Pneumothorax Treatment & Management

Despite general agreement on the management of pneumothorax, a full consensus about management of initial or recurrent pneumothorax does not exist. Professional societies differ in their approach to management and hospitalization. ^{[39, 38]}

This section presents a risk stratification framework as well as other approaches for choosing among options to restore lung volume and an air-free pleural space and to prevent recurrences. ^[1] These goals are applicable across diverse clinical presentations. The range of therapeutic options includes watchful waiting with or without supplemental oxygen, simple aspiration, tube drainage with or without medical pleurodesis, video-assisted thoracoscopic surgery (VATS) with pleurodesis and/or closure of leaks and bullectomy, and open surgical procedures such as thoracotomy for pleurectomy or pleurodesis.

Selection among the various management options requires an understanding of the natural history of pneumothorax, the risk of recurrent pneumothorax, and the benefits and limitations of each treatment option and discussion with the patient.

See also Restoring an Air-Free Pleural Space in Pneumothorax.

Pharmacotherapy

Medication may be necessary to treat a pulmonary disorder that causes the pneumothorax. For example, intravenous antibiotics are included in the treatment of a pneumothorax that developed as a sequela of staphylococcal pneumonia. In addition, studies suggest that the administration of prophylactic antibiotics during chest tube insertion may reduce the incidence of complications such as emphysema. Clearly, the use of analgesics can provide patient comfort until the thoracostomy tube is removed. Some authors advocate the use of intercostal nerve blocks to increase patient comfort and decrease the need for narcotic analgesics.

In patients with repeated pneumothoraces who are not good candidates for surgery, sclerotherapy with talc or doxycycline may be necessary.

The decision to observe or to treat with an immediate intervention should be guided by a risk stratification that considers the patient's presentation and the likelihood of spontaneous resolution and recurrence.

Patient presentation

The following are possible presentations of patients with pneumothorax:

• Asymptomatic (incidental finding) - Treatment decisions are guided by estimate of long-term recurrence risk.
• Symptomatic but clinically stable - Treatment is guided by local resources and conventions for the site of care; the British Thoracic Society (BTS) advocated for simple aspiration and deferring hospitalization in primary spontaneous pneumothorax (PSP) as initial management if the patient is stable ^[38] ; a small-bore catheter or chest tube placement was recommended by the American College of Chest Physicians (ACCP) Delphi consensus statement ^[39]
• Clinically fragile - Treatment is guided by local practice patterns for air evacuation and observation; comorbid conditions may preclude observation because of decreased cardiopulmonary reserve
• Life-threatening - Pneumothorax that causes hemodynamic instability is life-threatening and must be treated immediately with tube thoracostomy; all documents and recommendations call for intervention if a patient is unstable

Likelihood of resolution

The likelihood of a pneumothorax resolving is classified as follows:

• Very likely to resolve - Small pneumothorax in a hemodynamically stable patient without significant parenchymal lung disease; small iatrogenic pneumothorax
• May resolve - Large pneumothorax in a normal lung (eg, PSP or iatrogenic pneumothorax)
• Unlikely to resolve - Secondary pneumothorax, enlarging pneumothorax (suggests a continuing air leak)
• Will not resolve, could be fatal - Tension pneumothorax; unrecognized air leak

Likelihood of recurrence

The following categories of pneumothorax recurrence likelihood should be assessed:

• Unlikely to recur - Iatrogenic pneumothorax in normal lung
• May recur, but patient will likely be clinically stable
• May recur and the patient may be clinically unstable, but emergency care is readily accessible
• Very likely to recur - Diffuse and progressive pulmonary pathology (eg, lymphangioleiomyomatosis [LAM])
• Recurrence could be life-threatening - Poor cardiopulmonary reserve, limited access to emergency medical care

Selection of site of patient care

The following is a suggested guideline on determining where to administer care in a patient with a pneumothorax:

• Outpatient care - This can occur in asymptomatic patients or those with a small pneumothorax and reliable follow-up
• Emergency department (ED) care - Prolonged periods of observation are inefficient and clinically suboptimal; efficacy studies of manual aspiration and placement of one-way valves performed in EDs are an attempt to address these practical issues
• Inpatient care - This site of care is generally selected when high-flow oxygen is needed, the pneumothorax is larger but the patient is stable, or comorbidities increase concern about risk or follow-up; the average hospital stay is 2.8 days
• Intensive care unit (ICU) - ICU treatment and observation is appropriate for patients who are unstable or intubated

