Blackwell Science, LtdOxford, UKRESRespirology1323-77992004 Blackwell Science Asia Pty LtdMay 200492157164Review ArticlePneumothoraxMH Baumann and M Noppen

Respirology (2004) 9, 157–164

INVITED REVIEW SERIES: PLEURAL DISEASES

Pneumothorax
Michael H. BAUMANN1 AND Marc NOPPEN2

1
Division of Pulmonary and Critical Care Medicine, University of Mississippi Medical Center, Jackson,
Mississippi, USA and 2Interventional Endoscopy Clinic, Academic Hospital AZ-VUB, Brussels, Belgium

Pneumothorax
BAUMANN MH, NOPPEN M. Respirology 2004; 9: 157–164
Abstract: Spontaneous pneumothoraces can occur without obvious underlying lung disease (pri-
mary) or in patients with known underlying lung disease (secondary). Management guidelines for
spontaneous pneumothorax have been published by major professional organizations, but aware-
ness and application among clinicians seems poor. First episodes of primary spontaneous pneu-
mothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is
large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-
bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general,
definitive measures to prevent recurrence are recommended after the first recurrence of the pneu-
mothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery)
pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by
pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces
may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of
a chest tube. Selected patients may be treated conservatively, with approximately 10% of these
patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of
causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-
related pneumothoraces have CT findings that can predict their occurrence and the need for chest
tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation
or small bore chest tube placement, depending upon patient stability and the size of the
pneumothorax.

Key words: iatrogenic, pneumothorax, spontaneous, traumatic.

