You are on page 1of 7

Interactive CardioVascular and Thoracic Surgery Advance Access published November 1, 2012

Interactive CardioVascular and Thoracic Surgery 0 (2012) 1–7 doi:10.1093/icvts/ivs445

STATE-OF-THE-ART

Hiroyuki Kaneda*, Takahito Nakano, Yohei Taniguchi, Tomohito Saito, Toshifumi Konobu and Yukihito Saito
Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Kansai Medical University Hirakata Hospital, Osaka, Japan * Corresponding author. Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Kansai Medical University Hirakata Hospital, Kansai Medical University, 2-3-1 Shinmachi, Hirakatashi, Osaka 573-1191, Japan. Tel: +81-72-8040101; fax: +81-72-8042865; e-mail: kanedah@hirakata.kmu.ac.jp (H. Kaneda). Received 26 July 2012; received in revised form 19 September 2012; accepted 27 September 2012

Abstract
Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax. Keywords: Pneumothorax • Aspiration • Chest tube drainage • Observation • Initial management

INTRODUCTION
Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. Pneumothorax is generally classified as spontaneous, which occurs without preceding trauma; traumatic, which occurs as a result of direct or indirect trauma and iatrogenic. In addition, spontaneous pneumothorax is subclassified as primary spontaneous, which occurs in young patients without obvious underlying lung disease, or secondary spontaneous, which occurs as a complication of an underlying lung disease. The management of pneumothorax varies depending on whether it is primary or secondary [1, 2]. There are some published guidelines for the management of spontaneous pneumothorax. However, unfortunately, they differ in some respects, particularly in initial management. The consensus process of the American College of Chest Physicians guidelines showed simple aspiration to be rarely appropriate in any clinical circumstance [3]. On the other hand, the British Thoracic Society guideline 2003 recommends simple aspiration as the first-line treatment for all cases of primary spontaneous pneumothorax requiring intervention [4]. Another issue is that, in
† This article has been published in Japanese in the Journal of the Japan Society for Pneumothorax and Cystic Lung Diseases 2011;11:2–8.

actual clinical practice, there is considerable deviation from published guidelines, and this is internationally observed [5–7]. There is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax on the basis of the review and some other reported data. We believe that the management strategy for pneumothorax should be simple and clinically relevant and not dependent on the classification of pneumothorax.

SYSTEMATIC REVIEW AND META-ANALYSIS FOR PRIMARY SPONTANEOUS PNEUMOTHORAX
Some randomized controlled trials and meta-analyses [8–10] of pneumothorax treatment have been conducted. Here, we review these previous reports again. We searched the PubMed database (National Library of Medicine) for reports from January 1999 through August 2011. We used the following search terms: pneumothorax, combined with observation, aspiration or thoracocentesis and chest drain, chest tube or tube drainage. The search was limited to randomized controlled trials. The search and the review finally yielded four randomized controlled trials

© The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

PULMONARY

Three-step management of pneumothorax: time for a re-think on initial management†