Interval of observation

No protocols regarding serial radiography or imaging exist; the clinician typically reviews serial vital signs and clinical assessments, using the direction and rate of change in the patient’s clinical status to select imaging frequency. Monitoring pneumothorax size during this time is important, as follows:

• At 0-6 hours - The ACCP Delphi consensus statement recommended observation in an ED for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement of the lesion, in reliable patients ^[39] ; ED observation with a repeat radiograph 6 hours later used to be common but may be used less often now
• At 24-96 hours - Additional follow up in 2 days is recommended, with preference given to a 24-48 hour follow-up radiograph in the outpatient setting; outpatient follow-up during the 96-hour window is essential to distinguish between a resolved pneumothorax and one that needs evacuation; CT at this time distinguishes between PSP and secondary spontaneous pneumothorax (SSP)
• At 1 month - Full lung reexpansion can occur, on average, 3 weeks after the initial event

Several options are available to restore an air-free pleural space, including observation without oxygen, administering supplemental oxygen, simple aspiration, chest tube placement, one-way valve insertion, and thoracostomy with continuous suction. (See the video of chest tube insertion, below.)

Contou et al recommended that clinicians consider drainage via a small-bore catheter as a first-line treatment for pneumothorax of any cause. The authors found that drainage via catheter or via chest tube is similarly effective for the management for the management of pneumothoraces, including primary spontaneous pneumothorax, secondary spontaneous pneumothorax, and traumatic and iatrogenic pneumothoraces. ^[56]

See also Restoring an Air-Free Pleural Space in Pneumothorax.

Observation without oxygen

Simple observation is appropriate for asymptomatic patients with a minimal pneumothorax (< 15-20% by Light criteria; 2-3 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement (see Chest Radiography). Air is reabsorbed spontaneously by 1.25% of pneumothorax size per day. ^[57]

A multicenter, prospective, observational study reported on more than 500 trauma patients with occult pneumothorax identified on CT with an initially normal chest radiograph. ^[58] Controversy exists in the literature on the treatment of all patients with occult pneumothorax regarding whether to closely observe patients with occult pneumothorax or whether to place a chest tube. This is even more controversial in patients on positive-pressure ventilation. It is generally accepted after trauma to treat pneumothorax seen on chest radiographs with chest tube thoracostomy. Conversion to tension pneumothorax is the worst feared complication if left untreated.

The study arms included observation versus chest tube thoracostomy. ^[58] Only 6% of patients failed observation and developed pneumothorax, including only 15% failed observation on positive-pressure ventilation. In multivariate regression analysis, failure of observation was seen in patients with chest radiographic evidence of pneumothorax progression and symptoms of respiratory distress. According to this study, it is safe to closely observe trauma patients with occult pneumothorax on chest radiographs, even if receiving mechanical ventilation.

Supplemental oxygen

Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia and is associated with a fourfold increase in the rate of pleural air absorption compared with room air alone.

Simple aspiration

Simple aspiration in 131 cases of small spontaneous pneumothorax yielded successful results up to 87%. ^[59] Other studies described more limited success in up to 70% cases. ^[60] A subsequent ED study found needle aspiration to be as safe and effective as chest tube placement for PSP, conferring the additional benefits of shorter length of stay and fewer hospital admissions. ^[61]

Chest tube placement

A tube inserted into the pleural space is connected to a device with one-way flow for air removal. Examples of such devices are Heimlich valves or water seal canisters, as well as tubes connected to wall suction devices.

One-way valve insertion (portable system)

The typical goal of inserting one-way valve systems is to avoid hospital admission and still treat the spontaneous pneumothorax. One-way valves may also expedite hospital discharge and be used during transport of an injured patient.

A Heimlich valve is a one-way rubber flutter valve that allows complete evacuation of air that is not under tension. The proximal end attaches to the chest tube or catheter, and the distal end connects to a suction device or is left open to the atmosphere. Heimlich valves do not require suction and thus eliminate the chance of a tension pneumothorax; they also allow greater mobility and less discomfort for the patient. By decreasing the length of the hospital stay and allowing for outpatient care, medical costs are reduced as well.

