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Official reprint from UpToDate®

www.uptodate.com © 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Treatment of secondary spontaneous pneumothorax in

adults
Author: YC Gary Lee, MBChB, PhD
Section Editor: V Courtney Broaddus, MD
Deputy Editor: Geraldine Finlay, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2023. | This topic last updated: Jun 14, 2022.

INTRODUCTION

Pneumothorax (gas in the pleural space) can be a life-threatening condition that needs prompt
assessment.

The management of secondary spontaneous pneumothorax (SSP; ie, that which presents as a
complication of underlying lung disease) is discussed in this topic review. The epidemiology,
etiology, clinical presentation, and diagnosis of pneumothorax, and the management of
primary spontaneous pneumothorax (PSP; ie, that which occurs in the absence of lung disease)
are discussed separately. (See "Clinical presentation and diagnosis of pneumothorax" and
"Pneumothorax in adults: Epidemiology and etiology" and "Treatment of primary spontaneous
pneumothorax in adults".)

DEFINITION (SECONDARY PNEUMOTHORAX)

A spontaneous pneumothorax is considered one that presents in the absence of an external

factor. The management strategies of primary spontaneous pneumothorax (PSP; that which
presents in the absence of clinical lung disease) and secondary spontaneous pneumothorax
(SSP; that which presents as a complication of underlying lung disease) ( table 1) differ in
their threshold to perform a chest tube thoracostomy and to perform a definitive procedure to
prevent recurrence. Thus, following the radiographic identification of pneumothorax, clinicians
should quickly estimate the size, assess the degree of symptomatology, and attempt to classify

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the pneumothorax as primary (that without underlying lung disorder), secondary (that due to
underlying lung disorder), or other (trauma, iatrogenic) so that appropriate therapy can be
initiated. The diagnosis and classification of pneumothorax and treatment of primary
pneumothorax are discussed separately. (See "Pneumothorax in adults: Epidemiology and
etiology" and "Clinical presentation and diagnosis of pneumothorax" and "Treatment of
primary spontaneous pneumothorax in adults".)

INITIAL MANAGEMENT OF FIRST EVENT

Most patients with secondary spontaneous pneumothorax (SSP) are treated with supplemental
oxygen and removal of air from the pleural space, typically by chest tube thoracostomy.
Patients also typically undergo a definitive procedure to prevent recurrence during the same
hospitalization. Our approach expands upon that outlined in published clinical consensus
statements and guidelines from the American College of Chest Physicians (ACCP; 2001), the
British Thoracic Society (2010), the European Respiratory Society (2015), the Japanese
Association for Chest Surgery (2014), and others [1-5]. While some experts use a symptom-
driven approach and others prefer a size-driven approach, we prefer one that incorporates size
and symptoms.

Assessment of size and stability

Definition of size limits — There is no consensus statement regarding size to guide clinicians
when managing patients with SSP. Estimation of size is usually only performed on chest
radiography (and less commonly chest computed tomography [CT]); ultrasonography cannot
reliably quantify pneumothorax size and is generally imperfect. For pneumothorax identified
using ultrasound, we believe that chest radiography should be done to estimate the size,
although practice may vary considerably and no guidelines are available to facilitate this
decision. Our suggested cutoff from the pleural line to the apex of <2 cm (small pneumothorax)
and ≥2 cm (large pneumothorax) is based upon our experience and used as a general guideline
only. Further details regarding the assessment of size are provided separately. (See "Clinical
presentation and diagnosis of pneumothorax", section on 'Pneumothorax size'.)

Definition of stability — The definition of stability suggested by the ACCP [2] comprises
patients with all of the following:

● Respiratory rate <24 breaths per minute

● Heart rate <120 and >60 beats per minute
● Normal blood pressure (not defined)

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● Room air oxygen saturation >90 percent

● Ability to speak in whole sentences

Management strategy

Unstable patients — Instability due to pneumothorax (including tension pneumothorax) is

more common in patients with SSP than primary spontaneous pneumothorax (PSP). Patients
who are unstable due to SSP should undergo chest tube thoracostomy or alternatively, needle
decompression of the pleural space, if chest tube decompression is delayed. (See "Clinical
presentation and diagnosis of pneumothorax", section on 'Pneumothorax appearance and
types' and "Initial evaluation and management of blunt thoracic trauma in adults", section on
'Pneumothorax' and "Approach to shock in the adult trauma patient", section on 'Tension
pneumothorax'.)

