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Pneumothorax is defined as the presence of air or
gas in the pleural cavity. Primary spontaneous
pneumothorax (PSP) occurs in people without
underlying lung disease and in the absence of an
inciting event. Many patients whose condition is
labeled as primary spontaneous pneumothorax have
subclinical lung disease.

Secondary spontaneous pneumothorax (SSP) occurs
in people with a wide variety of parenchymal lung
diseases. Iatrogenic pneumothorax results from
incursion into the pleural space secondary to
diagnostic or therapeutic medical
intervention. Traumatic pneumothorax results from
injury, typically blunt or penetrating trauma. Tension
pneumothorax develops when air is trapped in the
pleural cavity under positive pressure.

This article identifies several areas of new information
in the medical literature: 1) studies comparing
aspiration and tube drainage for treatment of primary
spontaneous pneumothorax, 2) long term follow-up of
surgical treatment of pneumothorax, 3) assessment of
the impact of pleurodesis on transplantation outcomes
in patients with lymphangiomyomatosis, 4)
demonstrated utility of ultrasonography in the bedside
diagnosis of iatrogenic pneumothorax, and 5) inability
of ultrasonography to distinguish between
intrapulmonary bullae and pneumothorax.

The inner surface of the thoracic cage (parietal
pleura) is contiguous with the outer surface of the
lung (visceral pleura); this space contains a small
amount of lubricating fluid and is normally under
negative pressure compared to the alveoli.
Determinants of pleural pressure are the opposing
recoil forces of the lung and chest wall.

Primary spontaneous pneumothorax (PSP) is typically
observed in tall young people without parenchymal
lung disease and is thought to be related to increased
shear forces in the apex. PSP is associated with the
presence of apical pleural blebs lying under the
visceral pleura, but the exact anatomic site of air
leakage is often uncertain. Fluorescein-enhanced
autofluorescence thoracoscopy (FEAT), a novel
method to examine the site of air leak in PSP, shows
FEAT-positive lesions that are normal when
viewed under normal white-light thoracoscopy.

Blebs and bullae (sometimes called emphysematous-
like changes or ELCs) are related to the occurrence of
primary spontaneous pneumothorax. Thoracic
computerized tomography (CT) of patients with PSP
shows ipsilateral ELC in 89% and contralateral
changes in 80% compared to a rate of 20% among
control subjects matched for age and smoking.
Nonsmokers with PSP had CT ELC abnormalities of
80% compared with a rate of 0% among nonsmoker
controls without PSP.

While patients with PSP do not have overt
parenchymal disease, more than 90% of them are
smokers. The relative risk of PSP increases as the
number of cigarettes smoked per day increases. This
incremental risk with increasing number of cigarettes
smoked per day is much more pronounced in female

Lung inflammation and oxidative stress are
hypothesized to be important to the pathogenesis of
PSP.3 Current smokers, at increased risk for PSP,
have increased numbers of inflammatory cells in the
small airways. Bronchoalveolar lavage studies in
patients with PSP associated the degree of
inflammation with the extent of ELCs. One hypothesis
is that ELCs result from degradation of lung tissue
due to imbalances of enzymes and antioxidants
released by innate immune cells.4 In one study,
erythrocyte superoxide dismutase activity was
significantly lower and plasma malondialdehyde levels
higher in patients with PSP than in normal control

A growing body of evidence indicates that genetic
factors may be important in the pathogenesis of many
cases of primary spontaneous pneumothorax.
Familial clustering of this condition has been reported.
Genetic disorders that have been linked to primary
spontaneous pneumothorax include Marfan
syndrome, homocystinuria, and Birt-Hogg-Dube
(BHD) syndrome.

Birt-Hogg-Dube syndrome is an autosomal dominant
disorder that is characterized by benign skin tumors
(hair follicle hamartomas), renal and colon cancer,
and spontaneous pneumothorax. The spontaneous
pneumothorax occurs in about 22% of patients with
this syndrome. The gene responsible for this
syndrome has been identified and is a tumor
suppressor gene located on chromosome 17p11.2.
The gene encoding folliculin has been identified and
is thought to be the etiology of Birt-Hogg-Dube
syndrome. Multiple mutations have been found, and
phenotypic variation is recognized. In a recent study,
8 patients without skin or renal involvement had lung
cysts and spontaneous pneumothorax. A germ line
mutation to this gene has been found in 5 patients.
Genetic testing is now available.