In a pilot study, Marquette et al determined that using a serial-steps approach with a single system (small-caliber catheter/Heimlich valve) in patients with a first episode of PSP was as effective as simple manual needle aspiration or a conventional chest tube thoracotomy. ^[62] In 41 thin, young, smoking males, a one-way Heimlich valve was connected to the catheter, allowing the air to flow spontaneously outward for 24-48 hours; thereafter, if the lung failed to reexpand, wall suction was applied. Patients with an air leak persisting for more than 4 days were referred for surgery.

At 24 hours, the success rate was 61%, and at 1 week, it had risen to 85%; the actuarial 1-year recurrence rate was 24%. ^[62] When 24-hour and 1-week success rates and recurrence at 12 months were taken as end points, the method described above was effective as simple manual needle aspiration or a conventional chest tube thoracotomy. ^[62]

Heimlich valves are widely used in the care of patients with AIDS who have a median length of 20 days of chest tube placement to facilitate care and mobility.

Thoracostomy with continuous wall suction

First-time secondary SSP (including chronic obstructive pulmonary disease [COPD]) and traumatic pneumothorax typically require this approach. A small-bore catheter (eg, 7-14 French) is safe to use in most patients, whereas a larger chest tube (24 French) is also appropriate initially, and increasing suction pressure can be used if the lung fails to inflate.

A larger tube (eg, 28 French) can reduce resistance in patients who are ventilated and at greater risk for air leaks. Air leaks resolve within 7 days of treatment 80% of the time, with an average hospital stay of 5 days. Keep the tube in place for 24 hours after the air leak ceases.

Assess the ABCs (airway, breathing, circulation), and evaluate the possibility of a tension pneumothorax. Assess the vital signs, and perform pulse oximetry. A tension pneumothorax is almost always associated with hypotension.

Administer oxygen to the patient, ventilate the patient, and establish an intravenous (IV) line.

Tension pneumothorax

Failure of the emergency medical service personnel (EMS) and medical control physician to make a correct diagnosis of tension pneumothorax and to promptly perform needle decompression in the prehospital setting can result in rapid clinical deterioration and cardiac arrest. Most paramedics are trained and protocolized to perform needle decompression for immediate relief of a tension pneumothorax.

However, if an incorrect diagnosis of tension pneumothorax is made in the prehospital setting, the patient's life may be endangered by unnecessary invasive procedures. Close cooperation and accurate communication between the ED and the EMS personnel is of paramount importance.

To prevent reentry of air into the pleural cavity after needle thoracostomy and decompression in the prehospital setting, a one-way valve should be attached to the distal end of the Angiocath. If available, a Heimlich valve may be used. If a commercially prepared valve is not available, attach a finger condom or the finger of a rubber glove with its tip removed to serve as a makeshift one-way valve device.

Clothing covering a wound that communicates with the chest cavity can play a role in producing a one-way valve effect, allowing air to enter the pleural cavity but hindering its exit. Removing such clothing items from the wound may facilitate decompression of a tension pneumothorax.

A tension pneumothorax is a contraindication to the use of military antishock trousers.

Prehospital ultrasonography

In a preliminary 2006 study from Norway, Busch evaluated the feasibility of using portable ultrasound devices in an air rescue setting, concluding that prehospital US could provide diagnostic and therapeutic benefit when conducted by a proficient examiner who used goal-directed and time-sensitive protocols. ^[44] Further study in this area will further define the indications for and role of prehospital US.

Immediate attention to the ABCs (airway, breathing, circulation) while assessing vital signs and oxygen saturation is paramount, particularly in patients with thoracic trauma. Evaluate the patency of the airway and the adequacy of the ventilatory effort. Assess the circulatory status and the integrity of the chest wall. Carefully evaluate the cardiovascular system, because a tension pneumothorax and pericardial tamponade can cause similar findings.

ED care depends on the hemodynamic stability of the patient. All patients should receive supplemental oxygen to increase oxygen saturation and to enhance the reabsorption of free air.

It should be kept in mind that US is the only radiographic modality that allows patients with nonarrhythmogenic cardiac arrest to continue undergoing resuscitation while clinicians search for easily reversible causes of asystole or pulseless electrical activity (PEA). ^[63] In the CAUSE protocol, cardiac arrest patients, concurrent with resuscitation, receive bedside US to look for cardiac tamponade, massive pulmonary embolus, severe hypovolemia, and tension pneumothorax has been proposed for further investigation. ^[50]  (See Ultrasonography.)