Stable patients — Most clinically stable patients (see 'Definition of stability' above) with an
SSP should be treated with catheter or chest tube thoracostomy based upon the rationale that
compared with PSP, patients with SSP have underlying lung disease that increases the likelihood
of failure of aspiration, a prolonged air leak, and the development of tension [1,6].

Small (<2 cm at apex) — In patients with a small SSP (<2 cm from the pleural line to the
chest wall at the apex (see 'Definition of size limits' above)) who have significant symptoms, a
catheter or tube thoracostomy is preferred, and the patient should be hospitalized. (See 'Tube
or catheter thoracostomy' below.)

However, exceptions may exist. For example, for patients with a small SSP or patients who are
asymptomatic or have minimal symptoms, treating with observation or supplemental oxygen
and/or aspiration is appropriate. The threshold to admit the patients should be low. Progression
of symptoms or an enlarging pneumothorax is an indication for pleural drainage. The
administration and period of observation and follow up for those on oxygen and observation or
aspiration are discussed below. (See 'Aspiration' below and "Treatment of primary spontaneous
pneumothorax in adults", section on 'Supplemental oxygen and observation'.)

Large (≥2 cm at the apex) — For patients with a large SSP (≥2 cm from the pleural line to
the chest wall at the apex (see 'Definition of size limits' above)), prompt drainage by tube or
catheter thoracostomy and subsequent hospitalization are often indicated because of the risk
of respiratory impairment and need for definitive intervention [7]. (See 'Tube or catheter
thoracostomy' below.)

General supportive care — Patients with SSP are treated with supplemental oxygen, if needed,
and the underlying reason for pneumothorax is treated. Patients are generally admitted.
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Supplemental oxygen — Supplemental oxygen is discussed in the section below. (See

'Oxygen and observation' below.)

Treatment of the underlying lung disease — Patients with SSP have pneumothorax as a
complication of their underlying lung disease which may need to be treated together with the
pneumothorax. For example, pneumothorax may precipitate or be a complication of a chronic
obstructive pulmonary disease (COPD) exacerbation or asthma attack, necessitating therapy
with nebulized bronchodilators and corticosteroids. (See "COPD exacerbations: Management"
and "Acute exacerbations of asthma in adults: Home and office management".)

Therapies to avoid — Patients with SSP are more likely than those with PSP to need
concomitant therapies; however, some may worsen the pneumothorax and should be avoided.
As examples:

● Noninvasive ventilation (NIV) – In general, NIV should be avoided, when feasible (eg,
mild to moderate non-life-threatening obstructive sleep apnea) since it is plausible the
application of positive pressure increases the risk of a prolonged air leak and progression
to tension. In addition, a few anecdotal cases exist to support the development of
pneumothorax in those receiving NIV, although no reports have been published
demonstrating progression in those with established pneumothorax. Despite this risk,
cautious use may be warranted in select circumstances (eg, in patients with respiratory
failure who prefer to avoid mechanical ventilation who have a thoracostomy tube in
place). (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and
contraindications".)

● High-flow nasal oxygen via nasal cannulae (HFNC) – For similar reasons, HFNC is best
avoided due to the small amount of positive pressure that is delivered to the airway with
this mode of oxygen delivery. (See "Heated and humidified high-flow nasal oxygen in
adults: Practical considerations and potential applications".)

● Chest physical therapy – Based upon our experience we suggest individualizing airway
clearance measures in patients with pneumothorax based upon the risk of progression.
For example, on one hand the risk of progression may be higher in those on positive
expiratory pressure (PEP)/oscillating PEP and manual chest percussion while on the other
hand, the risk of mucus plugging from withholding therapy may also contribute to the
progression. Factors to take into consideration include the type of physical therapy, size of
the pneumothorax, and the presence of a catheter/chest tube. These recommendations
are typically most pertinent to those with cystic fibrosis. (See "Cystic fibrosis: Overview of
the treatment of lung disease", section on 'Chest physiotherapy'.)

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Nebulized therapy does not need to be held while pneumothorax is being treated.

Disposition — Almost all patients with SSP should be hospitalized, because the underlying
lung disease increases the risk for an adverse outcome (eg, respiratory failure, cardiovascular
collapse, recurrent event) [1,4,8]. Exceptions are rare but might include stable patients with
minimal symptoms and a small SSP (<2 cm), who may be observed in the outpatient setting if
follow-up and access to health care are good [4]. (See 'Small (<2 cm at apex)' above.)

