infections, or corticosteroids depending on the etiology.
- Recurrence prevention is crucial, as secondary pneumothoraces have high recurrence rates (up to 50%), making definitive interventions important in the management strategy. Given the high recurrence rate and the importance of preventing further episodes, the most recent and highest quality study 1 supports the use of VATS with pleurodesis or pleurectomy as a definitive intervention for secondary pneumothorax, emphasizing the need for prompt and effective management to improve patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Management Approach for Secondary Pneumothorax
The management of secondary pneumothorax depends on several factors, including the extent of cardiorespiratory impairment, degree of symptoms, and size of pneumothorax 2.
- Guidelines and Recommendations: The British Thoracic Society (BTS) and the American College of Chest Physicians (ACCP) have published guidelines for pneumothorax management, which include recommendations for diagnostic and management strategies 3.
- Treatment Options: For secondary pneumothorax, treatment options may include:
- Simple aspiration: This may be recommended for some cases of secondary pneumothorax, although the success rate is lower compared to primary spontaneous pneumothorax 4.
- Chest tube insertion: This may be recommended for patients with larger pneumothoraces or those who require intervention 3.
- Surgery: This may be recommended for patients with recurrent pneumothorax or persistent air leak 3.
- Pleurodesis: This may be recommended as an alternative to surgery for patients who decline surgery or are poor surgical candidates 3.
- Considerations: The management approach for secondary pneumothorax should take into account the underlying pulmonary disease and the patient's overall health status 3.
Comparison of Treatment Strategies
Different treatment strategies have been compared in various studies, including:
- Simple Aspiration vs. Chest Tube Insertion: Simple aspiration has been shown to be less painful and require less hospitalization than chest tube insertion, although the success rate may be lower for secondary pneumothorax 4.
- Surgery vs. Pleurodesis: Surgery and pleurodesis have been shown to be effective treatments for recurrent pneumothorax, although the choice of treatment depends on the individual patient's circumstances 3, 5.