Secondary spontaneous pneumothoraces (SSP)
occur in the presence of lung disease, primarily in the
presence of chronic obstructive pulmonary disease
(COPD). Other diseases that may be present when
SSPs occur includetuberculosis, sarcoidosis, cystic
fibrosis, malignancy, and idiopathic pulmonary

Pneumocystis jiroveci pneumonia (previously known
as Pneumocystis carinii pneumonia [PCP]) was a
common cause of secondary spontaneous
pneumothorax in patients with AIDS during the last
decade. With the advent of highly active antiretroviral
therapy (HAART) and widespread use of
trimethoprim-sulfamethoxazole prophylaxis, the
incidence of PCP and associated SSP has
significantly declined.

PCP is now primarily seen in patients who are
noncompliant with HIV therapy or trimethoprim-
sulfamethoxazole prophylaxis or those taking inhaled
pentamidine for PCP prophylaxis (probably related to
nonuniform distribution of the medication aerosol).
PCP in other immunocompromised patients is seen
only when trimethoprim-sulfamethoxazole prophylaxis
is withdrawn prematurely. For practical purposes, if
the immunocompromised patient has been taking
trimethoprim-sulfamethoxazole prophylaxis reliably,
PCP is reasonably excluded from the differential

Iatrogenic pneumothorax is a complication of medical
or surgical procedures. It most commonly results from
transthoracic needle aspiration. Other procedures
commonly causing iatrogenic pneumothorax are
therapeutic thoracentesis, pleural biopsy, central
venous catheter insertion, transbronchial biopsy,
positive pressure mechanical ventilation, and
inadvertent intubation of the right mainstem bronchus.
Therapeutic thoracentesis is complicated by
pneumothorax 30% of the time when performed by
inexperienced operators in contrast to only 4% of the
time when performed by experienced clinicians.

The routine use of ultrasonography during diagnostic
thoracentesis is associated with lower rates of
pneumothorax (4.9% vs 10.3%) and need for tube
thoracostomy (0.7% vs 4.1%). Similarly, in patients
who are mechanically ventilated, thoracentesis guided
by bedside ultrasonography without radiology support
results in a relatively lower rate of pneumothorax.
Traumatic pneumothoraces can result from both
penetrating and nonpenetrating lung injuries.
Complications include hemopneumothorax
and bronchopleural fistula. Traumatic
pneumothoraces can create a 1-way valve in the
pleural space (only letting in air without escape) and
can lead to a tension pneumothorax.

Tension pneumothorax typically occurs in the
intensive care setting in patients who are ventilated.
With air trapping in the pleural space, positive
pressure rises. This pressure compresses the
mediastinum, decreasing venous return to the heart
and reducing cardiac output. In addition, owing to
ipsilateral lung collapse and contralateral lung
compression, gas exchange is compromised, leading
to hypoxemia.

Most episodes of spontaneous pneumothorax (SP)
occur at rest. By definition, spontaneous
pneumothorax is not associated with trauma or stress.
• Acute onset of chest pain and shortness of breath
were present in all patients in one series.
Typically, both symptoms are present in 64% of
o Acute onset of chest pain - Severe and/or

stabbing pain, radiating to ipsilateral shoulder
and increasing with inspiration (pleuritic)
o Sudden shortness of breath

• Anxiety, cough, and vague presenting symptoms
(eg, general malaise, fatigue) are less commonly
• Dyspnea tends to be more severe with secondary
spontaneous pneumothoraces (SSPs) because of
decreased lung reserve.
• Bilateral pneumothorax - Primary bilateral
spontaneous pneumothorax (PBSP) was
significantly more common in patients with lower
BMI and among smokers.8

