From the Guidelines
Spontaneous pneumothorax is a condition where air accumulates in the pleural space without preceding trauma or medical intervention, causing partial or complete lung collapse, and can be subclassified into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) based on the presence of underlying lung disease 1. The most common causes of PSP are rupture of small blebs or bullae (air-filled sacs) on the lung surface, often located at the apex of the upper lobes. SSP can result from various lung conditions including COPD (especially emphysema), cystic fibrosis, tuberculosis, lung cancer, interstitial lung diseases, and Pneumocystis pneumonia. Other less common causes include catamenial pneumothorax (related to menstruation), Marfan syndrome, and Ehlers-Danlos syndrome. Some key points to consider in the management of spontaneous pneumothorax include:
- The size of the pneumothorax is no longer an indication for invasive management, although it does dictate the safety of conducting an intervention 1
- The use of chest drains is mainly centered around patients with high-risk characteristics 1
- Ambulatory treatment using a purpose-made device containing a one-way valve, or Heimlich valve attached to chest drain has the potential to allow outpatient management of pneumothorax 1
- Thoracic surgery is often the treatment of choice for ongoing air leak, or for those with recurrent pneumothorax 1 Patients typically present with sudden-onset chest pain and shortness of breath. Management depends on the size of the pneumothorax and patient's clinical status, ranging from observation with oxygen supplementation for small pneumothoraces to needle aspiration or chest tube insertion for larger ones. The current standard of care for PSP is drainage of symptomatic pneumothorax, either with needle aspiration (NA) or intercostal chest drain (ICD) attached to an underwater seal 1. Recurrence is common, particularly in PSP, and may require surgical intervention such as pleurodesis or bullectomy to prevent future episodes. Smoking cessation is strongly recommended as smoking increases the risk of both occurrence and recurrence.
From the Research
Definition and Classification of Spontaneous Pneumothorax
- Spontaneous pneumothorax is a pneumothorax that does not arise from trauma or an iatrogenic cause 2
- It can be classified into primary and secondary spontaneous pneumothorax based on the absence or presence of overt underlying lung disease 3, 2, 4
Causes of Spontaneous Pneumothorax
- Primary spontaneous pneumothorax is associated with underlying pleuropulmonary disease, despite the absence of overt lung disease 2
- Secondary spontaneous pneumothorax is caused by underlying lung disease, such as silicosis or Staphylococcus aureus pneumonia 5
- Genetic syndromes can also be an underlying cause of spontaneous pneumothorax, with a high risk of recurrence and extrathoracic manifestations 4
Risk Factors and Demographics
- Primary spontaneous pneumothorax typically occurs in young adults, especially males 5, 6
- Secondary spontaneous pneumothorax can occur in patients with underlying lung disease, regardless of age or sex 3, 5
- Simultaneous bilateral spontaneous pneumothorax is a rare condition, accounting for 1.3% of all spontaneous pneumothorax cases 5
Management and Treatment
- Management guidelines for spontaneous pneumothorax have been published, but awareness and application among clinicians seem poor 3
- Conservative management, including observation and small-bore chest tube placement, can be effective for selected patients with primary spontaneous pneumothorax 3, 2
- Definitive measures, such as pleurodesis, may be recommended after the first recurrence of pneumothorax to prevent further recurrences 3, 4