INITIAL MANAGEMENT OF RECURRENT EVENT

While patients with secondary spontaneous pneumothorax (SSP) should have a definitive
intervention after their first event to prevent recurrence, some patients are ineligible or
unwilling to undergo a definitive procedure. Should these patients recur, a chest tube or
catheter thoracostomy should be placed to manage recurrence and the option of a definitive
procedure should be revisited. (See 'Tube or catheter thoracostomy' below.)

INITIAL THERAPEUTIC OPTIONS

The majority of patients with secondary spontaneous pneumothorax (SSP) undergo tube or
catheter thoracostomy placement. Less commonly, for minimally symptomatic small
pneumothoraces, aspiration or oxygen and observation may be appropriate. (See 'Initial
management of first event' above.)

Tube or catheter thoracostomy — Chest tube or catheter (eg, pigtail catheter) thoracostomy
is generally preferred over simple aspiration for drainage of air in patients with SSP because it is
more likely to be successful [1,9]. In one trial, 28 patients with SSP were randomly assigned to
receive tube thoracostomy and 33 patients to simple aspiration [10]. The tube thoracostomy
group was more likely to have their pleural air completely evacuated than the needle aspiration
group (93 versus 67 percent). The lower success rate of pleural aspiration in SSP than in primary
spontaneous pneumothorax (PSP) may be due to a higher rate of persistent air leakage (ie,
larger leaks) [11].

Chest tube thoracostomy refers to the insertion of a standard chest tube, while catheter
thoracostomy refers to the insertion of a catheter, which is usually small, more pliable, and
therefore less painful (eg, pigtail catheter). The details regarding insertion and management is
similar to that described for patients with primary spontaneous pneumothorax (PSP), with
some minor differences which are discussed in the section below. (See "Treatment of primary

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spontaneous pneumothorax in adults", section on 'Initial thoracostomy management' and

"Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)

Ambulatory drainage device — A multicenter randomized trial examined the use of devices
involving one-way flutter valve to allow home management of SSP in 41 patients. However use
of ambulatory device had a high early treatment failure rate (46 percent) and was not
recommended [12].

Size — For most clinically stable patients with SSP, we prefer to use small-bore catheters (≤14
French [Fr]) or small-bore chest tubes (≤22 Fr) rather than large-bore chest tubes based upon
ease of insertion, patient comfort, and evidence that supports equal efficacy [13-15]. However,
some patients may benefit from the insertion of large-bore chest tubes only (24 to 28 Fr),
including the following:

● Patients with large air leaks – Patients with large air leaks may need a large-bore chest
tube to provide enough drainage capacity; alternatively, they may benefit from a second
small-bore catheter.

● Patients with concomitant empyema or hemothorax – Patients with concomitant

empyema or hemothorax are thought to benefit from large-bore tubes for drainage since
small-bore catheters are at increased risk of blockage from clot or debris. In the case of
hemothorax, the purpose of a chest tube is also to monitor the rate of blood loss, making
a large-bore tube desirable.

● Patients who are unstable with tension pneumothorax – In patients with tension
pneumothorax, a large-bore tube is often placed based upon the likelihood of a large or
persistent air leak.

● Patients with barotrauma from mechanical ventilation – Many experts prefer large-
bore chest tubes in patients with barotrauma, since the air leak is likely to be large and
may lead to tension pneumothorax, although the risk is unquantified. However, practice
varies greatly and is dependent upon availability of expertise and institutional practices. A
retrospective study of 62 mechanically ventilated patients reported lower success rates
with small-bore chest tubes when the pneumothorax was thought to be due to
barotrauma than when the pneumothorax was due to iatrogenic causes (43 versus 88
percent) [16]. Management of barotrauma during mechanical ventilation is discussed
separately. (See "Diagnosis, management, and prevention of pulmonary barotrauma
during invasive mechanical ventilation in adults".)

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Immediate follow-up — The general principles of immediate follow-up of patients with SSP
who have chest tube or catheter thoracostomy including the indications for the application of
suction (most patients are initially placed on water seal) are similar to that of patients with PSP.
However, the prevalence of prolonged (persistent) air leak (PAL) is more common. Thus, most
patients remain hospitalized with the chest tube in place until a definitive procedure is
performed to prevent recurrence. (See "Treatment of primary spontaneous pneumothorax in
adults", section on 'Follow-up thoracostomy management (one to five days)'.)