• General appearance
o Diaphoretic

o Splinting chest wall to relieve pleuritic pain
o Cyanotic (with tension pneumothoraces)
• Vital signs
o Tachypnea

o Tachycardia (most common finding) - If faster

than 135 beats per minute (bpm), tension
pneumothorax is likely
o Pulsus paradoxus

o Hypotension (often with tension

o Asymmetric lung expansion - Mediastinal and

tracheal shift to the contralateral side with a
large tension pneumothorax
o Distant or absent breath sounds

o Hyperresonance on percussion

o Decreased tactile fremitus

• Cardiovascular - Jugular venous distension
(tension pneumothorax)
• Neurologic - Altered mental status
• If patients who are mechanically ventilated are
difficult to ventilate during resuscitation, high peak
airway pressures are a clue to an impending
pneumothorax. A tension pneumothorax causes
progressive difficulty with ventilation as the
normal lung is compressed. On volume-control
ventilation, this is indicated by marked increase in
both peak and plateau pressures, with relatively
preserved peak and plateau pressure difference.
On pressure control ventilation, tension
pneumothorax causes sudden drop in tidal
volume. However, these observations are neither
sensitive nor specific for making the diagnosis of
pneumothorax or ruling out the possibility of

• Risks factors for primary spontaneous
pneumothorax (PSP)
o Smoking

 Of patients with PSP, 91% reportedly are

smokers or were smokers.
 The risk of PSP is related to the intensity

of smoking, with 102-times higher
incidence rates in males who smoke
heavily (ie, >22 cigarettes/d), compared
to a 7-fold increase in males who smoke
lightly (1-12 cigarettes/d).
o Tall, thin stature in a healthy person
o Marfan syndrome
o Pregnancy

 A 10-year retrospective series of 250 SP

cases found 5 pregnant women,
suggesting that pregnancy is an
unrecognized risk factor.9
 The cases were all managed successfully

with simple aspiration or vacuum-
assisted thoracostomy (VATS), and no
harm occurred to mother or fetus.9
o Familial pneumothorax

 Familial spontaneous pneumothorax has

been described as an autosomal
dominant inheritance with incomplete
penetrance. One family study reported 9
cases of SP among 54 members
 A review of the literature summarized 61

reports of familial spontaneous
pneumothorax among 22 families. Up to
10% patients with SP report a positive
family history.10
• Diseases and conditions associated with
secondary spontaneous pneumothorax
o Chronic obstructive lung disease
o Asthma
o HIV/AIDS with Pneumocystis jiroveci (PCP)
infection: 77% of AIDS patients with SP had
thin-walled cavities, cysts, and pneumothorax
from PCP infection.11
o Necrotizing pneumonia
o Bronchogenic carcinoma
o Metastatic malignancy
 Pneumothorax in a patient with

malignancy should prompt a look for
metastatic disease. Many different types
of malignancies have been implicated,
especially sarcomas, but also
genitourinary cancers and primary lung
 Chemotherapeutic agents and, at times,

the response of cancer to the agent can
induce SP.12
o Tuberculosis
o Cystic fibrosis (CF)
 Up to 18.9% of patients with CF have

been reported to have SP and have a
high incidence of recurrence on the same
side after conservative management
(50%) or intercostal drainage (55.2%).
The average annual incidence is 1 per
167 each year (Batten 1982).
 The risk of SP increases with cepacia or

pseudomonas infections, allergic
bronchopulmonary aspergillosis (ABPA),
and lower lung function.13 Pleurodesis
increases the risk of bleeding associated
with lung transplantation but is not an
absolute contraindication.
o Inhalational and intravenous drug use such
as marijuana and cocaine has been
implicated as etiology of SP as well.14
o Interstitial lung diseases associated with
connective tissue diseases
 Ankylosing spondylitis (AS) when apical

fibrosis is present: The typically low
incidence of SP in patients with AS
(0.29%) increases 45-fold to 13% when
apical fibrotic disease exists.15
o Idiopathic pulmonary fibrosis
o Sarcoidosis
o Lymphangioleiomyomatosis (LAM)
 SP may be the presenting sign of LAM, a
disease characterized by thin-walled
cysts in women of childbearing age.
 Respiratory failure may lead to a need

for lung transplantation, and prior
pleurodesis is no longer an absolute
contraindication for lung transplantation.
o Langerhans cell histiocytosis
o Acute respiratory distress syndrome
(ARDS) and positive pressure ventilation in
ICU: High peak airway pressures can
translate into barotrauma in up to 3% of
patients on a ventilator and up to 5% of
patients with ARDS.16
o Severe acute respiratory syndrome (SARS):
1.7% of patients with this acute viral
syndrome developed SP.17
o Thoracic endometriosis
 In a case series of 229 patients,