INTRODUCTION develop following direct or indirect trauma, often

to the chest, unrelated to any medical procedure.
Pneumothoraces are classified as spontaneous and Iatrogenic pneumothoraces result from medical
non-spontaneous.1,2 Spontaneous pneumothoraces interventions.1–3
occur without any preceding trauma or obvious pre- Whatever the cause or the type of pneumothorax,
cipitating causes. Spontaneous pneumothorax that tension pneumothorax may develop. Tension pneu-
occurs in patients with no underlying lung disease is mothorax is present when intrapleural pressure
termed primary spontaneous pneumothorax (PSP), exceeds atmospheric pressure throughout expira-
while secondary spontaneous pneumothorax (SSP) tion.1,3 The patient suffering from tension pneu-
refers to those that develop in the presence of an mothorax can rapidly develop extreme dyspnoea,
underlying lung condition, such as COPD, cystic unilateral chest hyperinflation, cyanosis, and haemo-
fibrosis, or Pneumocystis carinii pneumonia. Non- dynamic instability. Development of a tension pneu-
spontaneous pneumothoraces are classified as mothorax is usually a medical emergency requiring
traumatic and are subdivided into non-iatrogenic prompt intervention by any number of chest drainage
and iatrogenic. Non-iatrogenic pneumothoraces can techniques to relieve the intrapleural pressure.1,3 Of
note, the shift of the mediastinal structures to the
contralateral side of the pneumothorax, as may be
Correspondence: Michael H. Baumann, Division of detected by CXR, is a normal phenomenon related to
Pulmonary and Critical Care Medicine, University of pleural air entry and not a definite sign of tension
Mississippi Medical Center, Jackson, 2500 North State physiology. Tension pneumothorax should be a clini-
Street, MS 39216–4505, USA. cal diagnosis that should not await confirmation by
Email: mbaumann@medicine.umsmed.edu CXR.1,3
158
SPONTANEOUS PNEUMOTHORAX
PSP occurs at a frequency of 7.4–18 cases (age-
adjusted incidence) per 100 000 population per year
in men and in 1.2–6 cases (age-adjusted incidence)
per 100 000 population per year in women.4,5 The inci-
dence of SSP is comparable to that of PSP. In COPD
(the most common cause of SSP) spontaneous pneu-
mothorax occurs in 26 cases per 100 000 population
per year.6 In 2–6% of HIV positive patients, a sponta-
neous pneumothorax is known to develop, usually in
association with Pneumocystis carinii pneumonia,7
although this high incidence has undoubtedly
decreased since the advent of effective antiretroviral
therapy. In 8–20% of patients with cystic fibrosis,
spontaneous pneumothorax occurs at some time
during their lives.8 Because of the additional presence
of the patient’s underlying lung disease, SSP is
considered a potentially life-threatening event, while
PSP is virtually always a nuisance rather than a
life-threatening condition.9,10 Hence, management
strategies differ significantly between these two
presentations.
Primary spontaneous pneumothorax
PSP typically occurs in young adults (peak age inci-
dence 20–30 years). Risk factors are male gender, cig-
arette smoking and an asthenic physiognomy. PSP
usually presents with sudden chest pain or dis-
comfort. The diagnosis is made on an erect postero-
anterior CXR at inspiration. There is no need for
systematic radiographs taken at expiration.10
No precipitating cause(s) can usually be identified
for any episode of PSP in individual patients. Most
episodes occur at rest.11 The role of atmospheric pres-
sure or weather changes as the explanation of the
often observed clustering of pneumothoraces is
unclear.12,13
The management of PSP is typically characterized
by extensive practice variations and largely depends
on the specialty of the physician-in-charge (pulmo-
nologist, surgeon, emergency ward physician, radiol-
ogist, etc.), and the availability of therapeutic options,
especially video-assisted thoracoscopic surgery
(VATS).9,10 Such practice variations have led to the
development of management guidelines by the Brit-
ish Thoracic Society in 1993,14 and 2003,15 and by the
American College of Chest Physicians.16 However, evi-
dence suggests that guidelines are poorly used and
applied in clinical practice.17,18 If management guide-
lines are adhered to, however, therapeutic outcome
appears to be improved.19
The above-mentioned guidelines agreed that small
and asymptomatic first episodes of PSP should be
observed for several hours, followed by discharge
from hospital when the patient is stable. A large or
symptomatic first episode of PSP should be treated
by an air evacuation technique, which should be as
less invasive as possible. Small catheter manual
aspiration19–23 in an outpatient setting, or insertion of
a small (14-Fr) percutaneous catheter attached to a
Heimlich valve (outpatient setting) or to a water seal
MH Baumann and M Noppen
device (hospitalization),16 are successful in the major-
ity of cases. In the case of incomplete lung expansion
and/or persistent air leak, medical or surgical thora-
coscopy or, if that is unavailable, limited thoracotomy
should be performed within 3–4 days.
A definitive treatment to prevent recurrence is not
advocated after one single episode of PSP because the
majority of patients will never have recurrences.24
Exceptions are patients with professional risks (e.g.
aircraft personnel). There is good consensus, how-
ever, as well as clinical evidence,25 that recurrence
prevention treatment should always be offered after a
first recurrence of a pneumothorax.
Some controversy still exists around the optimal
procedure to prevent recurrence of the pneumotho-
rax. This is in part because of the different views
on the pathophysiology of PSP, especially on the
causal role of rupture of blebs or bullae (so-called
emphysema-like changes, ELC) in the development
of PSP. Although ELC, especially at the lung apices, are
present in the majority of PSP patients, they are not
always the actual site of the air leak.9,24,26 Air leakage
can occur elsewhere at the visceral pleura whether or
not ELC are present (‘pleural porosity’),27,28 or air can
pass through the mediastinal pleura following rup-
ture of alveoli into the peribronchovascular intersti-
tium.2 This may explain why recurrence rates of
PSP seem somewhat higher after ELC treatment (e.g.
bullectomy) alone (up to 20% recurrence)29–32 as
compared to pleurodesis by mechanical abrasion,
partial pleurectomy or talc poudrage (0–10% recur-
rence).9,29,33 While no large, randomized, prospective
study has compared various recurrence prevention
techniques, available data show that both VATS bul-
lectomy plus pleurodesis and medical talc poudrage
without bullae treatment, are equally effective.9,10 An
algorithmic approach to the treatment of PSP is
shown in Fig. 1.9
Several practical questions regarding PSP manage-
ment deserve consideration:
1. Should PSP patients stop smoking? Smoking
cigarettes undoubtedly increases the risk of develop-
ing PSP.4 It is less clear whether quitting smoking in
itself decreases the likelihood of PSP recurrence.
Smoking cessation appeared to reduce the recurrence
rate in one study.34 In another study, smoking cessa-
tion did not decrease the incidence of PSP except
when patients had stopped smoking for at least 1 year
before their first pneumothorax.35 Nevertheless, there
are many other important reasons to advise smoking
cessation in these, mostly young, patients.
2. Should patients be advised to rest or to
decrease physical activity after an episode of PSP?
Physical activity is not a risk factor for the occurrence
of PSP.11 Hence, there is no rationale to advise (rela-
tive) rest after a cured episode of PSP.
3. Does a recurrence of PSP increase the likeli-
hood of further recurrences? Recurrence rates after a
first episode of PSP treated with an air evacuation
technique vary from 16–52%, averaging 30%.36 After a
first recurrence, the likelihood of subsequent recur-
rences seems to increase progressively up to 62% for a
second and 83% for a third recurrence.37 These find-
ings may be biased by the fact that a younger age at
Pneumothorax 159