After a thoracostomy is placed we suggest the following:

● Sealed air leak – Patients with SSP in whom the air leak has sealed should proceed directly
to having a preventive measure. However, if patients choose to decline immediate
intervention, they can be discharged with an ambulatory valve (eg, Heimlich valve
( picture 1)), provided that there is no concurrent fluid that continues to drain, and
return for a definitive procedure as soon as possible at a later date. As a lesser option,
patients can have their chest tube/catheter removed in the same way as patients with PSP,
understanding the risk of recurrence is highest in the first 30 days after pneumothorax.
(See "Treatment of primary spontaneous pneumothorax in adults", section on 'Sealed air
leak'.)

● Prolonged (persistent) air leak – Compared with those who have PSP, PALs due to ruptured
subpleural bullae or cysts (eg, chronic obstructive pulmonary disease [COPD],
pneumocystis pneumonia) are more common and tend to persist longer in patients with
SSP [17,18]. These patients require definitive measures to seal the defect and prevent
future recurrence. In most patients, video-assisted or medical thoracoscopy (VATS) is
preferred, although nonsurgical pleurodesis (with chemical sclerosants) or prolonged
thoracostomy drainage are options in patients who are not good candidates for or are
unwilling to undergo surgery. Increasingly endobronchial valves are used as an alternative
option. Blood patch has been used but the evidence remains limited. Further details
regarding definitive management are provided separately. (See "Pneumothorax: Definitive
management and prevention of recurrence", section on 'Definitive measures' and
"Alveolopleural fistula and prolonged air leak in adults", section on 'Bronchoscopic
interventions'.)

Others — Oxygen with observation and aspiration are therapies that are only occasionally used
in patients with SSP.

Oxygen and observation — Supplemental oxygen (for a minimum of six hours) and
observation is an option for clinically stable patients who have a first episode of SSP that is

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small (<2 cm from the pleural line to the chest wall at the level of the apex) and who are
asymptomatic or minimally symptomatic or for patients in whom options are limited. (See
'Small (<2 cm at apex)' above.)

Unlike patients with PSP, hypoxemia is common in patients with SSP. Supplemental oxygen is
administered to virtually all patients with SSP to treat hypoxemia and facilitate absorption of air
from the pleural space [1]. The protocol is similar to that described for patients with PSP except
the threshold for admission and placement of a thoracostomy tube is lower. However, in
contrast with patients who have PSP in whom high flow oxygen can be administered liberally,
the fraction of inspired oxygen (FiO2) should be increased cautiously in patients with SSP who
have or are at risk for oxygen-induced hypercapnia (eg, moderate to severe COPD) [19]. Similar
to patients with PSP, high flow oxygen delivered via nasal cannulae (HFNC) should be avoided,
when feasible, since HFNC delivers a small amount of positive pressure to the airway that could
potentially worsen the pneumothorax and perpetuate the air leak. Titration of oxygen in
patients with hypercapnia is discussed separately. (See "The evaluation, diagnosis, and
treatment of the adult patient with acute hypercapnic respiratory failure", section on 'Titration
of oxygen' and "Heated and humidified high-flow nasal oxygen in adults: Practical
considerations and potential applications" and "Treatment of primary spontaneous
pneumothorax in adults", section on 'Supplemental oxygen and observation'.)

This strategy is not generally suitable for those with a recurrent event but can be rarely
considered in those with severe underlying lung disease and a small loculated pneumothorax in
whom other options are limited.

Aspiration — Aspiration is an option in stable patients with a small SSP (<2 cm from the
pleural line to the chest wall at the level of the apex) who have mild or no symptoms or for
those in whom options are limited. (See 'Small (<2 cm at apex)' above.)

This option is usually limited to centers with expertise. The procedure for aspirating air is
similar to that described in patients with PSP except the threshold for admission following
aspiration should be lower since the likelihood of failing aspiration is higher [10,11]. (See
"Treatment of primary spontaneous pneumothorax in adults", section on 'Aspiration' and 'Tube
or catheter thoracostomy' above.)

PREVENTING RECURRENCE AND FOLLOW-UP

In contrast with patients who have primary spontaneous pneumothorax (PSP), most patients
with a first episode of secondary spontaneous pneumothorax (SSP) should undergo a definitive