[12] Noppen et al. simple aspiration tended to be less favourable than tube drainage. The diamond at the bottom of the graph represents the overall odds ratio. 2). The outcome for success rate could not be precisely combined because of differences in the outcome definitions. 95% CI –2. –1. our institutional database showed 75 cases of chest tube drainage. 95% CI 0. the treatment cannot be compared. however. The random model uses a more flexible approach in which the effect sizes are normalized towards an overall mean effect size.38. 8]. of Table 1: Summary of the four studies included in the present meta-analysis Study Aspiration Total Harvey and Prescott [11] Andrivet et al. We analysed all data using both models. The software weighs the data from various publications according to their cohort size.2 H. The recurrence rate did not significantly differ between the two interventions (RR. Of the four papers described above.91. We calculated the number of patients showing ‘1-week success’ and excluded those showing ‘immediate success’. [13] Ayed et al. From January 2006 to December 2008. the collapsed lung is observed to gradually expand. The data can be analysed using a fixed or a random model. with a combined total of 331 patients [11–14].08. Fig. USA). the effect sizes of each study are conserved. 14]. We think that if there is a bias in the cases in which the air leak stopped before intervention. in 18 (72%). 0. All statistical analyses were conducted using Comprehensive Meta-analysis Software version 2 (Biostat. .89. In the fixed model. Fig. Many researchers have suggested that one of the principal objectives of pneumothorax treatment is to stop the air leak. On the basis of our meta-analysis. BACKGROUND BIAS ABOUT PERSISTENT AIR LEAK AND REANALYSIS WITH EXTRACTED DATA Kjaergard [15] described the cause of spontaneous pneumothorax to be lung perforation and air leak. The objective of this analysis was to examine the percentage of cases showing a persistent air leak over 3 days that stopped within 1 week after intervention. The data can be visualized graphically. Fig. A pooled result for success after 1 week or more was considered as the success rate. / Interactive CardioVascular and Thoracic Surgery (Table 1). Integrated analysis revealed that simple aspiration was associated with shorter hospitalization time (WMD. 0. but this difference between the two interventions was not statistically significant (RR. Ayed’s data showed that of 25 cases of persistent air leak. We presume that these cases of ‘immediate success’ include many that did not need any intervention.30 to –0. 1). although there is no significant difference in the success and recurrence rates.92. Englewood.61 days. The square size represents the cohort size. Kaneda et al. two reported ‘immediate success’ defined as persistent lung expansion after simple aspiration and lung expansion and chest tube removal within 3 days after tube drainage [13. Each horizontal line represents the 95% confidence interval (95% CI) for each study. simple aspiration is recommended for the initial management of pneumothorax because of the shorter hospitalization time. The width of the diamond is proportional to the overall 95% CI. Meta-analysis was performed by combining the reported success rate. This conclusion is consistent with that of a previously reported meta-analysis with randomized controlled trials and recent reviews [2.77–1. hospital stay and recurrence rate. further. 2). With regard to the success rate. All four trials compared simple aspiration with tube drainage. Relative risk (RR) was used as a summary statistic for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes. If the air leak is stopped. We retrospectively assumed that these cases did not have an air leak even before intervention and that we could observe for gradual lung expansion without any intervention. NJ. the air leak stopped within 1 week in the simple aspiration group. [14] 35 33 27 65 Immediate success – – 16 40 Success 28 22 25 58 Tube drainage Total 38 28 33 72 Immediate success – – 21 49 Success 38 26 28 63 Figure 1: Results of meta-analysis: hospital stay as weighted mean difference.58–1. of which 30 (40%) did not show air leak until the day after chest tube insertion. 95% CI 0.

This may be because tube drainage with continuous suction achieves complete lung re-expansion with contact between the visceral and parietal pleura. of 11 cases of persistent air leak. we cannot arrive at any conclusions after comparing the results of observational and interventional treatment. Few retrospective studies compared the success and recurrence rates of observational and interventional treatment (Table 2) [20–28]. the air leak stopped within 1 week in the simple aspiration group and. Because of improper evaluation of pneumothorax during the initial stages. it is not possible to correctly compare the efficacy of the treatment options. Taken together. It is necessary to develop a clear strategy for the initial management of pneumothorax for implementation in clinical cases and research trials. / Interactive CardioVascular and Thoracic Surgery 3 Figure 2: Results of meta-analysis: success rate and recurrence rate. our clinical experience and the reports indicate that treating the air leak with simple aspiration re-collapses the lung. However. Noppen’s data showed that. 21. whereas tube drainage continuously expands the lung. pneumothorax treatment has two goals: to rid the pleural space of its air and to decrease the PULMONARY . the air leak stopped within 1 week in the tube drainage group. it is necessary to address the question why simple aspiration is more effective in stopping an air leak than tube drainage. facilitating closure of the pleural defect. Simpson [19] reported that conservative management of much larger pneumothorax is possible if there is no underlying lung disease. in 14 (61%). Therefore. in 9 (82%). A review of these reports reveals that the success rate of observational treatment is very high and seems to be satisfactory [20. However. the data extracted from the above two reports consistently indicated that simple aspiration is more effective than tube drainage in stopping an air leak. the use of a water seal for tube drainage without expanding the lung too much is more effective than the continuous suction of the drainage [16–18]. Kaneda et al. the air leak stopped within 1 week in the tube drainage group. We think that this percentage includes cases without an air leak even before the intervention. As stated above. This result is not in agreement with the original result of the ‘success’ obtained from the two papers. The latter is not desirable to close the perforation of the lung. Here. COMPARISON OF OBSERVATIONAL AND INTERVENTIONAL TREATMENT Considering that expanding the lung has adverse effects on stopping the air leak.H. observation without rapidly expanding the lung would be the best management. When air leak is a complication after pulmonary resection. Inducing adhesion formation over the pleural defect to help prevent recurrence has been discussed [24. of 12 cases of persistent air leak. 29–31]. the recurrence rate of observational treatment tends to be higher than that after intervention [23–26]. no clear conclusion can be reached because of the potential bias in patient backgrounds. RETHINK ABOUT RAPID AIR ELIMINATION According to Light [1]. 26–28]. Our institutional database showed that 40% of cases of chest tube drainage did not show an air leak the day after chest tube insertion. in 7 (58%). These reports involved a relatively small number of patients and all the analyses were retrospective. if there is a bias in the cases in which the air leak was stopped. 23 cases of persistent air leak.

