Series
Spontaneous pneumothorax: time to rethink management?

https://doi.org/10.1016/S2213-2600(15)00220-9Get rights and content

Summary

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

Introduction

Spontaneous pneumothorax is a common clinical problem. However, the best management strategy is controversial, with substantial variation in practice, largely driven by a paucity of evidence. In this Series paper, we provide an overview of existing data and suggest that new approaches to definition, risk stratification, and treatment of pneumothorax might be necessary. We challenge the traditional view of primary spontaneous pneumothorax occurring in patients with no underlying lung disease; it may be that such patients should be considered on a continuum with secondary spontaneous pneumothorax. We explore the evidence behind current management guidelines, with emphasis on newer and controversial strategies such as conservative or ambulatory management, methods of risk stratification in primary spontaneous pneumothorax (including lung density assessment and air-leak measurement), as well as medical and surgical approaches to treating prolonged air leak and preventing recurrence.

Key messages

  • There is increasing evidence of underlying lung abnormalities in patients traditionally labelled as having primary spontaneous pneumothorax

  • Advances in our understanding could allow a reclassification of pneumothorax that more clearly addresses the underlying cause

  • Careful consideration of specific disorders associated with causes of pneumothorax might lead to improvements in management tailored to the individual patient

  • If radiological, clinical, and demographic information can be shown to stratify patients according to risk of recurrence after an initial pneumothorax, this would allow the early targeted use of recurrence-prevention strategies

  • Research into the use of Heimlich valves might lead to an increase in their use in the future, allowing ambulatory management in the patient's home

  • The safety and efficacy of conservative management in patients with large primary spontaneous pneumothoraces is being assessed in a large randomised controlled trial that is currently recruiting participants

  • Smoking cessation is associated with a reduction in the risk of recurrent pneumothorax and is strongly advised in all patients

Section snippets

(Re)classification of pneumothorax

The classification of pneumothorax as either primary or secondary dates back to the early 20th century; the first description of pneumothorax in patients with no known underlying respiratory disease was published by Kjærgaard in 1932.1 This report acknowledged the distinction between “pneumothorax simple” (in patients with no underlying lung disease) and pneumothorax secondary to tuberculous disease. It was important to distinguish between tuberculosis and other causes of pneumothorax to avoid

Specific causes of pneumothorax

Although height and male sex are risk factors for primary spontaneous pneumothorax,9 smoking is the most important risk factor contributing to development of the disease. Large observational studies of primary spontaneous pneumothorax have shown that most patients are smokers and detected a dose-response relation between number of cigarettes smoked and risk of pneumothorax.10 Smoking cessation is associated with a substantial reduction in the risk of recurrence.11

Cannabis smoking is associated

Current guidelines

As early as 1966, differing approaches to pneumothorax management were postulated. In the same issue of one journal, one article suggested active surgical management,28 whereas another recommended a policy of non-intervention and outpatient management.29 Nearly 50 years later, questions remain about the respective roles of conservative and more invasive treatment. International guidelines stratify patients to treatment options depending on the combination of symptoms and an assessment of the

Lung apposition and pneumothorax resolution

Fundamental to the lack of progress in management of primary spontaneous pneumothorax is a poor understanding of its precise causal mechanisms. For decades, clinicians believed that primary spontaneous pneumothorax resulted from the leakage of air from the lung into the pleural cavity via a single breach site (eg, bleb) in the visceral pleura. A major revelation the past decade is that the “one-airway-one-bleb-one-leak” concept is over-simplistic and likely to be incorrect. Although blebs can

Lung density and risk stratification

An accurate assessment of the risk of recurrence is crucial to improving care in spontaneous pneumothorax. Most centres (and international guidelines) recommend reserving definitive recurrence prevention approaches until the second or third presentation of primary spontaneous pneumothorax. This recommendation is based on the commonly quoted figure of a 20–30% risk of recurrence after an initial primary spontaneous pneumothorax; however, high-quality studies have quoted recurrence rates in

Ambulatory care: the role of Heimlich valves

The clinical value of observing stable patients, especially those with primary spontaneous pneumothorax, for days in hospital can be questioned. Patients requiring chest drain insertion have historically been admitted to hospital and the drain connected to a bulky underwater seal or suction device. This approach has remained unchanged despite decades of documented use of Heimlich valves (one-way valves connected to the end of the chest drain), which allow greater mobility and potentially allow

Digital air-leak measurement

When standard management does not sufficiently resolve the air leak, surgical referral is recommended.31 However, the optimum timing of definitive intervention is unknown. Current guidelines suggest that in patients with a persistent air leak or failure of lung re-expansion, an early (3–5 days) thoracic surgical opinion should be sought, but there are no published data on prediction of persistent air leak or requirement for inpatient surgical intervention.

If persistent air leak could be

Conservative management

International guidelines suggest a role for conservative management (observation alone) of clinically stable patients with primary spontaneous pneumothorax with close radiological follow-up to ensure resolution.30, 31 The previously mentioned study in Australasia (ACTRN12611000184976) is randomly assigning clinically stable patients with large primary spontaneous pneumothoraces to either observation without pleural intervention or standard care with needle aspiration and intercostal drain

Prevention of pneumothorax recurrence

Medical or surgical pleurodesis is advised for second ipsilateral primary spontaneous pneumothorax.30, 31, 35 However, because of the high rates of recurrence reported in the first year, the argument could be made to offer pleurodesis at the first episode.

Chen and colleagues55 provide an important insight into the feasibility of pleurodesis after simple aspiration for primary spontaneous pneumothorax and attempt to redefine a treatment algorithm for the first episode of the disease. There are,

Targeted surgical management

Elective surgery is commonly undertaken to reduce the risk of recurrent pneumothorax after a second episode, but surgical intervention is also recommended when simple medical management does not resolve an acute air leak.31 However, the best possible timing for surgery has not been established. UK guidelines suggest 5–7 days from the onset of air leak but evidence is limited.31 Indeed, one study including patients with both primary and secondary spontaneous pneumothoraces reported that after 14

Important questions for future research

The identification of factors predicting both persistent air leak and recurrence of pneumothorax would be of great value in early stratification of patients to the appropriate management strategy. Digital measurement of air leak and radiological features, respectively, could hold promise in this area. Modern resources potentially allow a more detailed work-up of patients with primary spontaneous pneumothorax than was possible historically; however, the extent to which this will alter management

Conclusions

Pneumothorax has been an under-researched area, and available evidence has been of fairly low quality, giving rise to international guidelines largely based on consensus and observational evidence, with few areas of agreement between them. Future high-quality studies may allow development of tailored management strategies, increasingly personalised care, a move towards outpatient-based treatment, and more conservative management. A risk stratification system at first presentation could identify

Search strategy and selection criteria

We identified relevant studies for inclusion in this Series paper by searches of Medline, between Jan 1, 1980 to Jan 13, 2015, without language restrictions, with the search term “pneumothorax” appearing within the title and abstract of relevant study types (all clinical trials, guidelines, reviews, systematic reviews, and meta-analyses). Studies were restricted to those on adult patients and recent studies were prioritised. Additionally, the most up-to-date guidelines from international

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