Primary and secondary spontaneous pneumothorax

If the PSP is smaller than 15% (or estimated as small) and the patient is symptomatic but hemodynamically stable, needle aspiration is the treatment of choice.

If the PSP is smaller than 15% and if the patient is asymptomatic, many consider observation to be the treatment of choice. (If the patient is admitted, administer oxygen, as this has been shown to speed resolution of the pneumothorax.)

If the PSP is greater than 15% (or estimated as large) aspiration using a pigtail catheter left to low suction or water seal is recommended. Strong suction should not be used with a spontaneous pneumothorax because of an often-delayed presentation and, thus, an increased risk of reexpansion pulmonary edema (see Complications).

Spontaneous pneumothorax is a life-threatening condition in patients with severe underlying lung disease; thus, tube thoracostomy is the procedure of choice in SSP.

Pleurodesis decreases the risk of recurrence, as does thoracotomy or video-assisted thoracoscopic surgery (VATS) to excise the bullae.

Iatrogenic and traumatic pneumothorax

Aspiration is the technique of choice for iatrogenic pneumothoraces, because recurrence is usually not a factor. Tube thoracostomy is reserved for very symptomatic patients.

In general, traumatic pneumothorax should be treated with a chest tube, particularly if the patient cannot be closely observed. Chest tubes are attached to a one-way valve apparatus that uses a water chamber to avoid a direct connection to atmospheric pressure (so that during inspiration, when negative pressure is generated, air does not rush into the pleural space), allowing continuous removal of air from the pleural cavity during respiration. Changing the pressure above the water seal allows below-atmospheric suction for further removal of air. The collapsed lung reexpands and heals, preventing continued air leakage. After air leaks have ceased for 24 hours, the vacuum may be decreased and the tube removed.

The process of lung reexpansion and healing is not immediate and may be complicated by pulmonary edema; therefore, a chest tube is usually left in place until the clinical conditions are met; any complications warrant longer placement.

A subset of patients who have a small (< 15-20%), minimally symptomatic pneumothorax may be admitted, observed closely, and monitored by using serial chest radiographs. In these patients, administration of 100% oxygen promotes resolution by speeding the absorption of gas from the pleural cavity into the pulmonary vasculature.

Although commonly used, few data exist in the medical literature showing the efficacy of the procedure or reviewing the field-use and incidence of the needle decompression.

Tension pneumothorax

Tension pneumothorax remains a life-threatening condition diagnosed under difficult conditions, with a simple emergency procedure as treatment (ie, needle decompression). Make sure no contraindications exist for the placement of an emergency decompression catheter into the thorax. Previous thoracotomy, previous pneumonectomy, and presence of a coagulation disorder, for example, are relative contraindications, because failure to treat tension pneumothorax expectantly can result in patient death.

In emergency circumstances, decompression catheters should be placed in the second intercostal space in the midclavicular line. This site was confirmed in a review of 100 thoracic CT scans by measuring the distance from the midline to the internal mammary artery (IMA) and the average thickness of the tissues. ^[64] This procedure punctures the skin and, possibly, the pectoralis major muscle, external intercostals, internal intercostals, and parietal pleura. Placement in the middle third of the clavicle minimizes the risk of injury to the IMA during the procedure. ^[64] The catheter should be placed just above the cephalad border of the rib; the intercostal vessels are largest on the lower edge of the rib.

Harcke et al had similar results when they used CT analysis of deployed male military personnel to determine that the mean horizontal thickness at the second right intercostal space in the midclavicular line was 5.36 cm and that an 8-cm angiocatheter would reach the pleural space in 99% of the male soldiers in this series. ^[65]

Unfortunately, in a 2005 study of emergency physicians, 21 of whom had completed advanced trauma and life support (ATLS) training, only 60% were able to correctly identify the second intercostal space when attempting to locate the needle thoracostomy site on a human volunteer, and all placed the thoracentesis needle medial to the midclavicular line. ^[63] In the same study, 8% of participants inappropriately identified the site used for needle pericardiocentesis, and 4% inappropriately identified the fifth intercostal space in the anterior axillary line. ^[63]

A 2011 study by Sanchez et al suggested that the anterior approach is typically more successful than the lateral approach when it comes to angiocatheters, though the anterior approach is not failsafe. Further, longer angiocatheters may increase the chances of decompression, but the risk of damage to surrounding vital structures is higher. ^[66]

In relation to the development of apparent life-threatening hemorrhage after decompression in the second intercostal space at the anterior, midclavicular line in patients with no initial evidence of hemothorax on presentation, it has been suggested that a potentially safer option is to decompress a pneumothorax in the fifth intercostal space at the anterior axillary line, similar to recommendations for chest drain insertion.