PSP

yes
Signs of tension Immediate needle decompression
followed by CTD and further treatment
no

PTX size < 20 %† PTX size > 20 %

or < 3 cm apex-cupula, or > 3 cm apex-cupula,
and asymptomatic or symptomatic

observation
± oxygen supplements
follow-up

1st episode 2nd or more

*
Air evacuation treatment Recurrence prevention treatment

Simple manual Small bore CTD CTD with

Thoracoscopy chemical pleurodesis
aspiration at waterseal or
(medical or surgical) if thoracoscopy refused
attached to Heimlich
or contraindicated

Success at Unsuccessful
No ELC’s or
1 attempt at 1st attempt Visible air leak
no air leak found
at ELC
at ELC’s

success persistent
air leak Talcage or ELC treatment ** +
(> 4 days) mechanical pleurodesis
pleurodesis (talcage, mechanical)
† 20% by Light Index (reference 1)
Figure 1 An algorithmic approach to *After informed consent (see text), or in certain patient groups (aircraft personnel, divers and others)
the treatment of primary spontaneous * * Staple bleb/bullectomy, electrocoagulation, ligation
PSP: primary spontaneous pneumothorax; CTD: chest tube drainage; ELC's: emphysema-like changes
pneumothorax. Reproduced with permission from reference number 9.

