From the Guidelines
Drainage of symptomatic pneumothorax, either with needle aspiration or intercostal chest drain attached to an underwater seal, is the current standard of care for spontaneous pneumothorax. The diagnosis of spontaneous pneumothorax is typically made based on clinical presentation and imaging studies, such as chest X-ray or CT scan. According to the British Thoracic Society guideline for pleural disease 1, the treatment approach depends on the size and symptoms of the pneumothorax.
Key Considerations
- Small, asymptomatic pneumothoraces may be managed conservatively with observation and supplemental oxygen.
- Larger or symptomatic cases require intervention, such as needle aspiration or chest tube placement, to evacuate the air.
- Ambulatory treatment using a purpose-made device containing a one-way valve or Heimlich valve attached to a chest drain may be an alternative for outpatient management.
- Thoracic surgery is often the treatment of choice for ongoing air leak or recurrent pneumothorax.
Treatment Options
- Needle aspiration: a minimally invasive procedure to remove air from the pleural space.
- Intercostal chest drain: a tube inserted into the chest to remove air and fluid from the pleural space.
- Chemical pleurodesis: a procedure to adhere the lung to the chest wall to prevent future pneumothoraces.
- Thoracic surgery: a surgical procedure to repair or remove damaged lung tissue.
Prevention of Recurrence
- Pleurodesis (chemical or mechanical) to adhere the lung to the chest wall.
- Surgery (VATS) to repair or remove damaged lung tissue.
- Avoiding activities that change pressure gradients, such as flying or scuba diving, until fully recovered.
- Quitting smoking to reduce recurrence risk.
From the Research
Diagnosis of Spontaneous Pneumothorax
- Spontaneous pneumothorax is typically diagnosed with a chest X-ray, as chest pain and dyspnea are the most common presenting symptoms 2
- The diagnosis is often confirmed with a chest X-ray in the majority of cases 2
Treatment Goals
- The treatment goals of spontaneous pneumothorax consist of elimination of the pleural air and prevention of future recurrence 3, 4
- Air evacuation, cessation of persistent air leak, and prevention of recurrence are the main objectives of pneumothorax treatment 4
Treatment Options
- Therapeutic options include bed rest, oxygen supplementation, manual aspiration, chest tube drainage, thoracoscopic and surgical interventions 3
- Conservative approach with avoidance of invasive treatment has risen to be a main consideration for primary spontaneous pneumothorax (PSP) patients who are clinically stable with minimal symptoms 4
- Non-surgical treatment in secondary spontaneous pneumothorax (SSP) is becoming more common due to concerns about morbidity and mortality after surgical pleurodesis 4
- Video-assisted thoracoscopic surgery has in most centers replaced open surgery for spontaneous pneumothorax 2
Management of First Episode
- The management of a first episode of spontaneous pneumothorax is controversial, and the best technique to be used as an initial intervention, aspiration or intercostal drainage, is still debated 5
- Aspiration appeared to offer advantages as an initial strategy over intercostal drainage in terms of hospital stay and with significant effectiveness in secondary pneumothorax 5
Recent Advances
- Recent advances in the management of pneumothorax have produced the largest randomised controlled trials in the field yet and have revolutionised the management of spontaneous pneumothorax 6
- The introduction of conservative and ambulatory care in appropriate patients in recent guidelines now allows these patients to be managed in the outpatient setting and reduces their risk of complications compared to conventional chest drain insertion 6