If a hemothorax is associated with the pneumothorax, additional chest tubes may be needed to assist drainage of blood and clots. If the hemopneumothorax requires insertion of a second chest tube, the second tube should be directed inferiorly and should be posterior to the apex of the diaphragm.

Another point to take note of is that a significant number of patients have a larger chest wall than can be penetrated by a catheter length of 5 cm. In particular, men undergoing treatment for tension pneumothorax are more likely to have a larger body habitus with wider chest wall, so that performing needle thoracostomy may necessitate the use of a catheter longer than 5 cm to reliably penetrate into the pleural space.

In one study, a catheter length of patients at an American level 1 trauma center showed that a catheter length of 5 cm would reliably penetrate the pleural space in only 75% of patients. ^[67] A 2008 study analyzing average chest-wall thickness at the second intercostal space in the midclavicular line concluded that a 4.5-cm catheter length may not penetrate the chest wall in approximately 10-35% of trauma patients, depending on age and sex. ^[68]

Catamenial pneumothorax

Oral contraceptives carry a high success rate in the treatment of catamenial pneumothorax, though this condition may also (rarely) be treated surgically. Most cases present during or shortly after menses, and the spontaneous pneumothorax is usually right-sided.

Pneumomediastinum

Most patients with pneumomediastinum should be observed for signs of serious complications (eg, pneumothorax, tension pneumothorax, mediastinitis). If the pneumomediastinum occurred from the inhalation of cocaine or smoking of marijuana, observation in the ED for progression may be indicated.

A follow-up chest radiograph should be obtained in 12-24 hours to detect any progression or complication, such as pneumothorax. If no progression occurs at 24 hours and if no evidence of mediastinitis exists, the patient may be discharged.

If the patient has had repeated episodes of pneumothorax or if the lung remains unexpanded after 5 days with a chest tube in place, operative therapy may be necessary. The surgeon may use treatment options such as thoracoscopy, electrocautery, laser treatment, resection of blebs or pleura, or open thoracotomy. Other surgical indications are as follows:

• Persistent air leak for longer than 7 days
• Recurrent, ipsilateral pneumothorax
• Contralateral pneumothorax
• Bilateral pneumothorax
• First-time presentation in a patient with a high-risk occupation (eg, diver, pilot)
• Patients with acquired immunodeficiency syndrome (AIDS) (often because of extensive underlying necrosis)
• Unacceptable risk of recurrent pneumothorax for patients with plans for extended stays at remote sites
• Lymphangiomyomatosis, a condition causing a high risk of pneumothorax ^[69]

VATS is chosen for recurrent PSP or SSP, particularly for pediatric patients, in whom it has been shown to have better outcomes and shorter recovery. VATS is an alternative to thoracotomy and is performed with the patient under general anesthesia using a camera and small trocar access ports. Other indications include an unexpanded lung 5 days after tube thoracostomy, bronchopleural fistula persisting for 5 days or longer, recurrent pneumothorax after chemical pleurodesis, and occupational reasons (eg, airplane pilots, deep-sea divers).

In a meta-analysis of 12 trials that randomized 670 patients, VATS was associated with shorter length of stay (reduction, 1.0-4.2 days) and less pain or use of pain medication than thoracotomy in the five of seven trials in which the technique was used for pneumothorax or minor lung resection. ^[70]  In the treatment of pneumothorax, VATS was associated with substantially fewer recurrences than pleural drainage in two trials. ^[70] VATS with resection of large bullous lesions is associated with a recurrence rate of 2-14%.