45]. The incidence is reportedly 1–5% of spontaneous pneumothorax [22. Therefore. tube drainage is more effective. Attempts have been made to define the management of pneumothorax according to its size [1.4% of the patients with complete atelectasis and that 10% of those . We think that the air leak in itself is also an indication for intervention. because the development of lung collapse reveals the existence of the air leak. [27] Chen et al. It is widely accepted that a small primary spontaneous pneumothorax in patients without respiratory symptoms can be conservatively managed. the lung gradually expands without any interventional treatment [20.5–1.0001) 0. we would like to propose a new strategy that is based on the presence of symptoms of acute respiratory dysfunction and an air leak. because lung collapse with continuous air leak finally develops tension pneumothorax. but the change in the rate of collapse is important. We think that the indications for interventional treatment to expand the lung should be much more refined. although sudden death has been reported [24. For preventing the development of tension pneumothorax. The incidence of bilateral pneumothorax is reported to be 0. However.9% [20. 24. It is absolutely necessary to expand the lungs. Patients with severe underlying lung disease tend to develop severe acute respiratory dysfunction even with a relatively small pneumothorax. for example. Tension pneumothorax must be treated by immediately evacuating the air. and fewer patients should need intervention. Integration was performed by adding the number of cases of success/recurrence and dividing by the total number of cases. Some investigators also indicated that the presence of intrapleural air in itself is not an indication for intervention [19. and expanding the lung rapidly is necessarily dispensable during initial management because it does not complete treatment. / Interactive CardioVascular and Thoracic Surgery Table 2: Success and recurrence rates of observational and interventional treatment Author and year Success rate Hyde [20] Beumer [21] Kelly [28] Kelly et al. we suggest that repeating simple aspiration is more effective for stopping the air leak than tube drainage.0001) 6 18 49 33 63 a Data are presented as the percentage of success or recurrence (for a large pneumothorax). Although needle decompression is useful for the emergent release of pleural tension. Here. the management of a moderately collapsed lung remains controversial [3. Continuous air leak can progress into tension pneumothorax with the risk of sudden death. Therefore. [26] Our institutional cases Integration with four prospective trialsa Recurrence rate Stradling and Poole [22] Ruckley and McCormack [23] Seremetis [25] O’Rourke and Yee [24] Chen et al.014 (<0. INDICATIONS FOR INTERVENTIONAL TREATMENT Pneumothorax is generally considered to be a benign disease with good prognosis. Expanding the collapsed lung is not desirable to stop the air leak. Intervention is also necessary in such cases. 35] and our experience during clinical practice show that the lung should not be rapidly expanded unless necessary. 4]. cases of tension pneumothorax that are considered to have a persistent air leak should be eventually treated with tube drainage rather than repeating aspiration. A continuous air leak in the absence of tension pneumothorax can be detected with careful examination. the diagnosis of tension pneumothorax is undoubtedly an indication for immediate intervention (Table 3). On the basis of the discussion in the second section. Kaneda et al. In these cases.4 H.12 (<0. The purpose of tube drainage and simple aspiration should not be expansion of the lung but recovery of respiratory dysfunction. A review of the data available thus far [19. many other researchers also described that eliminating intrapleural air is the main principle of pneumothorax treatment [32. 37]. 36. tube drainage for expanding at least one side of the lung is necessary to save the patient’s life. 38]. likelihood of a recurrence. although prospective randomized trials with patients having the same background of air leak are necessary to reach a clear conclusion. A recent retrospective study [46] compared complete and partial atelectasis in patients with primary spontaneous pneumothorax and found that 29. 27. 22]. such as the patient’s symptoms and repeated chest radiographs. but is suspected to subsequently occur. 42–44]. Another certain indication of intervention is bilateral pneumothorax that rarely occurs. but also causes potentially lifethreatening acute respiratory dysfunction. 22. the size of the pneumothorax at a certain point of time is not very important. If there is no air leak. 33]. [26] Integration with three prospective trialsa Observational treatment Aspiration – – 50–83 50 (60) – 100 (0) 83 – – – 0 22 Tube drainage – – 66–97 73 (73) 50 61 (65) 91 – 15 38 24 7 25 P-value 86 91 90 79 (5) 95 78 (0) 0. 34]. in cases of tension pneumothorax and cases in which there is a continuous air leak even if tension pneumothorax is not diagnosed during consultation. There are several case reports of diagnostic difficulty or missed diagnoses of tension pneumothorax [39–41]. The initial treatment of a case of totally collapsed lung without severe respiratory dysfunction that is suspected not to be tension pneumothorax is controversial.