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intervention during the same hospitalization (eg, within three to five days), to prevent
recurrence ( algorithm 1). This approach is based upon the high recurrence rate (generally
>50 percent), the higher likelihood of a life-threatening event, and the high efficacy of
pleurodesis in this population. Individual exceptions may apply to patients with very small
loculated pneumothoraces (eg, patients with cystic fibrosis [4]) or patients who decline
pleurodesis. In most cases, video-assisted thoracic surgery (VATS) or medical thoracoscopy with
blebectomy and a procedure to induce pleurodesis (eg, surgical abrasion or chemical
pleurodesis) is the first choice procedure based upon its high efficacy. For those unable or
unwilling to undergo VATS, medical chemical pleurodesis at the bedside is preferred.
Additionally, for patients with emphysema who meet inclusion and exclusion criteria for lung
volume reduction surgery (LVRS), it may be appropriate to perform LVRS at the time of surgical
pleurodesis. Further details regarding the recurrence rate and follow up of patients who
undergo definitive measures are discussed separately. (See "Pneumothorax: Definitive
management and prevention of recurrence" and "Treatment of primary spontaneous
pneumothorax in adults", section on 'Outpatient follow-up'.)

After therapy, outpatient follow up is similar to that described for patients with primary
spontaneous pneumothorax. In brief, patients should be evaluated clinically and radiologically
in about two to four weeks after admission during which time, they are instructed to return to
the hospital with symptoms of chest pain or dyspnea since recurrence is greatest during the
first month after presentation. Patients should be assessed for control of their underlying lung
disease, advised to stop smoking cigarettes as well as other tobacco products, marijuana, and
illicit drugs, and to avoid air travel, scuba diving, and exercise for a limited period. Additional
details are provided separately. (See "Treatment of primary spontaneous pneumothorax in
adults", section on 'Outpatient follow-up'.)

OTHER PNEUMOTHORAX TYPES

The optimal management of pneumothorax associated with other etiologies is unstudied and is
generally based upon biologic plausibility and experience ( table 1).

● Iatrogenic/trauma – Patients with iatrogenic pneumothorax are generally treated as if

they had primary spontaneous pneumothorax and few require pleurodesis unless they
have a prolonged (persistent) air leak (PAL) that is not responsive to conservative therapy.
Acute management of traumatic pneumothorax is discussed separately. (See "Initial
evaluation and management of blunt thoracic trauma in adults", section on
'Pneumothorax' and "Initial evaluation and management of blunt thoracic trauma in
adults", section on 'Occult pneumothorax'.)
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● Structural abnormalities – The optimal treatment of patients with pneumothorax

associated with structural abnormalities of the lung including Marfan or Ehlers-Danlos
syndrome is unknown but in general they are treated in a similar fashion to those with
secondary spontaneous pneumothorax based upon the assumption that recurrence is
likely to be high.

● Miscellaneous – In patients with miscellaneous causes of pneumothorax including

anorexia, exercise, illicit drug use, immunosuppressant drugs, air travel, or scuba diving,
treatment of pneumothorax should be individualized based upon the symptoms and
assessed risk of recurrence. Some societies recommend bilateral pleurectomy for deep
sea divers who wish to resume diving [1]. Recommendations for patients traveling by air
are provided separately. (See "Pneumothorax and air travel".)

PNEUMOTHORAX AND PREGNANCY

Our experience and case reviews support the occurrence of primary spontaneous
pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) during pregnancy,
although the exact incidence of either entity is unknown [20]. Older studies suggest that
recurrence is greater during pregnancy, although it is plausible that recurrence is due to
progression of underlying lung disease that was undetected or unsuspected following the first
event.

From a management perspective during pregnancy, general principles are as follows:

● Guidelines and experts support conservative measures including aspiration and oxygen in
most stable women who develop PSP during pregnancy (provided there is no evidence of
fetal distress) [1,21]. Chest tube or catheter thoracostomy is appropriate for pregnant
patients with SSP, patients in whom pneumothorax develops during labor and delivery, or
those in whom fetal distress is evident. (See "Treatment of primary spontaneous
pneumothorax in adults", section on 'Aspiration' and "Treatment of primary spontaneous
pneumothorax in adults", section on 'Tube or catheter thoracostomy' and "Treatment of
primary spontaneous pneumothorax in adults", section on 'Supplemental oxygen and
observation'.)

● Because the risk of recurrence during future pregnancies is presumed to be high,

pleurodesis should be offered to women after delivery, although case reports and
anecdotal evidence report successful pregnancies without recurrence in patients in whom
a definitive intervention has not been performed [20]. Similarly, experts delay investigative

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testing to uncover possible underlying lung disease (eg, suspicion for

lymphangioleiomyomatosis in a pregnant woman with pneumothorax should be high)
such as chest computed tomography and lung function testing, until after delivery. (See
"Clinical presentation and diagnosis of pneumothorax" and "Clinical presentation and
diagnosis of pneumothorax", section on 'Postdiagnosis evaluation'.)