catamenial pneumothorax caused by
thoracic endometriosis was localized to
the visceral pleura in 52% of patients and
to the diaphragm in 39% of patients.
 Treatment is almost always surgical;
most cases present during or shortly after
menses, and the SP is usually right-
sided. It occurs mostly in women aged
30-40 years.
 The risk of thoracic endometriosis can

not be predicted from the site of
peritoneal lesions.18
• Causes of iatrogenic pneumothorax
o Transthoracic needle aspiration biopsy of

pulmonary nodules
o Transbronchial biopsy

o Thoracentesis

o Central venous catheter insertion

o Intercostal nerve block

o Tracheostomy

o Cardiopulmonary resuscitation

o Positive pressure ventilation and ARDS in the

ICU: High peak airway pressures can
translate into barotrauma-associated
pneumothorax in up to 3% of patients on a
ventilator and up to 5% of patients with
o Acupuncture
oNasogastric feeding tube placement
• Causes of traumatic pneumothorax
o Trauma - Penetrating and nonpenetrating

o Rib fracture

o High-risk occupation (eg, diving, flying)

Laboratory Studies
• Arterial blood gas - In patients with severe
underlying lung disease and in those with
persistent respiratory distress despite treatment
o Hypoxemia occurs with increased alveolar-

arterial oxygen tension gradient.
o Hypoxemia tends to be more severe in

patients with secondary spontaneous

Imaging Studies
• Chest radiograph (confirms pneumothorax)
o A linear shadow of visceral pleura with lack of

lung markings peripheral to the shadow may
be observed, indicating collapsed lung.
o In supine patients, deep sulcus sign with
radiolucency along costophrenic sulcus may
help to identify occult pneumothorax.
o Mediastinal shift toward the contralateral lung

may also be apparent.
o Small pleural effusions commonly are present

and increase in size if the pneumothorax
does not reexpand.
o Airway or parenchymal abnormalities in the

contralateral lung suggest causes of
secondary pneumothorax. Evaluation of the
parenchyma in the collapsed lung is less
o For more information, see eMedicine

Radiology article Pneumothorax.
• Method to estimate the fractional size of
o Calculate the ratio of the transverse radius of

the pneumothorax (cubed) to the transverse
radius of the hemithorax (cubed).
o To express the pneumothorax size as a

percentage, multiply the fractional size by
o The cut-point distinguishing small and large
pneumothoraces varies somewhat among
professional societies and experts. The
British Thoracic Society uses 2 cm as the cut-
off,19 the American College of Chest
Physicians uses 3 cm as the cut-point,20 and
the Light Index uses 15% of the thoracic
volume on the posterior-anterior film as the
cut point.21
• Lateral decubitus film
o Confirmation of a suspected pneumothorax

that is not readily observed on standard
supine anteroposterior (AP) radiograph can
be demonstrated by obtaining a lateral
decubitus film with the involved hemithorax
positioned uppermost.
• Rib films
o Rib films are indicated if the patient has

localized rib pain.
o Rib films are also indicated when evaluating

the patient's posttrauma status if nothing is
found on the main posteroanterior (PA) and
lateral films.
• CT scan
o CT scan is not recommended for routine use
but can help to accomplish the following:
• Distinguish between a large bulla and a


♣Indicate underlying emphysema or
emphysemalike changes
♣ Determine the exact size of the

pneumothorax, especially if it is small
♣ Confirm the diagnosis of pneumothorax

in patients with head trauma who are
mechanically ventilated
o CT is widely used in actual clinical practice to

assess the possibility of associated
concurrent pulmonary disease because of the
inherent superiority of CT scans to visualize
the details of lung parenchyma and pleura.
 Ultrasonography
o Ultrasonography is increasingly used in the

acute care setting as a readily available
bedside tool, especially in ICU and
emergency departments.
♣ Traumatic pneumothorax in the ICU

setting can be followed accurately and
early (initial 24 hours) with
ultrasonography alone for resolution of
the lesion.
♣ Lung sliding is the terminology for normal

pleural movement in patients without
pneumothorax.22 One study showed
absent lung sliding from an anterior
approach indicated pneumothorax (n =9)
with 81% sensitivity and 100% specificity.
o Ultrasonography has high sensitivity
(95.65%), specificity (100%), and diagnostic
effectiveness (98.91%) for pneumothorax
when using CT as the criterion standard. The
sensitivity drops in the ICU, especially in
patients with acute respiratory distress
syndrome (ARDS).23
o Ultrasonography cannot be used to
discriminate between a COPD-associated
bleb and pneumothorax.24