Efficacy of tube drainage in preventing recurrence is controversial. Observational treatment to avoid rapid lung expansion can help in sustention of closing the perforation. The objective of the first step is resolving acute respiratory dysfunction.). In this first step. The most important task in this step is to determine whether there is an air leak. such as PULMONARY . etc. surgery (bullectomy. the patients easily develop tension pneumothorax. bronchial intervention. If the existence of an air leak is confirmed by the patient’s symptoms or physical examination. observation of lung collapse on a chest radiograph and high intrathoracic pressure.H. pleurodesis. such as infection of the lung and pleura and restrictive lung impairment. Simple aspiration might be permissible for an air leak although insertion of a chest tube is ultimately necessary for continuous drainage of the air. because such interventions potentially lead to the recurrence of the leak by increasing the size of the perforation. the patient needs affirmative treatment. it is essential to maintain the stoppage of the air leak. when compared with partial atelectasis. Table 4: Three-step management of pneumothorax Step Step 1a Treatment objective Acute respiratory dysfunction To recover from respiratory function To avoid respiratory dysfunction Recommended treatment Tube drainage (or simple aspiration) Tube drainage (or simple aspiration) Step 2 Air leak To maintain stoppage of air leak To stop air leak To stop air leak after drainage Observational treatment Repeating aspiration (vs tube drainage) Water seal management in tube drainage. we are required to consider whether intervention is necessary to treat acute respiratory dysfunction and other potentially lethal complications. THREE-STEP MANAGEMENT OF PNEUMOTHORAX We propose that the management of pneumothorax should be divided into three steps depending on the main objective of treatment (Table 4). / Interactive CardioVascular and Thoracic Surgery 5 Table 3: Recommended initial management depending on clinical condition Pneumothorax type Tension pneumothorax Treatment purpose To recover from acute respiratory dysfunction Recommended treatment Any interventiona First: aspiration (diagnosis) Second: tube drainage Drainage of at least one side of the lung Any interventiona Any interventiona Any interventiona Any interventiona (aspiration > drainage) Observational treatment Bilateral pneumothorax With severe lung disease Suspected air leak Completely collapsed lung Symptomatic Supposed absence of air leak a To recover from acute respiratory dysfunction To recover from acute respiratory dysfunction To avoid acute respiratory dysfunction To avoid acute respiratory dysfunction To avoid acute respiratory dysfunction Symptomatic relief To maintain stoppage of air leak Tube drainage or repeating aspiration. If no air leak is found and the lung has not collapsed completely. which is mostly performed in the emergency department of a hospital. Kaneda et al. In this step. any intervention is necessary. which constitutes the second step. bulla ligation. the objective of treatment is resolving the air leak. Besides. surgery (bullectomy.). such as severe chest pain. etc. Therefore. complete atelectasis is estimated to more frequently have a persistent air leak. In cases where interventional treatment is given at the first step and a persistent air leak is found. It must be noted that interventions are never performed for treating the air leak. with partial atelectasis showed persistent air leak after tube drainage. a completely collapsed lung is more likely to subsequently lead to serious complications. This comes under the ‘initial management’ of the disease. others Step 3 Recurrence To prevent recurrence Pleurodesisb. in addition to the patient’s symptoms and the size of the pneumothorax in the chest radiograph. we think that a completely collapsed lung is in itself an indication for tube drainage. pleurectomy. If complete atelectasis accompanies a continuous air leak. Thus. even before tube drainage. others a b Step 1 is defined as initial management.

