From the Guidelines
The most current advice for managing secondary spontaneous pneumothorax (SSP) generally favors early intervention with intercostal drainage over conservative management for most patients, as recommended by the British Thoracic Society guideline for pleural disease 1. For small pneumothoraces (less than 2 cm rim of air or less than 15% of the hemithorax) in clinically stable patients without significant breathlessness, conservative management with observation, oxygen supplementation, and close monitoring may be appropriate. However, for larger pneumothoraces, patients with significant symptoms, or those with underlying lung disease, prompt intercostal drainage is recommended, as stated in the BTS guidelines for the management of spontaneous pneumothorax 1. This typically involves insertion of a small-bore chest tube using the Seldinger technique, placed in the "safe triangle", and connected to an underwater seal system with suction if needed. Chemical pleurodesis or thoracic surgery may be considered in certain cases to reduce the risk of recurrence, as discussed in the British Thoracic Society guideline for pleural disease 1. Key considerations in the management of SSP include:
- Patient symptoms and stability
- Size of the pneumothorax
- Underlying lung disease
- Risk of recurrence
- Potential benefits and risks of different management strategies, including intercostal drainage, conservative management, and surgical intervention. The preference for early drainage in SSP stems from the understanding that patients with underlying lung disease have less pulmonary reserve and are more likely to experience significant physiological compromise even with relatively small pneumothoraces, making them less suitable candidates for observation alone compared to those with primary spontaneous pneumothorax, as noted in the BTS guidelines 1 and the British Thoracic Society guideline for pleural disease 1.
From the Research
Conservative Management vs Intercostal Drainage for Secondary Spontaneous Pneumothorax
- The current advice for managing secondary spontaneous pneumothorax (SSP) is evolving, with some studies suggesting that conservative management may be a viable option for selected patients 2, 3.
- A retrospective cohort study found that conservative management of SSP was safe and effective, with no patients requiring subsequent intervention, and resulted in shorter inpatient stays compared to intercostal catheter placement 2.
- Another study found that ambulatory management of SSP using a one-way valve was effective and safe, with similar outcomes to primary spontaneous pneumothorax, and resulted in significant cost savings 3.
- However, a randomized controlled trial found that the use of a pleural vent for ambulatory management of SSP had a high rate of early treatment failure, and recommended against its use in SSP 4.
- The use of an Atrium Pneumostat valve, on the other hand, was found to be a safer alternative, with no early treatment failures and a trend towards lower length of stay 4.
- A review of current guidance, controversies, and recent advances in the management of SSP highlights the need for further research and debate on the optimal management strategy for this condition 5.