● For pregnant women with or without a previous episode of pneumothorax who are at risk
of developing pneumothorax during labor and delivery, close consultation with thoracic
surgery, pulmonary, and obstetrics and gynecology consultants is advised. Most experts
advise elective, assisted delivery at or near-term, with regional anesthesia to reduce
maternal effort [1]. Regional anesthesia is also preferable in those in whom cesarean
section is indicated.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Chronic obstructive
pulmonary disease" and "Society guideline links: Pneumothorax".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")

SUMMARY AND RECOMMENDATIONS

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● Assess size and symptoms – Following the diagnosis of secondary spontaneous

pneumothorax (SSP; that which presents as a complication of an underlying lung
disorder), clinicians should quickly estimate the size on chest radiography and assess the
degree of symptomatology, so that appropriate management can be instituted. Our
suggested cutoffs for size is based upon our experience and should be used as a general
guideline only (see 'Definition (secondary pneumothorax)' above and 'Initial management
of first event' above and 'Assessment of size and stability' above):

• Small – A space from the pleural line to the apex of <2 cm (small pneumothorax).

• Large – A space from the pleural line to the apex of ≥2 cm (large pneumothorax).

• Stability – A stable patient is one who can speak in full sentences who also has a
respiratory rate <24 breaths per minute, heart rate between 60 and 120 beats per
minute, normal blood pressure, and room air oxygen saturation greater than 90
percent.

● Management – The following is a reasonable strategy:

• Stable patients – For most patients with SSP, we suggest supplemental oxygen and
removal of air from the pleural space by chest tube or catheter thoracostomy rather
than more conservative measures (Grade 2C).

• Unstable patients – For patients who are unstable, if chest tube placement is delayed,
needle decompression of the pleural space should be performed. This approach is
based upon the rationale that the presence of underlying lung disease increases the
likelihood of a prolonged air leak and respiratory failure thereby increasing the failure
rate for conservative measures.

• Alternative approaches – Exceptions exist, and conservative measures including

oxygen and observation or aspiration may be considered on a case-by-case basis for
clinically stable patients who have mild or no symptoms and a small pneumothorax; in
such cases, progression of symptoms or an enlarging pneumothorax are indications
for pleural drainage. (See 'Management strategy' above.)

● Supportive care – Additional measures include the following (see 'General supportive
care' above):

• Oxygenation and ventilation – The fraction of inspired oxygen (FiO2) should be

increased cautiously in patients who have or who are at risk for oxygen-induced
hypercapnia; in addition, high-flow oxygen delivered via nasal cannulae (HFNC) and
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noninvasive ventilation should be avoided. Whether chest physical therapy should be

avoided is unclear. (See 'Oxygen and observation' above.)

• Treat the underlying disorder – Patients should have their underlying disorder
treated, and, in almost all cases, patients with SSP should be admitted because the
underlying lung disease increases the risk for an adverse outcome (eg, respiratory
failure, cardiovascular collapse, recurrent events). (See 'Treatment of the underlying
lung disease' above and 'Disposition' above.)

• Thoracostomy management – For patients in whom a chest tube or catheter

thoracostomy is indicated, a small-bore catheter (≤14 French [Fr]) or tube (≤22 Fr) is
generally preferred over large-bore tubes. However, some patients may benefit from
the insertion of large-bore chest tubes (24 to 28 Fr), including patients who are
unstable, have concomitant empyema, hemothorax or barotrauma, or fail small-bore
drainage. In general, suction is not initially applied, and the tube or catheter is
connected to a water seal device. (See 'Tube or catheter thoracostomy' above.)

● Definitive intervention for first episode – For most patients with a first episode of SSP,
we recommend that a definitive intervention be performed during the same
hospitalization (eg, within three to five days) to prevent recurrence rather than waiting for
a second event ( algorithm 1) (Grade 1B). In most patients, video-assisted or medical
thoracoscopy is preferred. In patients who are not good candidates for or are unwilling to
undergo surgery, nonsurgical pleurodesis (eg, blood patch or chemical pleurodesis) or
prolonged thoracostomy drainage are options. (See 'Preventing recurrence and follow-up'
above and "Pneumothorax: Definitive management and prevention of recurrence".)

● Special populations

• Miscellaneous etiologies – The optimal management of pneumothorax associated

with other etiologies (eg, iatrogenic, trauma, structural abnormalities, exercise,
anorexia, drugs ( table 1)) is unstudied and is generally based upon biologic
plausibility and experience. (See 'Other pneumothorax types' above.)