the first occurrence of PSP is an independent risk fac-
tor for future recurrences.34
4. Should PSP patients be allowed to fly? Because
of the repetitive changes in ambient pressure during
airline travel (cabin pressures are lowered to around
550 mmHg during flight), frequent flyers (e.g. pilots,
flight attendants) theoretically may have an increased
risk of developing PSP, although this has not been
substantiated.38 However, because development of a
pneumothorax immediately prior to or early in flight
is more dangerous (according to Boyle’s law, a volume
of gas will expand with decreasing ambient pres-
sures), military regulations,39 as well as international
flight regulations,40 impose a recurrence prevention
treatment after a first episode of PSP in aviation per-
sonnel. Potential passengers who have had a PSP may
theoretically board commercial aircraft once all air is
evacuated from the pleural space, although some
data suggest that safe air travel can only be guaran-
teed after a 2-week waiting period.41 Safety regula-
tions impose a waiting period of 3 weeks after a
treated pneumothorax event.40 Patients with pneu-
mothoraces can be transported by air as long as an
open connection between the pleural space and the
ambient atmosphere is present (e.g. chest tube cou-
pled to a water seal device or to a Heimlich valve).
5. Should PSP patients be allowed to dive? Intra-
pulmonary (e.g. emphysema, blebs, bullae) or intra-
pleural (e.g. pneumothorax) air will expand during
ascent from a dive (Boyle’s law). A history of PSP, or
the documented presence of emphysema, blebs or
bullae are considered contraindications for diving.42,43
Secondary spontaneous pneumothorax
While PSP is almost always a benign disorder without
the need for immediate intervention, SSP is a poten-
tially life-threatening event because of compromised
respiratory reserves due to the underlying lung dis-
ease.2 Virtually every lung disease has been reported
to be associated with SSP, but COPD is by far the most
common underlying disorder.10
In contrast to PSP, dyspnoea is usually more severe
and sometimes even life-threatening in the SSP
patient.2,10 The diagnosis can usually be made on an
erect posteroanterior CXR, although CT is sometimes
necessary to differentiate pneumothoraces from large
thin-walled bullae.44
Because of the underlying lung disease, recurrence
rates are higher in SSP, varying from 40 to 80%
depending upon the underlying cause. Patients with
160
SSP usually require immediate and effective therapy
to treat the presenting episode of pneumothorax, and
most authors also recommend immediate definitive
therapy for recurrence prevention after the first
episode of SSP.10,16 The British Thoracic Society
guidelines15 recommend evacuation of the pneu-
mothorax by manual aspiration in young (< 50 years)
asymptomatic patients with a small pneumothorax,
and upon successful lung re-expansion, a 24-h period
of inpatient observation. The American College of
Chest Physicians guidelines16 also recommend hospi-
talization in all cases. Small pneumothoraces may be
observed or treated with a small bore chest tube.
Large or symptomatic pneumothoraces should
always be treated with a chest tube (coupled to a
Heimlich valve or water seal device). In very large
and/or unstable pneumothoraces, insertion of a
moderate-sized chest tube is advocated, and a large-
bore chest tube is recommended when a large air leak
is suspected or when positive pressure ventilation is
required.16
Recurrence prevention after the first episode of SSP
is recommended by most. A thoracoscopic approach
(medical or surgical) with an effective pleurodesis
technique (pleural abrasion, partial pleurectomy, or
talc poudrage) is preferred over instillation of a scle-
rosant (tetracycline, talc slurry, etc.) through a chest
tube.16,45 In case of a persistent air leak, early (within
3–5 days) thoracoscopic intervention is recom-
mended.15,16 Ideally, therefore in centres where thora-
coscopy is readily available, patients with SSP should
undergo immediate thoracoscopy. If general anaes-
thesia and positive pressure ventilation are used,
prior placement of a small bore chest tube is probably
recommended.
A specific type of SSP is catamenial pneumothorax,
occurring within 24–72 h after the onset of menstru-
ation.46 A recent prospective study suggests that cat-
amenial pneumothorax may be more common than
previously thought,47 and should therefore be system-
atically searched for in menstruating women with
pneumothoraces. In most cases, diaphragmatic
abnormalities related to endometriosis are often
found during thoracoscopy.47 Because recurrences are
frequent, recurrence prevention treatment is indi-
cated after a first event of catamenial pneumothorax.
In addition, hormonal menstruation suppression
treatment may be indicated.
NON-SPONTANEOUS PNEUMOTHORAX
As opposed to patients with a spontaneous pneu-
mothorax, no professional society guidelines exist for
the care of patients with a non-spontaneous pneu-