Whereas thoracotomy has been the criterion standard, it is increasingly being replaced by VATS in the treatment of chronic or persisting pneumothoraces, for the aforementioned reasons. Recurrence rates with thoracotomy are as low as 4%. ^[71]

Talc has been the preferred agent for pleurodesis (see below). It can be administered by insufflation or as a slurry. Insufflation of talc and thoracotomy has had a recurrence rate of 0-7%.

In patients with repeated pneumothoraces who are not good candidates for surgery, pleurodesis (or sclerotherapy) may be necessary. Pleurodesis decreases the chance of pneumothorax recurrence and should be performed in consultation with the surgeon. This procedure should be performed just after reinflation of the lung if the presence of an air leak is not a contraindication. The two major sclerosing agents are talc and tetracycline derivatives (eg, minocycline, doxycycline). 

Talc (5-10 g in 250 mL sterile isotonic sodium chloride solution) is usually insufflated during VATS or thoracotomy, but one study of 32 patients demonstrated findings of successful treatment with a chest tube (10% recurrence at 5 years).

In a large Department of Veterans Affairs study, tetracycline pleurodesis had a 25% recurrence in patients compared with 41% in control subjects. However, tetracycline no longer is available for pleurodesis because of stringent manufacturing requirements. Nonetheless, its derivatives minocycline and doxycycline have been shown to be successful sclerosing agents. Bleomycin was found to be ineffective in rabbits and is expensive.

Pleurodesis is painful, and the patient should be premedicated with benzodiazepine and intrapleural lidocaine (see Medications).

Misdiagnosis is the most common complication of needle decompression. If a pneumothorax but not a tension pneumothorax is present, needle decompression creates an open pneumothorax. Alternatively, if no pneumothorax exists, the patient may develop a pneumothorax after the needle decompression is performed. Additionally, the needle may create a lung laceration, which, though rare, can cause significant pulmonary injury or hemothorax. If the needle is initially placed too medial to the sternum, needle decompression may cause a hemothorax by lacerating the inferior set of intercostal vessels or the internal mammary artery.

Damage to the intercostal neurovascular bundle and lung parenchymal injury can occur following thoracostomy tube placement, especially if trocars are used for placement, and there is an increased risk of postoperative bleeding after lung transplantation for medical pleurodesis and surgery (though length of hospital stay is not affected). ^[69]

Accidental disconnection and malpositioning of Heimlich valves can complicate an attempted outpatient treatment of pneumothorax via pigtail catheter.

Pneumothorax complications include the following:

• Hypoxemic respiratory failure
• Respiratory or cardiac arrest
• Hemopneumothorax
• Bronchopulmonary fistula
• Pulmonary edema (following lung reexpansion)
• Empyema
• Pneumomediastinum
• Pneumopericardium
• Pneumoperitoneum
• Pyopneumothorax

Complications of surgical procedures include the following:

• Failure to cure the problem
• Acute respiratory distress or failure
• Infection of the pleural space
• Cutaneous or systemic infection
• Persistent air leak
• Reexpansion pulmonary edema
• Pain at the site of chest tube insertion
• Prolonged tube drainage and hospital stay

Reexpansion pulmonary edema

Reexpansion pulmonary edema is a unilateral pulmonary edema that is seen after reinflation of a collapsed lung. It can also occur in the opposite lung. The incidence, etiology, risks, and mortality rates of this condition are controversial.

Findings from animal studies and several case reports in humans indicate that reexpansion pulmonary edema may occur more often if a pneumothorax is present for longer than 3 days, if the evacuation volume is greater than 2000 mL, and if suction is applied. This information is important because in one study, 46% of patients waited more than 2 days after their symptoms started to seek medical attention, and, in another study, 18% waited more than 7 days.

Tension pneumothorax

A worsening pneumothorax, usually with a one-way valve phenomenon, can allow air into the intrapleural space and prevent its escape, causing mediastinal shift, pulmonary shunting, and circulatory collapse.

Treatment of tension pneumothorax is done on an emergency basis and should be performed before confirmatory radiologic studies. Needle decompression is performed before definitive treatment with tube thoracostomy (see Hospital Management).

In mechanically ventilated patients, high pressures and air trapping place patients at risk for tension pneumothorax if the thoracostomy is not functioning. Patients with smaller pneumothoraces that would otherwise be managed with aspiration or observation sometimes undergo thoracostomy because of the need for mechanical ventilation.