Medical Care
Despite large areas of agreement on 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.25,20

This management section presents a risk stratification
framework for choosing among options to restore an
air-free pleural space and prevent recurrences.26 While
these goals are consistent across diverse clinical
presentations, the range of options includes watchful
waiting without or with supplemental oxygen, simple
aspiration, tube drainage without or with medical
pleurodesis, vacuum-assisted thoracostomy (VATS)
with pleurodesis and/or closure of leaks and
bullectomy, and open surgical procedures such as
thoracotomy for pleurectomy or pleurodesis.

Selection among options requires an understanding of
the natural history of pneumothorax, the risk of
recurrent pneumothorax, and the benefits and
limitations of treatment options.

Risk stratification
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's presentation
o Asymptomatic (incidental finding): Treatment

decisions are guided by estimate of long-term
recurrence risk.
o Symptomatic but clinically stable: Treatment

is guided by local resources and conventions
for the site of care. The British Thoracic
Society (BTS) advocates for simple aspiration
and deferring hospitalization in primary
spontaneous pneumothorax (PSP) as initial
management if stable.25 A small bore catheter
or chest tube placement is recommended by
the American College of Chest Physicians
(ACCP) Delphi consensus statement.20
o Clinically fragile: Treatment is guided by local

practice patterns for air evacuation and
observation. Comorbid conditions may
preclude observation because of decreased
cardiopulmonary reserve.
o 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
o Very likely to resolve - Small pneumothorax in

a hemodynamically stable patient without
significant parenchymal lung disease; small
iatrogenic pneumothorax
o May resolve - Large pneumothorax in a

normal lung (eg, PSP or iatrogenic
o Unlikely to resolve - Secondary

pneumothorax, enlarging pneumothorax
(suggests a continuing air leak)
o Won't resolve, could be fatal - Tension

pneumothorax; unrecognized air leak
• Likelihood of recurrence
o Unlikely to recur (iatrogenic pneumothorax in

normal lung)
o May recur, but will likely be clinically stable
o May recur and be clinically unstable but
emergency care readily accessible
o Very likely to recur (diffuse and progressive
pulmonary pathology; eg,
lymphangioleiomyomatosis [LAM])
o Recurrence could be life-threatening (poor
cardiopulmonary reserve, limited access to
emergency medical care)

Selection of site of care

• Outpatient care: This can occur in asymptomatic
patients or those with a small pneumothorax and
reliable follow-up.
• Emergency department (ED) care: ED care is
changing. Prolonged periods of observation are
less practical because of large patient volumes;
efficacy studies of manual aspiration and
placement of one-way valves are based in EDs in
an attempt to address these practical issues.
• Inpatient observation: 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.
• ICU: ICU treatment and observation is
appropriate for patients who are unstable or

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 clinical status
to select imaging frequency. Monitoring
pneumothorax size during this time is important.
o 0-6 hours: The ACCP Delphi consensus

statement recommends 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.20 Emergency
room observation with a repeat radiograph 6
hours later used to be common but may be
used less often now.
o 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-h
(4-d) window is essential to distinguish
between a resolved pneumothorax and one
that needs evacuation. A CT scan at this time
distinguishes between PSP and secondary
spontaneous pneumothorax (SSP).
o 1 month: Full re-expansion can occur, on
average, 3 weeks after the initial event.

Options to restore an air-free pleural space

• Observation without oxygen: Simple observation
is appropriate for asymptomatic patients with a
minimal pneumothorax (<15-20% by Light's
criteria; 2-3 cm from apex to cupola by alternate
criteria) with close follow-up, ensuring no
enlargement. Air is reabsorbed spontaneously by
1.25% of size pneumothorax per day.27
• Supplemental oxygen: Oxygen administration at 3
L/min nasal canula or higher flow treats possible
hypoxemia and is associated with a 4-fold
increase in the rate of pleural air absorption
compared with room air alone.
• Simple aspiration: In an earlier report, simple
aspiration in 131 cases of small SP yielded
successful results up to 87%.28 Other data
describe more limited success in up to 70%
cases.29 A more recent ED study supports needle
aspiration as safe and effective as chest tube for
PSP, conferring the additional benefits of shorter
length of stay and fewer hospital admissions.30
• Aspiration procedure description
o Prepare the skin with Betadine solution and