mothorax. Information is limited but several publica-
tions provide helpful information to guide the care of
these patients.
Non-iatrogenic traumatic pneumothorax
Annually, more than 50 000 trauma-related pneu-
mothoraces (non-iatrogenic traumatic pneumotho-
MH Baumann and M Noppen
races) occur in the USA, with chest trauma
contributing directly to 25% of these deaths and sig-
nificantly to an additional 50%. Pneumothorax ranks
second only to rib fracture as the most common sign
of chest injury and can be seen in 40–50% of chest
trauma patients.48–50 Blunt trauma to the abdomen
may also precipitate a traumatic pneumothorax.49,50
Up to 51% of trauma patients that present have an
occult pneumothorax, one not seen on an initial CXR
but found later with additional imaging.49 Early incor-
poration of a routine CT of the chest in all chest and
multitrauma patients, and maintaining a high suspi-
cion may be required to successfully diagnose a
traumatic pneumothorax.51 Given the likelihood of
progression with mechanical ventilation,48,50 early
detection is critical, particularly in patients who may
require positive pressure ventilation.
Traumatic pneumothoraces are usually managed
with placement of a chest tube.48,52 Nearly 20% of
traumatic pneumothorax patients have an accompa-
nying haemothorax,51 potentially prompting chest
drainage independent of the presence of pleural air.
However, chest tube placement may not be required
in all traumatic pneumothoraces regardless of an
occult or non-occult presentation.48,52–54 A failure rate
of 7–9% has been reported for conservative (obser-
vational) management of non-occult traumatic
pneumothoraces.52,53 The largest of these studies lim-
ited chest tube placement in 804 traumatic pneu-
mothorax patients to those with: lung collapse of
> 1.5 cm by CXR; smaller but bilateral pneumothora-
ces; requirement for mechanical ventilation; and to
those with limited respiratory reserve.53 The study
did not define whether the 1.5-cm distance was from
the chest apex to lung or other reference point. All
patients were treated in hospital and only four
patients had gun shot wound-related pneumothora-
ces. Of the 804 patients, 329 (41%) were treated
conservatively (observation alone) and 29 (8.8%)
required chest tube placement due to pneumothorax
enlargement.
Occult traumatic pneumothoraces may also be
treated conservatively in selected patients. However,
up to 38% of occult pneumothoraces may progress
with the application of positive pressure ventilation.48
Utilizing a CT-directed size classification of the pneu-
mothorax, Wolfman et al. provided a systematic
approach to the conservative management of occult
non-iatrogenic traumatic pneumothoraces.49 Minus-
cule pneumothoraces were defined as air collections
£ 1-cm thick and seen in no more than four contigu-
ous 10-mm thick slices. Anterior pneumothoraces
were air collections located anteriorly, > 1-cm thick,
not extending to the mid coronal line, and seen on
four or more contiguous slices. Anterolateral pneu-
mothoraces were pleural air collections extending at
least to the mid coronal line. Due to the preference of
the study institution’s surgeons, chest tubes were
placed in all patients with anterolateral pneumotho-
races. Also, all mechanically ventilated patients with
an anterior pneumothorax received a chest tube. With
these restrictions, 24 of 27 patients (89%) with a
minuscule or anterior pneumothorax, did not require
a chest tube when managed conservatively.49 Con-
Pneumothorax
Non-Occult
Pneumothorax
> 1.5
cm size
Chest tube
Clinically
stable
Hospital
observation
Figure 2 Treatment of non-iatrogenic
traumatic pneumothorax. Adapted from reference number 3
versely, more than one in 10 patients managed con-
servatively, eventually required a chest tube.
In summary (Fig. 2), placement of a chest tube in
occult and non-occult traumatic pneumothorax
patients is a reasonable initial approach in the major-
ity of patients. However, carefully selected patients
may be closely monitored without chest tube place-
ment; approximately 10% of these patients eventually
require a chest tube. The institution of positive pres-
sure ventilation should prompt strong consideration
for chest tube placement in all non-iatrogenic trau-
matic pneumothorax patients. Given the potential
need to drain both blood and air, and the potential for
a significant air leak if the patient is mechanically
ventilated, a larger bore tube (28–36-Fr) should be
considered.3
Iatrogenic traumatic pneumothorax
Ever increasing utilization of invasive diagnostic and
therapeutic interventions undoubtedly inflates the
already significant incidence of iatrogenic pneu-
mothoraces. Clinicians must be vigilant for their
occurrence even when the potential inciting inter-
ventions are at body sites remote from the chest.55 Sig-
nificant time delays between an instigating event and
discovery of a resulting iatrogenic pneumothorax
compound the problem of the many potential causes.
Up to 4% of patients with an iatrogenic pneumotho-