Rios CL. prospective. Rhea JT. Eur Respir J 1996. British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work? J Accid Emerg Med 1998. Spontaneous pneumothorax. and therefore. Kelly AM. Chest 2008. Eur Respir J 2006. Spontaneous pneumothorax in the apparently healthy. Ayed AK. Am J Respir Crit Care Med 2002. Pelletier LC. Kerr D.34:442–3. Simpson G. Phua GC. classifying pneumothorax is sometimes clinically difficult before computed tomography is performed. Tan KL et al. McCabe G. Verdant A. DeLuca SA. unless necessary. Aspiration versus tube drainage in primary spontaneous pneumothorax: a randomised study. Chest 1989.121:831–5. [2] Noppen M. Ruckley CV. Cossette R. Chest 1995. Our proposed three-step management strategy can be applied not only to primary spontaneous pneumothorax but also secondary and traumatic pneumothorax. These three characteristics correspond to the three steps of our proposed management in pneumothorax. Hyde L.43:476–80. Heffner JE. Redington AE. Ayed AK. targeting the air leak. Clooney M. however.9:1773–4. Koh MS. O’Rourke JP. redo thoracoscopy. Dontigny L. Treatment options and long-term results. Katholi CR. Lindskog GE. Dis Chest 1963. El-Shanawany T.96:1302–6. frequently occurring recurrence. [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] ACKNOWLEDGEMENTS We thank Tomoko Fuji for her data management and Yoko Oda for her assistance in this study. Civilian spontaneous pneumothorax. [9] [10] [11] [12] [13] [14] CONCLUSION [15] We believe that there are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction.98: 579–90. BTS guidelines for the management of spontaneous pneumothorax. Djedaini K. Comparison of thoracic drainage vs immediate or delayed needle aspiration.21:139–44. BMJ 1994. Harvey J. which is the obvious cause of the disease. After confirming the air leak. [7] Kelly AM. [4] Henry M. Thorax 1966.19:303–8. Curr Opin Pulm Med 1995. Spontaneous pneumothorax. Clooney M. Cochrane Database Syst Rev 2007. i. Swartzel RL. Spontaneous pneumothorax. Low SY. randomized pilot study. Yee ES. AMA Arch Surg 1957. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. Respiration 2008. Management of recurrent primary spontaneous pneumothorax after thoracoscopic surgery: should observation.155:24–9. Kuo SW. Conflict of interest: none declared. Getz SB Jr. Huang PM. to stop the air leak. Mercier C. Riordan JF. Am J Surg 1983.309:1338–9.75:693–8. Zehtabchi S. Outcomes of emergency department patients treated for primary spontaneous pneumothorax. This procedure is a part of the next aspect of the second step. or thoracotomy be used? Surg Endosc 2009. Friedberg JS. Kirby TJ. Miller AC.144:733–6. Verstraeten A. O’Sullivan RG. Management of spontaneous pneumothorax: back to the future. 134:1033–6.58(Suppl 2):ii39–52.76:121–7. Kucharczuk JC. Baumann MH. Kaneda et al. Ong TH. Mathur A. Management of spontaneous pneumothorax. Wakai A.6 H. Conservative management of spontaneous pneumothorax. Treatment of spontaneous pneumothorax: a more aggressive approach? Chest 1997. Noppen M.108:335–9. The management of spontaneous pneumothorax. Kaiser LR et al. Prescott RJ. Ann Thorac Surg 2003. 100e1. The central idea is that the lung should not be expanded rapidly.24:CD004479. If an air leak is absent and repeated pneumothorax is observed.90:261. Respir Med 2004. Lee YC. [3] Baumann MH. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Ann Emerg Med 2008.1:313–7. Quantification of pneumothorax size on chest radiographs using pleurodesis or surgery. [6] Mendis D. Harvey J. Cerfolio RJ. J Am Med Assoc 1954. Roddie ME. Intern Med J 2008. Poole G. Management of spontaneous pneumothorax. Beasley WE 3rd. Strange C. Dreyfuss D. [8] Devanand A.75:1593–6.15:317–21. Alexander P. Teboul JL. Jackson JE.96:1302–6. Kjaergard H.22:163–5. Suction versus water seal after thoracoscopy for primary spontaneous pneumothorax: prospective randomized study.289:71. Arnold T. drainage. spontaneous or secondary. Kelly AM. Outpatient management of intercostal tube drainage in spontaneous pneumothorax. Lee JM.71:1613–7. Pneumothorax. A ten-year review of spontaneous pneumothorax in an armed forces hospital. Thorax 2003. Brochard L. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter.145:823–7. Bleier JI. Greene RE. [5] Soulsby T. The objective of treatment has not been clarified in published trials. Marshall MB. Spontaneous pneumothorax and its treatment. The management of spontaneous pneumothorax. Hsu HH. Am Rev Respir Dis 1964. Acta Med Scand 1932.27:477–82.43(Suppl):1–159. Chest 1970. Light R. Ann Thorac Surg 2001. it is not possible to compare the treatment strategies between different trails because of inappropriate evaluation of the air leak.165:1240–4. Radiology 1982. Kircher LT Jr. Prospective randomized trial compares suction versus water seal for air leaks. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Beumer HM. Lopez A. Intern Med J 2004. Stradling P.51:91–100. Wood V. Page A. aggressive treatment is necessary to prevent the recurrence. interventions such as simple aspiration or chest drainage and observational treatment may be used for the management of the air leak. Traditional pneumothorax management depended on the classification of pneumothorax into primary. Determining the size of pneumothorax in the upright patient. Br Med J (Clin Res Ed) 1984. author reply 443–4. Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed? Postgrad Med J 2002.112:789–804. Thorax 1966. Chest 2001. Simple aspiration versus chest-tube insertion in the management of primary [29] [30] [31] [32] [33] [34] [35] [36] [37] . Halasz NA. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. De Keukeleire T. Suction vs water seal after pulmonary resection: a randomized prospective study. Spontaneous pneumothorax: a consideration of pathogenesis and management with review of seventy-two hospitalized cases. Slabbynck H.78:80–4. [26] [27] [28] REFERENCES [1] Light RW. Secondary spontaneous pneumothorax would require more interventions than primary spontaneous pneumothorax in Step 1. Diseases of the pleura.57:65–8.38:64–7. air leak. Chest 2002. Deeb ME. Chen JS. Sukumar M. Strange C.119:590–602. Chandrasekaran C.e. Andrivet P. Bass C. Driesen P. / Interactive CardioVascular and Thoracic Surgery spontaneous pneumothorax: a systematic review. McCormack RJ. Review of management of primary spontaneous pneumothorax: is the best evidence clearer 15 years on? Emerg Med Australas 2007. Klein J et al. Deviation from published guidelines in the management of primary spontaneous pneumothorax in Australia.21:145–9. Mathie A. Ann Thorac Surg 1976. Seremetis MG. Collins CD. which comes under the third step.

