Editorials

Management of Secondary Spontaneous Pneumothorax: There's Confusion in the Air

Clearly, the higher recurrence rate of SSP in these patients [1], confirms the need for an innovative intervention. The patients with SSP usually present with severe dyspnea and chest pain requiring an urgent hospitalization, supplemental oxygen, aspiration and TTD according to the severity of the pneumothorax [2,4,6]. A protocol to operate on a patient experiencing 7 to 10 days of an air-leak is agreed upon by the majority of physicians, and video-assisted thoracoscopic surgery bullectomy is one of the preferred methods in the treatment of SSP due to a prolonged air-leak [1,4].

Reports of the surgical results for pneumothorax in elderly patients have been limited,2 and there is no report focusing on octogenarians or the older population. Careful attention is needed when considering the treatment strategy for secondary pneumothorax in elderly patients compared with primary spontaneous pneumothorax in younger patients, who are relatively manageable because of the absence of underlying lung disease.3 Refractory pneumothorax requiring a longer period of chest drainage may result in deterioration of quality of life and induces other medical maladies, especially in elderly patients.

Although COPD is the disease most commonly associated52,56 with secondary spontaneous pneumothorax,58 infectious pathogens, such as pneumocystis carinii,56 interstitial lung disease, connective tissue disease, pleural-based cancers, and rarely, thoracic endometrial implants, can also cause spontaneous pneumothorax.51 Secondary spontaneous pneumothorax in the setting of COPD is associated with a 4-fold increased risk of dying,59,60 and in one study, 5% of patients with a pneumothorax related to COPD died before intervention.61 It is critical to recognize diminished pulmonary reserve in any patient with a pneumothorax, including those related to trauma or iatrogenic causes.

In addition, talc pleurodesis is likely to be very painful in patients with normal parietal pleural surfaces (such as those with primary pneumothorax) and therefore deep sedation or general anaesthesia may be required for this treatment. Secondary pneumothorax in patients with chronic obstructive pulmonary disease (COPD) heralds increased mortality and often requires prolonged hospital admission.77 These patients are often poor surgical candidates because of poor lung function and are at high risk from general anaesthesia; there is no evidence base on which to determine treatment in this very difficult group.