• Pregnancy – The management of pneumothorax in pregnancy is similar to that for

patients who are not pregnant except pleurodesis is generally deferred until after
delivery. For those who are at risk of developing pneumothorax during labor and
delivery, most experts advise a multidisciplinary approach that involves elective,
assisted delivery at or near-term, with regional anesthesia to reduce maternal effort.
Regional anesthesia is also preferable in those in whom cesarean section is indicated.
(See 'Pneumothorax and pregnancy' above.)
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ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Richard W Light, MD, now deceased, who
contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of

spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010.
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2. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an
American College of Chest Physicians Delphi consensus statement. Chest 2001; 119:590.
3. Tschopp JM, Bintcliffe O, Astoul P, et al. ERS task force statement: diagnosis and treatment
of primary spontaneous pneumothorax. Eur Respir J 2015; 46:321.
4. Flume PA, Mogayzel PJ Jr, Robinson KA, et al. Cystic fibrosis pulmonary guidelines:
pulmonary complications: hemoptysis and pneumothorax. Am J Respir Crit Care Med 2010;
182:298.
5. Goto T, Kadota Y, Mori T, et al. Video-assisted thoracic surgery for pneumothorax:
republication of a systematic review and a proposal by the guideline committee of the
Japanese association for chest surgery 2014. Gen Thorac Cardiovasc Surg 2015; 63:8.
6. Chee CB, Abisheganaden J, Yeo JK, et al. Persistent air-leak in spontaneous pneumothorax--
clinical course and outcome. Respir Med 1998; 92:757.

7. Schoenenberger RA, Haefeli WE, Weiss P, Ritz RF. Timing of invasive procedures in therapy
for primary and secondary spontaneous pneumothorax. Arch Surg 1991; 126:764.
8. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous
pneumothorax: state of the art. Eur Respir J 2006; 28:637.
9. Light RW. Pleural controversy: optimal chest tube size for drainage. Respirology 2011;
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10. Andrivet P, Djedaini K, Teboul JL, et al. Spontaneous pneumothorax. Comparison of thoracic
drainage vs immediate or delayed needle aspiration. Chest 1995; 108:335.
11. Kiely DG, Ansari S, Davey WA, et al. Bedside tracer gas technique accurately predicts
outcome in aspiration of spontaneous pneumothorax. Thorax 2001; 56:617.

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12. Walker SP, Keenan E, Bintcliffe O, et al. Ambulatory management of secondary

spontaneous pneumothorax: a randomised controlled trial. Eur Respir J 2021; 57.
13. Chang SH, Kang YN, Chiu HY, Chiu YH. A Systematic Review and Meta-Analysis Comparing
Pigtail Catheter and Chest Tube as the Initial Treatment for Pneumothorax. Chest 2018;
153:1201.
14. Tsai WK, Chen W, Lee JC, et al. Pigtail catheters vs large-bore chest tubes for management
of secondary spontaneous pneumothoraces in adults. Am J Emerg Med 2006; 24:795.

15. Cafarotti S, Dall'Armi V, Cusumano G, et al. Small-bore wire-guided chest drains: safety,
tolerability, and effectiveness in pneumothorax, malignant effusions, and pleural
empyema. J Thorac Cardiovasc Surg 2011; 141:683.
16. Lin YC, Tu CY, Liang SJ, et al. Pigtail catheter for the management of pneumothorax in
mechanically ventilated patients. Am J Emerg Med 2010; 28:466.
17. Mathur R, Cullen J, Kinnear WJ, Johnston ID. Time course of resolution of persistent air leak
in spontaneous pneumothorax. Respir Med 1995; 89:129.

18. Sepkowitz KA, Telzak EE, Gold JW, et al. Pneumothorax in AIDS. Ann Intern Med 1991;
114:455.
19. O'Driscoll BR, Howard LS, Davison AG, British Thoracic Society. BTS guideline for
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20. Lal A, Anderson G, Cowen M, et al. Pneumothorax and pregnancy. Chest 2007; 132:1044.
21. Nwaejike N, Elbur E, Rammohan KS, Shah R. Should pregnant patients with a recurrent or
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Topic 6691 Version 29.0

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GRAPHICS

Specific diagnostic or management strategies of pneumothorax

Specific diagnostic or management strategies to be

Pneumothorax type
considered

Primary spontaneous Likely benign course with conservative management; drainage of

pneumothorax pleural gas (typically aspiration), VATS for PAL; lower risk of
recurrence.