rax, after central line placement, have a delayed (8–
96-h) CXR diagnosis.56 Iatrogenic pneumothoraces
may have considerable associated costs including
161
Occult
Pneumothorax
CT size
classification
< 1.5
cm size Minuscule/ Anterolateral
anterior
Chest tube
Clinically Clinically Clinically
unstable stable unstable
Chest tube Hospital Chest tube
observation
Strongly consider chest tube placement in all
mechanically ventilated patients
possible morbidity, mortality, and in one series, pro-
longed hospitalization in 8% of affected patients.57–59
A patient’s clinical presentation may vary consider-
ably based upon the inciting mechanism, underlying
lung disease, and the presence or absence of mechan-
ical ventilation.3
The exact incidence rate of iatrogenic pneumotho-
races is unknown.3 The six most common causes
of iatrogenic pneumothorax among 535 Veterans
Administration patients were transthoracic needle
lung biopsy (24%), subclavian vein catheterization
(22%), thoracentesis (20%), transbronchial lung
biopsy (10%), pleural biopsy (8%), and positive pres-
sure ventilation (7%).59
The most common of these, transthoracic needle
lung biopsy has associated variables that may predict
the risk of pneumothorax. Cox et al. noted that CT evi-
dence of emphysema in the lung lobe of the biopsy
(P = 0.01) and smaller lung lesions (£ 2 cm, P = 0.001)
correlated with the occurrence of pneumothorax.60
Additionally, traversing aerated lung en route to the
target lesion increased the rate of pneumothorax
occurrence compared with biopsy of a juxtapleural
lesion (pneumothorax rate approximately 50% vs
15%, respectively). The number of needle passes,
needle size and lesion location did not correlate
with pneumothorax rate.60 Arguably, preoperative
lung function may predict iatrogenic pneumothorax
rates but studies vary considerably.61–65
Treatment of iatrogenic pneumothoraces should
focus upon the least invasive intervention appropri-
ate to the patient’s underlying lung health and clinical
circumstances.3 Adopting the degree of collapse from
162
Focus on least invasive intervention appropriate to patient’s condition, however,
strongly consider chest tube placement in all mechanically ventilated patients
Pneumothorax
< 3 cm or
< 15% size
Clinically stable Clinically unstable or
symptomatic
(or if transthoracic lung
biopsy related
Observation
pneumothorax and CT
(if transthoracic lung
evidence of emphysema,
biopsy related
regardless of stability)
pneumothorax and
no CT evidence of
emphysema,
observation is Small-bore
reasonable) chest tube
Consider outpatient management in selected patients
Adapted from reference number 3
the spontaneous pneumothorax literature16,66 as an
indicator of treatment choice, an iatrogenic pneu-
mothorax ≥ 3 cm (from chest apex to lung) or > 15% in
size by CXR should be considered for drainage using a
smaller bore chest tube (£ 16-Fr).3 Simple aspiration
of the pneumothorax is possible but given the myriad
of commercially available small bore chest tubes that
can be attached to a Heimlich valve or similar one-
way valve,67 use of these devices offers greater versa-
tility. Aspiration can be attempted with a small bore
tube, and if unsuccessful, the device may be left in
place, in effect converting simple aspiration to place-
ment of a small bore chest tube.
The need for drainage can be predicted after tran-
sthoracic needle lung biopsy. Cox et al. noted that the
presence of CT evidence of emphysema predicted a
threefold higher (27% with emphysema vs 9% with-
out; P < 0.01) need for chest tube placement in
patients sustaining a needle lung biopsy-related
pneumothorax.60 Careful observation of patients with
an iatrogenic pneumothorax < 15% or < 3 cm in size
and no CT evidence of emphysema, versus prompt
placement of a chest tube in patients with CT evi-
dence of emphysema, regardless of pneumothorax
size, seems a reasonable treatment approach.3 Appro-
priately selected patients with an iatrogenic pneu-
mothorax may be safely managed with placement of a
chest tube and subsequent outpatient follow up.68–70
Any patient with an iatrogenic pneumothorax on
mechanical ventilation should be strongly considered
for placement of a chest tube in lieu of observation.
Iatrogenic traumatic pneumothoraces may be
caused by a myriad of diagnostic and therapeutic
interventions and have a delayed presentation
(Fig. 3). Transthoracic needle lung biopsy is one of the
MH Baumann and M Noppen
Pneumothorax
≥ 3 cm or
> 15% size
Small-bore
chest tube
Figure 3 Treatment of iatrogenic
pneumothorax.
most common causes of iatrogenic pneumothorax.
Associated CT findings can predict the likelihood of a
pneumothorax occurrence and the need for chest
tube placement. Small iatrogenic pneumothoraces
from other causes in clinically stable patients may
be carefully observed; clinical instability, significant
symptoms, or a larger pneumothorax should prompt
placement of a small bore chest drain.
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