REVIEW

CURRENT
OPINION Management of pneumothorax: an update
Alejandro Aragaki-Nakahodo

Purpose of review
Pneumothorax is a global health problem. To date, there is still significant variation in the management of
pneumothorax. For the past few years, there have been significant developments in the outpatient
management of both primary and secondary spontaneous pneumothorax (SSP). We will review the latest
evidence for the management of nontraumatic pneumothorax (spontaneous and iatrogenic) to include
pneumothorax associated with COVID-19 infection.
Recent findings
Outpatient management of both primary and SSP may be safe and feasible.
Summary
Outpatient management of both primary and SSP should be included in treatment options discussion with
patients.
Keywords
iatrogenic pneumothorax, management, spontaneous pneumothorax

INTRODUCTION studies. The 2010 British Thoracic Society (BTS)

The aim of this review is to summarize the latest
evidence for the management of nontraumatic
pneumothorax (spontaneous and iatrogenic).
REVIEW
Pneumothorax refers to air in the pleural cavity.
Spontaneous pneumothorax occurs in the absence
of thoracic trauma and is further classified in
primary spontaneous pneumothorax (PSP) and
secondary spontaneous pneumothorax (SSP). PSP
affects young individuals with apparently normal
lungs, whereas SSP develops in patients with known
lung disease. Iatrogenic pneumothorax is the
leakage of respiratory air into the pleural space after
a medical intervention, such as acupuncture, image-
guided lung biopsy, bronchoscopic lung biopsy,
thoracentesis, or central line placement [1–4].
pneumothorax guidelines quote a reported inci-
dence of 18–28/100 000 cases per year for men
and 1.2–6/100,000 for women. A more recent
study in France (2008–2011) showed an incidence
of 22/100,000 cases per year.
When pneumothorax occurs without any pre-
ceding trauma or injury, it is described as a sponta-
neous pneumothorax. Spontaneous pneumothorax
is further classified into PSP and SSP. PSP affects
patients less than 45 years of age without preexisting
pulmonary disease, with an unremarkable contra-
lateral lung in the X-ray. If the patient has known
lung disease, if a pathological lung structure is noted
in the X-ray, or if the patient is 45 years or older and
smokes, a SSP is suspected. This pneumothorax
classification is of decisive importance for the diag-
nosis and management of affected patients as SSP is
associated with higher morbidity and mortality
&

To date, there is still significant variation in the than PSP [5 ].

management of pneumothorax (as reflected in
international guidelines), however, for the past
few years, there has been increased pneumothorax-
related research, particularly PSP.
SPONTANEOUS PNEUMOTHORAX
Pneumothorax is a global health problem. The cur-
rent incidence is unknown, and most of the pub-
lished data comes from small retrospective registry
Director of Interventional Pulmonology, Pulmonary and Critical Care
Medicine Division, University of Cincinnati, Cincinnati, Ohio, USA
Correspondence to Alejandro Aragaki-Nakahodo, MD, Director of Inter-
ventional Pulmonology, Pulmonary and Critical Care Medicine Division,
University of Cincinnati, Cincinnati, Ohio, USA. Tel: +1 513 558 3028;
e-mail: aragakao@ucmail.uc.edu
Curr Opin Pulm Med 2022, 28:62–67
DOI:10.1097/MCP.0000000000000839

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 Management of pneumothorax Aragaki-Nakahodo

When there is clinical suspicion for tension

KEY POINTS
 Outpatient management options are now available
both for primary and secondary
spontaneous pneumothoraces.
 Decision for a definite intervention in spontaneous
pneumothorax and iatrogenic pneumothorax is driven
by patient’s symptoms and/or hemodynamic instability.
pneumothorax (hemodynamic compromise due to
increasing intrapleural pressure), urgent decompres-
sion with a cannula anteriorly in the second inter-
costal space in the midclavicular line must be
performed, even in the absence of confirmatory
imaging studies.