Prevention of recurrence

Strategies for the prevention of recurrent pneumothorax include observation, surgical and nonsurgical pleurodesis, and bleb resection. Other important points to keep in mind include the following:

• Prompt recognition and treatment of bronchopulmonary infections decrease the risk of progression to a pneumothorax
• If subclavian vein cannulation is required, the supraclavicular approach should be used rather than the infraclavicular approach whenever possible to help decrease the likelihood of pneumothorax formation
• The incidence of iatrogenic tension pneumothorax may be decreased with prophylactic insertion of a chest tube in patients with a simple pneumothorax that requires positive pressure ventilation
• Pleurodesis decreases the risk of recurrence of spontaneous pneumothorax, as does thoracotomy or VATS to excise the bullae

A study by Chen et al found that pleural abrasion with minocycline pleurodesis was as effective as apical pleurectomy for patients with PSP with high recurrence risk. Patients undergoing both procedures had similar durations of postoperative chest drainage, lengths of hospital stay, complication rates, long-term residual chest pain, and long-term pulmonary function. The rate of recurrence was 3.8% for both procedures. ^[72]

An Italian study reported on a fibrin sealant that was found to be safe and effective for preventing alveolar air leaks after lung resections. The sealant also reportedly shortened the duration of postoperative alveolar air leaks. ^[73]

A Japanese study found that the use of an absorbable polyglycolic acid sheet to cover the staple line after thoracoscopic bullectomy may prevent the recurrence of PSP. ^[74]

Observation

Observation is appropriate for iatrogenic pneumothorax in an individual with normal lungs who has responded to treatment with observation or simple aspiration. Simple aspiration or chest tube drainage of pneumothorax does not prevent recurrence. In fact, recurrences have been reported to occur in up to 32% of PSPs. ^{[75, 71]}

One study showed that a Heimlich valve with small-caliber catheter was less effective in preventing recurrence than closed thoracostomy. In another study, the recurrence rate after 1 year with Heimlich valve versus chest tube placement was not significantly different. ^[76]  Recurrent spontaneous pneumothorax requires more definitive treatment to prevent recurrence. Recurrence rates are higher with SSP than with PSP; hence, observation is less often chosen as an approach in SSP.

Surgical pleurodesis

A patient treated with surgical pleurodesis has a recurrence prevention rate of greater than 90%. Practice variation depends on local practitioner experience, resources, and success with approaches ranging from VATS (recommended by the American College of Chest Physicians [ACCP]) ^[39]  to surgical thoracotomy and pleurectomy (recommended by the British Thoracic Society [BTS] because of the absolute lowest recurrence rates). ^[38]

Nonsurgical pleurodesis

"Medical" thoracoscopy requires only local anesthesia or conscious sedation, in an endoscopy suite, using nondisposable rigid instruments. Thus, this procedure is considerably less invasive and less expensive, but it is also less effective, particularly in inexperienced hands. Patient comorbidity plays a role in selection of appropriate intervention. The main diagnostic and therapeutic indications for medical thoracoscopy are pleural effusions and pneumothorax. ^[77]

Success rates for chemical sclerosing agents are up to 91% versus 95-100% for surgical techniques. ^[78]  In an early study, chemical pleurodesis resulted in a significant reduction of recurrence compared to chest tube drainage alone. ^[79]  Chemical pleurodesis and surgery were equally effective and were both superior to conservative therapy in preventing the recurrence of pneumothorax in LAM.

Physicians from various services may be needed to care for patients who require tube thoracostomy, pleurodesis, or surgical thoracotomy and admission. A surgeon and a pulmonologist should evaluate patients underlying lung disease or with recurrent disease to determine the cause and further management.

Treatment of tension pneumothorax should commence immediately after diagnosis, without delay for further consultation and/or evaluation.

A trauma or general surgeon should evaluate patients with trauma, and the patient is often admitted for observation.

When a patient is on positive-pressure ventilation and normal respiratory function is preserved, routinely follow up decompressed tension pneumothoraces by watching for recurrence of the condition. Chest radiography is helpful but not required.

Direct patients indicating a readiness to quit smoking to their primary care physician or offer referral for cessation management. This may include nicotine replacement and non-nicotine pharmacotherapy (eg, bupropion or varenicline).

Patients should receive follow-up care from a pulmonary physician within 7-10 days.