cover with sterile drapes.
o Use a 1% Xylocaine solution for local

o Select the puncture site at the second or third

intercostal space in the midclavicular line or
in the fourth or fifth intercostal space over the
superior rib margin in the anterior axillary line.
o Place a plastic catheter over the needle into

the pleural space.
o Use a 3-way stopcock and large syringe to

evacuate air. When no more air can be
aspirated or the patient suddenly coughs, the
lung most likely has reexpanded.
o Remove the catheter, and massage the
insertion site with sterile gauze to seal the
channel into the pleural space.
o Obtain a follow-up chest radiograph.

• Chest tube for air removal: A tube inserted into
the pleural space is connected to a device with
one-way flow. Examples of such devices are
Heimlich valves or water seal canisters, and
tubes connected to wall suction devices.
o Portable system (insertion of a one-way

valve): The typical goal of one-way valve
systems is to avoid hospital admission and
still treat the SP. One-way valves may also
expedite hospital discharge and be used
during transport of an injured patient. A
Heimlich valve allows for complete
evacuation of air that is not under tension.
Heimlich valves do not require suction and
eliminate the chance of a tension
pneumothorax; they 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, the efficacy and safety of a
serial-steps approach with a single system
(small-caliber catheter/Heimlich valve) were
evaluated in 41 thin, young, smoking male
patients with a first episode of PSP. A one-
way Heimlich valve was connected to the
catheter, allowing the air to flow
spontaneously outward for 24-48 h.
Thereafter, if the lung failed to re-expand,
wall suction was applied. Patients with an air
leak persisting for >4 days were referred for
surgery. The 24-h and 1-wk success rates
were 61% and 85%, respectively, and the
actuarial 1-yr recurrence rate was 24%.
When 24-h and 1-wk success rates and
recurrence at 12 months were taken as end
points, the method described here is as
effective as simple manual needle aspiration
or a conventional chest tube thoracotomy.31

Heimlich valves are crucial in the care of
patients with AIDS who have a median length
of 20 days of chest tube placement.
• Thoracostomy with continuous (wall) suction:
First-time SPS (including COPD) and traumatic
pneumothorax typically require this approach. A
small-bore catheter (eg, 7-14F) is safe to use in
most patients, while a larger chest tube (24F) is
also appropriate initially, and increasing suction
pressure can be used if the lung fails to come up.
A larger tube (eg, 28F) 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.

Prevention of recurrent pneumothorax

• 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.
Recurrences have been reported to occur in up to
32% of PSP.32,33 A recent 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
vs. chest tube placement was not significantly
different.34 Recurrent spontaneous pneumothorax
requires more definitive treatment to prevent
recurrence. Recurrence rates are higher with SSP
than PSP; hence, observation is less often
chosen as an approach in SSP.
• Pleurodesis: A patient treated with surgical
pleurodesis has a recurrence prevention rate of
greater than 90%. Talc is the preferred agent for
pleurodesis. It can be administered by insufflation
or as a slurry. Practice variation depends on local
practitioner experience, resources, and success
with approaches ranging from video-assisted
thoracotomy (recommended by the American
College of Chest Physicians)20 to surgical
thoracotomy and pleurectomy (recommended by
the British Thoracic Society because of the
absolute lowest recurrence rates).19
• Nonsurgical pleurodesis: "Medical" thoracoscopy
requires only local anesthesia or conscious
sedation, in an endoscopy suite, using
nondisposable rigid instruments. Thus, it is
considerably less invasive and less expensive,
but 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
o Tetracycline and talc are well-studied

effective agents for medical pleurodesis; the
latter was 5% more effective in 1 randomized
study.36 Success rates for chemical are up to
91% vs. 95-100% in surgical
techniques.37 Chemical pleurodesis resulted in
a significant reduction of recurrence
compared to chest tube drainage alone in an
early study.38
o Chemical pleurodesis and surgery were

equally effective and were both superior to
conservative therapy in preventing the
recurrence of pneumothorax in LAM.