 Pneumothorax recurrence prophylaxis should be PRIMARY SPONTANEOUS

discussed both for primary and secondary
spontaneous pneumothorax.
Although PSP is defined as occurring in the
absence of lung disease, these patients do not have
‘normal lungs’. Most patients have emphysema-like
changes (ELC) in the lungs on CT scans (blebs and
bullae). It is unclear if these lesions are the actual
site of the air leakage. Autofluorescence studies
have described areas of parenchymal abnormalities
(pleural porosity), not related to blebs and bullae.
These anatomical findings have been targeted dur-
ing the surgical management of pneumothorax.
SSP can affect a very diverse group of airway and
lung diseases (see Table 1). The most common cause
worldwide is tuberculosis. In the developed world,
the most common cause is chronic obstructive pul-
monary disease (COPD).
Patients suffering from pneumothorax usually
present with chest discomfort and/or shortness of
breath. The source of the chest pain is not clear,
although most experts agree it is due to parietal
pleural inflammation and/or tearing of small pleural
adhesions (see Table 2).
PEUMOTHORAX MANAGEMENT
The 2010 BTS guidelines for the management of
spontaneous pneumothorax recommends stan-
dard chest X ray images to diagnose pneumotho-
rax. In uncertain or complex cases, CT chest is
recommended (presence of bullous lung disease
can lead to wrong diagnosis and unnecessary
procedures).
A visible rim of > 2 cm at the level of the hilum
between the lung margin and chest wall deter-
mines a large from a small pneumothorax. Patients
with PSP usually present with minimal symptoms
and the decision to treat could be assisted by
calculating the pneumothorax size [6]. However,
patients with small pneumothoraces but severe
symptoms may require intervention (ongoing
air leak with progressive lung collapse) whereas a
stable patient with a large pneumothorax may be
initially managed conservatively with observation
only (air leak was a transient event and has already
healed).
In recent years, conservative treatment has been
heavily studied, as PSP usually is not accompanied
by prominent symptoms and worsening into ten-
sion pneumothorax is very rare [3,7].

Table 1. Underlying causes of secondary spontaneous pneumothorax [5 ] &

Common Pulmonary tuberculosis, chronic obstructive pulmonary disease

Uncommon Cystic fibrosis; lung cancer; Pneumocystis jirovecii (PCP) infection
Rare Interstitial lung disease (idiopathic pulmonary fibrosis, sarcoidosis, pulmonary Langerhans cell histiocytosis,
lymphangioleiomyomatosis); connective tissue disorders (rheumatic arthritis, scleroderma, ankylosing spondylitis, Marfan
syndrome); catamenial pneumothorax

Table 2. Characteristics of primary and secondary spontaneous pneumothorax [4]

PSP SSP

Proportion of all spontaneous pneumothorax, % 85 15

Patient’s age, years 3518 53  20
Gender, male:female 76:24 80:20
Underlying lung disease No Yes
Clinical picture Often complaint-free Depending on the severity of underlying lung disease
Concurrent diseases Rare Frequent

PSP, primary spontaneous pneumothorax; SSP, secondary spontaneous pneumothorax.

