From the Guidelines
Spontaneous pneumothorax should be treated with simple aspiration as the first line of treatment for primary pneumothoraces, and tube drainage for large secondary pneumothoraces, with consideration of surgical intervention after a first recurrence to prevent further episodes, especially in high-risk patients. Spontaneous pneumothorax is the sudden collapse of a lung without trauma or medical intervention, occurring when air enters the pleural space. Primary spontaneous pneumothorax typically affects tall, thin young males and is caused by the rupture of small blebs or bullae on the lung surface, often related to smoking 1. Secondary spontaneous pneumothorax occurs in patients with underlying lung diseases such as COPD, cystic fibrosis, tuberculosis, lung cancer, or interstitial lung disease.
Causes and Risk Factors
The causes of spontaneous pneumothorax include:
- Rupture of small blebs or bullae on the lung surface
- Underlying lung diseases such as COPD, cystic fibrosis, tuberculosis, lung cancer, or interstitial lung disease Risk factors for recurrence include:
- Continued smoking
- Age under 50
- Male gender
- Tall stature
- Low body weight
- Underlying lung disease
Treatment
Treatment depends on the size and symptoms of the pneumothorax. Small, asymptomatic pneumothoraces may be managed with observation and oxygen therapy. Larger or symptomatic cases require needle aspiration or chest tube insertion to remove the air. In severe cases, pleurodesis (chemical or mechanical irritation of the pleural surfaces to create adhesions) or surgery may be necessary. Simple aspiration is recommended as the first line of treatment for primary pneumothoraces, with a success rate of 59-83% 1. For secondary pneumothoraces, tube drainage is recommended as the initial treatment, especially for large pneumothoraces (>2 cm) or in patients over 50 years old.
Recurrence Prevention
The recurrence rate is approximately 30% after a first episode, rising to 50% after a second episode 1. Definitive treatments like pleurodesis or video-assisted thoracoscopic surgery (VATS) with bleb resection and pleurodesis should be considered after a first recurrence to prevent further episodes, especially in high-risk patients. A recent study suggests that surgical intervention may be considered at an earlier stage, prior to the first recurrence, in an elective context 1. However, the decision to proceed with surgical intervention should be individualized, taking into account the patient's preferences, underlying lung disease, and overall health status.
From the Research
Causes of Spontaneous Pneumothorax
- Primary spontaneous pneumothorax (PSP) is an important disease commonly seen in young males 2
- Secondary spontaneous pneumothorax (SSP) may occur due to underlying lung disease 3
- Traumatic pneumothorax (PTX) can occur in patients with severe polytrauma and chest injuries 4
Treatment of Spontaneous Pneumothorax
- Simple observation in stable patients with PSP is reasonable, and encouraging smoking cessation is paramount 3
- Needle aspiration (NA) has been widely adopted due to simplicity and reported efficacy and safety, and is as effective as tube thoracostomy regarding immediate success rate and 12-month recurrence rate 2
- Tube thoracostomy is commonly used, at least in the USA, as a primary treatment modality, which requires hospitalization 2
- Video-assisted thoracoscopic surgery (VATS) with the resection of bullae/blebs and mechanical pleurodesis can be an effective treatment to prevent recurrence in patients with their first presentation of primary spontaneous pneumothorax, especially when high-resolution computed tomography demonstrates bullae ≥2 cm 5
- Simple needle aspiration can be a reasonable approach for hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation 4
Risk Factors for Recurrence
- Presence of bullae ≥1 cm on high-resolution computed tomography increases the risk of recurrence 5
- Size of bullae is related to the risk of recurrence, with larger bullae having a higher risk of recurrence 5
- Patients with SSP are at higher risk of recurrence due to underlying lung disease 3
- Smoking is a risk factor for recurrence, and encouraging smoking cessation is important 3