From the Guidelines
The recurrence rate of spontaneous pneumothorax is approximately 32% after a single episode, with a range of 13-39% after a first episode of secondary spontaneous pneumothorax. This is based on the most recent and highest quality study available, the British Thoracic Society guideline for pleural disease published in 2023 1. The recurrence rate is a significant concern, and current practice is to consider surgical intervention after the second episode to reduce subsequent recurrences.
Risk Factors and Prevention Strategies
Risk factors for recurrence include being male, tall and thin body habitus, smoking, younger age, and the presence of blebs or bullae on imaging. Prevention strategies include smoking cessation and, in cases of recurrence, more definitive treatments such as pleurodesis (chemical or mechanical) or surgical interventions like video-assisted thoracoscopic surgery (VATS) with pleurectomy or bullectomy. According to the British Thoracic Society guideline, chemical pleurodesis can be considered for the prevention of recurrent secondary spontaneous pneumothorax in adults, and thoracic surgery can be considered for the treatment of pneumothorax in adults at initial presentation if recurrence prevention is deemed important 1.
Management and Treatment
After a second pneumothorax, the risk of subsequent episodes increases, which is why definitive interventions are typically recommended after a second occurrence. These procedures significantly reduce recurrence rates to approximately 1-5%. Patients should be counseled about symptoms of recurrence, including sudden chest pain and shortness of breath, and advised to seek immediate medical attention if these develop. The British Thoracic Society guideline provides conditional recommendations for the use of chemical pleurodesis and thoracic surgery in the management of spontaneous pneumothorax, highlighting the importance of individualized treatment plans and consideration of patient-specific factors 1.
From the Research
Recurrence Rate of Spontaneous Pneumothorax
- The recurrence rate of primary spontaneous pneumothorax (PSP) is approximately 30% 2.
- The recurrence rate of secondary spontaneous pneumothorax (SSP) is unknown 2.
- A study comparing simple drainage, talc pleurodesis, and tetracycline pleurodesis found recurrence rates of 36%, 13%, and 8% respectively 3.
- Talc pleurodesis has been shown to be more effective in preventing recurrence compared to doxycycline solution, with a significantly lower recurrence rate 4.
- Factors associated with higher recurrence after doxycycline treatment include low weight, high height to weight ratio, and recurrent diagnosis of spontaneous pneumothorax 4.
- Chemical pleurodesis, including talc slurry and doxycycline solution, is a safe and effective procedure for preventing pneumothorax recurrence in patients with spontaneous pneumothorax 5, 6.
Risk Factors for Recurrence
- Low weight and high height to weight ratio are associated with higher recurrence after doxycycline treatment 4.
- Recurrent diagnosis of spontaneous pneumothorax is also a risk factor for higher recurrence after doxycycline treatment 4.
- The presence of bullae with a diameter of > 2 cm is associated with a higher risk of treatment failure after talc pleurodesis 6.
- Women with spontaneous pneumothorax have an increased risk of secondary spontaneous pneumothorax (SSP) 2.
- Asthma is a common cause of SSP in young people 2.
Treatment Options
- Simple drainage, talc pleurodesis, and tetracycline pleurodesis are treatment options for spontaneous pneumothorax, with talc pleurodesis showing the lowest recurrence rate 3.
- Chemical pleurodesis, including talc slurry and doxycycline solution, is a safe and effective procedure for preventing pneumothorax recurrence in patients with spontaneous pneumothorax 5, 6.
- Operative procedures, such as surgery, have a clear protective effect against recurrence in spontaneous pneumothorax and should be considered as a treatment option 2.