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Interventional pulmonology
Is there a role for conservative treatment in
primary spontaneous pneumothorax?
&&
Brown et al. [8 ] completed a conservative vs inter-
ventional treatment trial for PSP recently. They
included patients with unilateral large pneumotho-
rax with 32% or more collapse (per the Collins
method [6]). The conservative group included at least
4 h of observation, no oxygen needs, ability to ambu-
late comfortably, and a stable repeat chest X ray. The
intervention group included a  12 Fr chest tube
placement with follow-up imaging at 1 and 4 h; if
lung reexpanded at 1 h, a 3-h clamping trial followed.
If the 4-h chest X ray was stable, the chest tube was
removed; if recurrence of pneumothorax, patient was
admitted to the hospital. This trial provided some
evidence that conservative treatment was noninfe-
rior to interventional treatment (small bore chest
tube placement) when lung reexpansion was assessed
at 8 weeks after randomization: 94.4% reexpansion in
the conservative group vs 98.5% reexpansion in the
intervention group. Adverse effects were also less
prevalent in the conservative treatment group. Meth-
odological flaws included the lack of the 8-week visit
in the original statistical analysis plan.
What is the best intervention for primary
spontaneous pneumothorax?
Much debate remains on which intervention is the
most appropriate for an initial episode of PSP. What
seems to be settled in the discussion is the use of
small-bore chest tubes (size  14 Fr) over large-bore
chest tubes [9,10]. Chang et al. [10] demonstrated
small-bore chest tubes were as effective as large-bore
for air drainage. Small-bore tubes also had shorter
drainage duration and hospital stay. Large-bore
chest tubes are reserved for refractory pneumotho-
rax and in emergencies (tension pneumothorax).
Needle aspiration (NA) of a PSP is better toler-
ated than chest tube placement. Efficacy of NA and
chest tube placement varies among studies [11,12].
A 2017 Cochrane review found low to moderate
evidence that NA results in shorter duration of
hospitalization and less adverse events [11]. Mum-
madi et al. [12] concluded NA was top ranked in
safety while small bore chest tube placement as top
ranked in efficacy. Tan et al. [13] described a higher
initial success rate for chest tube placement when
compared to NA (immediate air drainage) however
there is no significant difference in the 1-week suc-
cess rate, 3-month recurrence rate, 1-year recurrence
rate, and recurrence time between the 2 groups. The
2010 BTS Guidelines define successful NA when the
pneumothorax rim is < 2 cm and there is symptom
improvement. Patients can be discharged home and
have close follow-up as an outpatient. NA should be
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stopped after 2.5 l of air has been aspirated as lung
reexpansion is highly unlikely. Chest tube insertion
would be needed at this point [2].
PSP has a 32% recurrence rate, especially during
the first year. Smoking cessation decreases this
risk four-fold [15]. Surgery or thoracoscopy is recom-
mended for persistent air leak lasting at least
3–7 days, or recurrence [7]. The optimal surgical
technique in PSP is unknown, with thoracotomy
with pleurectomy or mechanical pleurodesis and
video-assisted thoracic surgery (VATS) with wedge
resection and mechanical/chemical pleurodesis the
most efficacious surgeries in terms of recurrence after
surgery for PSP (1–5%) [2,14,15]. As mentioned pre-
viously, surgical resection of apical blebs/bullae, the
so called ELC does not necessarily prevent recurrence.
It is well known that bullectomy alone is inferior to
addition to pleurodesis [16]. The concept of ‘pleural
porosity’ (parenchymal abnormality independent of
blebs/bullae) might explain this interesting finding.
Pleural porosity is not found in patients without a
pneumothorax episode [17]. Olesen et al. [18] chal-
lenge the pleural porosity paradigm in a randomized
trial that compared conventional chest tube manage-
ment vs chest tube management followed by surgical
treatment of PSP. The surgical intervention group
(VATS with bleb/bullae resection and mechanical
pleurodesis) had significantly lower recurrence when
compared to conventional chest tube management
(13% vs 40%). VATS performed significantly better
for bullae > 1 cm, and there was a size-response
relationship with increased risk of recurrence for
larger bullae. Olesen et al. propose consolidated med-
ical and surgical management of the first episode of
PSP when chest CT imaging revealed bullae > 2 cm.
Contralateral recurrence in patients with PSP is
approximately 15%. Liu et al. [19] described their
single-center experience with simultaneous contra-
lateral blebectomy during VATS þ mechanical
pleural abrasion for unilateral PSP. The percentage
of contralateral recurrence decreased from 14.6%
to 2.9%.
Even when the risk of tension pneumothorax is
very low in PSP, some physicians are reluctant to
outpatient management of PSP for fear of legal
&&
claims [20]. Hallifax et al. [21 ] compared an ambu-
latory device (Rocket Pleural Vent, Rocket Medical,
Watford, UK; this device includes an 8 Fr small bore
catheter and a one-way valve mechanism) vs stan-
dard guideline-based management of PSP (aspira-
tion, chest tube insertion, or both). The primary
outcome was length of stay including readmission
within 30 days after randomization. At day 30, the
median hospitalization was significantly shorter
in the ambulatory device (0 vs 4 days) at the expense
of increased adverse events (55% vs 39%). Adverse
Volume 28  Number 1  January 2022