165:1127–30. Holloway VJ. Unsuspected tension pneumothorax as a hidden cause of unsuccessful resuscitation. Pneumothorax: experience with 1. Watts BL.17:222–3. Ann Emerg Med 1983. Ryu JW.117:1279–85. Spontaneous pneumothorax in the Royal Navy. Recurrent and chronic spontaneous pneumothorax.22:8–16. Wasserberger J. Spontaneous pneumothorax: is it under tension? J Accid Emerg Med 2000. Seo PW. Harris JK. Tension pneumothorax–time for a re-think? Emerg Med J 2005. Emerg Med J 2001. Radiology 1949.87:875–9. Complete atelectasis of the lung in patients with primary spontaneous pneumothorax.18:319–20.53:157–67. Spontaneous pneumothorax. Refaely Y. PULMONARY . Tension pneumothorax: a difficult diagnosis. Park S.3:88–111.12:411–2. Howell MA. Rojas R. Balasubramaniam S. Golden R. Thorax 1948. [45] Cliff JM.H. / Interactive CardioVascular and Thoracic Surgery interpleural distances: regression analysis based on volume measurements from helical CT. 7 [38] [39] [40] [41] [42] Leigh-Smith S.50:517–26. Harris T. Proc R Soc Med 1957. Brock RC. [44] Weissberg D. Chest 2000.199 patients. a study of 105 cases. AJR Am J Roentgenol 1995. Ann Thorac Surg 2009. Kaneda et al. [46] Ryu KM. [43] Rottenberg LA.