What is the management for a reoccurrence of spontaneous pneumothorax after initiating BiPAP (Bilevel Positive Airway Pressure)?

Management of Recurrent Spontaneous Pneumothorax After BiPAP Initiation

For recurrent spontaneous pneumothorax after BiPAP initiation, immediate chest tube placement with a large-bore tube (24F-28F) is recommended, followed by early surgical intervention if the air leak persists beyond 3-5 days. 1

Initial Management

• Insert a large-bore chest tube (24F-28F) to manage the potentially large air leak that can occur with positive pressure ventilation 1, 2
• Connect the chest tube to a water seal device with suction to help re-expand the lung 1, 2
• High volume, low pressure suction systems (such as Vernon-Thompson pump or wall suction with pressure-reducing adaptor) are recommended 2
• Apply -10 to -20 cm H2O suction with an air flow volume capacity of 15-20 L/min 2
• Avoid high pressure, high volume suction as it can lead to air stealing, hypoxemia, or perpetuation of persistent air leaks 2
• Monitor with serial chest radiographs to assess pneumothorax resolution and lung re-expansion 1

Timing of Surgical Intervention

• For patients with pneumothorax after BiPAP (considered a secondary pneumothorax), seek early thoracic surgical consultation (within 2-4 days) if air leak persists 2
• Earlier surgical referral is particularly important in cases with:
  • Underlying lung disease
  • Large persistent air leak
  • Failure of the lung to re-expand 2
• While 79% of secondary pneumothoraces with persistent air leaks resolve by 14 days 2, 3, the risk of complications with BiPAP warrants more aggressive management

Surgical Options

• Video-assisted thoracoscopic surgery (VATS) or medical thoracoscopy is the preferred surgical approach 2, 4
• Surgical intervention typically includes:
  • Bullectomy (if bullae are present)
  • Pleural symphysis procedure (pleurodesis) 2
• Staple bullectomy is the preferred procedure for bullectomy 2
• For pleural symphysis, options include:
  • Parietal pleurectomy
  • Talc poudrage
  • Parietal pleural abrasion 2

Non-Surgical Management for Poor Surgical Candidates

• For patients unable or unwilling to undergo surgery, chemical pleurodesis can be considered 2
• Chemical pleurodesis should be performed by a respiratory specialist 2
• Preferred agents for chemical pleurodesis through chest tube:
  • Talc slurry (very good consensus)
  • Doxycycline (good consensus) 2, 1

Special Considerations with BiPAP

• Avoid clamping the chest tube in the presence of an active air leak, especially with continued BiPAP use, to prevent tension pneumothorax 1
• Consider temporary discontinuation of BiPAP if possible, or use of lowest effective pressures 1
• Ensure complete resolution of pneumothorax and cessation of air leak before considering chest tube removal 1
• If BiPAP must be continued, surgical intervention should be strongly considered even after first episode due to high risk of recurrence 2

Prevention of Recurrence

• For secondary pneumothoraces (which includes those occurring with BiPAP), definitive measures to prevent recurrence are recommended after the first episode 5
• Most experts (81%) recommend intervention to prevent pneumothorax recurrence after the first occurrence of secondary pneumothorax due to potential lethality 2
• Surgical approaches have significantly lower recurrence rates compared to medical pleurodesis 2, 4

Follow-up Care

• After resolution, careful monitoring is required if BiPAP therapy must be resumed
• Consider gradual reintroduction of BiPAP at lower pressures if absolutely necessary 1
• Regular follow-up imaging is recommended to detect early recurrence 1