events with the ambulatory device included device
malfunction (tube kinking).
SECONDARY SPONTANEOUS
PNEUMOTHORAX MANAGEMENT
SSP is less likely to be tolerated than PSP because of
underlying lung disease. The air leak is less likely to
resolve spontaneously as well. For these reasons, all
patients with SSP should be admitted to the hospital
and most of them will need a small-bore chest tube
placement. An intervention will be determined by the
patient’s symptoms and not by pneumothorax size.
What is the best intervention for secondary
spontaneous pneumothorax?
NA success is much smaller than in PSP cases, there-
fore it is not recommended for SSP. Every symptom-
atic SSP patient will need a small bore chest tube
placement. Patients with a persistent air leak should
be discussed with a thoracic surgeon at 48 h [2]. The
recommended surgical technique is parietal pleur-
ectomy or alternatively a pleurodesis procedure. SSP
presenting as bilateral pneumothoraces and contra-
lateral recurrence are indications for surgical treat-
ment of both sides (bilateral thoracotomy or VATS)
[22]. Patients that are inoperable may be appropriate
for pleurodesis (talc slurry or talc poudrage). SSP
patients are usually older, with underlying chronic
lung disease and more frequent comorbidities. Their
greater surgical and anesthesia risk influences the
indication and operative technique. If a patient is a
lung transplant candidate, coordination with a lung
transplantation center should be arranged [4]. Ichi-
nose et al. [23] retrospectively reviewed patients who
underwent surgery for SSP. They found that surgery
for SSP caused by underlying diseases other than
interstitial pneumonia (COPD and others) had
favorable results (treatment success 83–86% vs
45%). The caveat for this study was the absence of
pleurodesis for surgical management of SSP. Wang
et al. [24] evaluated in a retrospective study the effect
of same admission pneumothorax recurrence pro-
phylaxis (SARP) in SSP patients, which comprised
VATS, open surgery or medical pleurodesis. SARP
was associated with lower mortality, lower all-cause
readmission, and lower pneumothorax recurrence
in SSP admissions.
&&
Walker et al. [25 ] attempted to compare ambu-
latory management of SSP against standard of care.
The primary endpoint (length of stay) was like the
&&
RAMPP trial by Halifax [21 ] with the Rocket Pleural
Vent used to manage the SSP. Given the high pro-
portion of patients with an already placed chest
tube, the protocol was modified to include patients
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Management of pneumothorax Aragaki-Nakahodo
with a chest tube in place < 36 h, with a one-way
valve (Atrium Pneumostat) connected to the chest
tube. There was a higher rate of early treatment
failure with the Pleural vent device (46%). Interim
analysis found this unacceptable and stopped the
use of the Rocket Pleural Vent Device. The Atrium
Pneumostat had no treatment failures, suggesting it
could be a safe alternative for ambulatory manage-
ment of SSP.
The COVID-19 pandemic has placed a significant
burden on healthcare systems around the world.
Pneumothorax is a complication of COVID-19 but
does not appear to be an independent marker of poor
prognosis [26]. Limited case series describe successful
observation strategies for COVID-19 patients and
ventilator-induced pneumothoraces [27]. Hemody-
namic instability will determine if an intervention is
warranted (tension physiology). As some patients
with COVID-19 infection will need systemic anti-
coagulation (for deep venous thrombosis treatment
or as part of extracorporeal membrane oxygenation
circuits), pneumothoraces could be underlying
hemopneumothoraces instead. If technically feasi-
ble, a small-bore chest tube is preferred over a large-
bore chest tube.
IATROGENIC PNEUMOTHORAX
MANAGEMENT
Multiple thoracic interventions are prevalent now-
adays in the day-to-day management of patients
with shortness of breath, abnormal thoracic imag-
ing studies, and/or need for central line catheter
placement in the intensive care unit. Transthoracic
lung biopsy, transbronchial lung cryobiopsies and
bronchoscopic lung volume reduction have signifi-
cant risk for postprocedural pneumothorax.
Usually, post procedure observation for up to 4 h
is recommended based on expert opinion [3]. Chest
X ray or thoracic ultrasound can help determine if
there is an iatrogenic pneumothorax. In patients
with a small pneumothorax and no dyspnea or
pleuritic chest pain, observation alone is reasonable.
For large and/or symptomatic pneumothorax (pleu-
ral rim > 2 cm), a small-bore chest tube should be
placed. If persistent air leak > 5 days or inadequate
expansion of the lung, a consultation with thoracic
surgery is recommended. Iatrogenic pneumothorax
is not the same as PSP or SSP, hence, pneumothorax
recurrence prophylaxis is not recommended.
CONCLUSION
The best management strategy for PSP remains to be
established. There are several options available, and
which one is used will depend on a case-by-case
www.co-pulmonarymedicine.com 65
Interventional pulmonology