Surgical Care
• Indications for surgical assistance
o Persistent air leak for more than 7 days

o Recurrent ipsilateral pneumothorax

o Contralateral pneumothorax

o Bilateral pneumothorax

o First-time presentation in a patient with a

high-risk occupation (eg, diver, pilot)
o Patients with AIDS often need this

intervention because of extensive underlying
o The risk of recurrent pneumothorax may also

be unacceptable for patients with plans for
extended stays at remote sites.
o Lymphangiomyomatosis, a condition causing

a high risk of pneumothorax39
• Video-assisted thoracoscopic surgery (VATS)
o VATS is appropriate for recurrent primary

spontaneous pneumothorax (PSP) or
secondary spontaneous pneumothorax
o VATS with resection of large bullous lesions

is associated with a recurrence rate of 2-14%.
o VATS is done under general anesthesia

using a camera and 2 trocar ports.
o In a meta-analysis of 12 trials that
randomized 670 patients, VATS was
associated with shorter length of stay
(reduction 1.0-4.2 d) and less pain or use of
pain medication than thoracotomy in the 5 out
of 7 trials in which the technique was used for
pneumothorax or minor lung resection. In the
treatment of pneumothorax, VATS was
associated with substantially fewer
recurrences than pleural drainage in 2 trials.40
• Thoracotomy
o Insufflation of talc and thoracotomy has a

recurrence rate of 0-7%.
o Recurrence rates are as low as 4%, which

may be higher than open procedure case
o Talc is the preferred agent for pleurodesis. It

can be administered by insufflation or as a
• Complications of surgical procedures include the
o Failure to cure the problem

o Acute respiratory distress or failure

o Infection of the pleural space
o Cutaneous or systemic infection
o Persistent air leak
o Reexpansion pulmonary edema
o Prolonged tube drainage and hospital stay
o Increased risk of post-operative bleeding after
lung transplantation (for medical pleurodesis
and surgery; not found to affect the length of
hospital stay)39

• Consult with a surgeon about patients who
require a chest tube, pleurodesis, or surgical
thoracotomy and thoracoscopy.
• If patients have underlying lung disease, thereby
increasing the chance of recurrence, consult a
pulmonary specialist.
• 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 such as bupropion or

The goals of pharmacotherapy are to reduce
morbidity and to prevent complications. In addition to
the medications listed below, talc may be used as a
sclerosing agent for pleurodesis by mixing 2-5 g in
250 mL of sterile isotonic sodium chloride solution to
form a slurry or poudrage. Acute respiratory distress
syndrome (ARDS) has been reported after use of talc
as a pleural sclerosing agent but is considered to be a
rare complication.

Local anesthetics
Used for thoracentesis and chest tube placement.

Lidocaine hydrochloride (Xylocaine, Dilocaine,

Local anesthetic used as 1% solution. Onset of action
is within 45-90 seconds. Duration of anesthesia is 10-
20 min.
Adverse effects with use as local anesthetic include
allergic reactions.

Opiate analgetics
Used for pain control.

Meperidine hydrochloride (Demerol)

Onset of analgesia occurs within 5 min. Titrate dose
to effect. Half-life of the parent drug is 2.5-4 h,
prolonged in patients with liver disease. Half-life of the
active metabolite, normeperidine, is 15-30 h.
Accumulates with high dose and renal insufficiency.

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

• Patients should not travel by air or travel to
remote sites until radiography shows complete
• Patients cannot smoke. They should be assessed
as to readiness to quit, educated about smoking
cessation, and provided with pharmacotherapy if
ready to quit. 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
such as bupropion or varenicline.

• Respiratory or cardiac arrest
• Hemopneumothorax
• Bronchopulmonary fistula
• Pain at the site of chest tube insertion, infection,
and hemorrhage

• Complete resolution of uncomplicated
pneumothorax takes approximately 10 days.
• The recurrence rate of primary spontaneous
pneumothorax (PSP) is 32%. The presence of
emphysematouslike changes in PSP has no
predictive value for the future development of
• Age is a predictor of recurrence.
• Contralateral recurrence of PSP: A retrospective
study of 231 patients with PSP showed that 33
(14%) had a contralateral recurrence.8 Low BMI
was deemed a risk factor for contralateral
recurrence on univariate and multiple logistic
regression analysis. Contralateral blebs were
seen by CT in higher frequency in the patients
with contralateral recurrence than those without a
contralateral recurrence. In this series, all patients
with contralateral recurrence were treated

Patient Education
• Smoking cessation