Spontaneous pneumothorax
If bilateral/hemodynamically unstable Ò
small- vs large-bore chest tube

Primary spontaneous NO Age > 50 and significant smoking history; YES Secondary spontaneous
pneumothorax evidence of underlying lung disease on pneumothorax
exam or chest X ray?

Size > 2cm Insertion of

and/or
YES ambulatory device
breathless and outpatient
follow-up
YES
YES Size > 2cm
and/or
breathless
Needle aspiration
NO 16-18G cannula
Aspirate < 2.5L

NO
Success
YES (<2cm and NO Outpatient
Consider discharge breathing management
and outpatient improved) with one way
follow-up in valve device
2-4 weeks for SSP cases

Some patients with

large pneumothorax Admit
Small-bore
and minimal High flow oxygen
symptoms could be chest tube
8 – 14 Fr 24 hr observation
managed conservatively
as outpatients
Thoracic Surgery
consultation in PSP
cases with apical Same admission
bullae > 2 cm pneumothorax
Admit recurrence
prophylaxis

FIGURE 1. Management algorithm for spontaneous pneumothorax. Adapted from MacDuff et al. [2].

basis, determined by operator experience, patient Acknowledgements

choice and ability of the healthcare system to None.
develop ambulatory care facilities to allow patients
to be followed carefully if conservative or outpatient Financial support and sponsorship
device management is selected. The decision to None.
proceed directly to surgery for PSP recurrence pre-
vention could be hard to justify since PSP usually is Conflicts of interest
an asymptomatic event, unless there is radiologic There are no conflicts of interest.
evidence of apical bullae > 2 cm. PSP recurrence is an
indication for surgical intervention.
REFERENCES AND RECOMMENDED
SSP management relies on patient’s symptoms. A
READING
small-bore chest tube is usually the standard of care, Papers of particular interest, published within the annual period of review, have
with a one-way valve (Atrium Pneumostat) as an been highlighted as:
& of special interest
interesting alternative for outpatient management && of outstanding interest

(provided symptoms are improved, patient is hemo-

dynamically stable, and close follow-up can be
guaranteed). Given the high recurrence rate for
SSP, a definite treatment to prevent pneumothorax
recurrence is generally indicated, whether unilateral
or bilateral. The patient’s preference should be part of
the decision-making process, where benefits and risks
should be thoroughly discussed.
A proposed algorithm is summarized in Fig. 1.
Iatrogenic pneumothorax management is based on
patient’s symptoms. The algorithm for PSP manage-
ment could be applied for iatrogenic pneumothorax
cases, obviating the recurrence prophylaxis section.
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