Secondary spontaneous PAL is more likely; early intervention with pleurodesis (blood,
pneumothorax chemical, surgical) is typically needed; higher risk of recurrence.

COPD Smoking cessation.

CF May consider limited pleurodesis strategies if transplantation

is planned.

Malignancy Chemotherapeutic agents or radiation may be appropriate.

Pneumothorax may not heal and PAL may be likely such that
aggressive surgical strategies may fail.

Infection Antimicrobials are warranted. Pneumothorax may not heal

and PAL may be likely such that aggressive surgical strategies
may fail.

Cystic lung disorders Investigations or therapies targeted at suspected cause may

be warranted (eg, lung biopsy, VEGF-D levels, folliculin gene
analysis, rapamycin*).

Catamenial (endometriosis) Hormonal therapy may be warranted.

Architectural abnormalities May need specific investigations targeted at suspected cause

(eg, Marfan syndrome, Ehlers- (eg, homocysteine levels).
Danlos syndrome,
Homocystinuria)

Iatrogenic Likely benign course (unless patient is mechanically ventilated).

Conservative management with drainage of air is usually
sufficient.

Traumatic May need to co-manage parenchymal trauma and other vascular

and orthopedic aspects of chest trauma.

Miscellaneous

Anorexia Nutrition needs to be addressed, PAL may be likely.

Exercise Likely benign course and conservative management with

drainage of air may be sufficient.

Illicit drug use Cessation of drug use.

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Immunosuppressant drugs Cessation of offending agent, if feasible.

Air travel Avoidance of air travel for short period after definitive
management.

Scuba diving Avoidance of scuba diving until definitive management.

VATS: video-assisted thoracoscopic surgery; PAL: prolonged (persistent) air leak; COPD: chronic
obstructive pulmonary disease; CF: cystic fibrosis; VEGF-D: vascular endothelial growth factor-D.

* Rapamycin, as an immunosuppressant, is a useful therapy for some patients with

lymphangioleiomyomatosis but should not be started until the pneumothorax has healed for
about six weeks. Please refer to the UpToDate topics on sporadic lymphangioleiomyomatosis:
clinical presentation and diagnostic evaluation and sporadic Lymphangioleiomyomatosis: treatment
and prognosis.

Graphic 120903 Version 1.0

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Heimlich valve

This graphic shows a Heimlich valve which allows the unidirectional

flow of air away from the leak. The rubber flap in between both ends
functions as the one way valve.

Modified from: Health Education: Heimlich Valve for Chest Drainage. Mount Carmel
2014.

Graphic 117649 Version 1.0

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Indications for definitive therapy in adult patients with non-

traumatic pneumothorax

Definitive therapy is a treatment that has the ultimate goal of reducing or

preventing recurrent pneumothorax and assumes that trials of primary therapy
have been attempted (eg, observation, needle or chest tube thoracostomy). This
algorithm assumes that sufficient information (including chest computed
tomography) is available to distinguish primary pneumothorax (no underlying
lung disorder) from secondary pneumothorax (known underlying disorder).

VATS; video-assisted thoracoscopic surgery; PSP: primary spontaneous

pneumothorax.

* The risk of recurrence in patients with secondary pneumothorax is much higher

than with primary pneumothorax (approximately 30 to 50 % in the first year),
thereby justifying a definitive procedure following chest tube thoracostomy.

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¶ The risk of recurrence is considered low (10 to 15 % at one year) in patients with
PSP, such that most patients with a first episode of PSP do not typically undergo
definitive treatment until it recurs. However, a small percentage of patients who
are considered at a higher than usual risk of recurrence may need a preventive
intervention. Risk factors for recurrence include large, bilateral, or life-threatening
PSP, high risk profession or hobbies, prolonged air leak after thoracostomy, and a
high burden of cysts. Patients who desire to avoid recurrence or are undergoing
thoracoscopy for another reason may also be offered definitive therapy.

Δ Pneumothorax may be the presenting feature in some patients with an

unknown primary lung disorder such as catamenial pneumothorax and
lymphangioleiomyomatosis. Lung biopsy may be indicated in such situations
during which a definitive procedure for pneumothorax can be performed. Refer to
UTD topic for details.

◊ Choosing among these options is typically at the discretion of the surgeon and
practice varies widely among institutions and countries. Surgeons may also
combine pleurodesis with a blebectomy/bullectomy. Rarely, some surgeons
perform bullectomy alone. Recurrence rates after surgical pleurodesis are less
than 5 to 10 % during the first year.

§ Medical pleurodesis involves instilling a chemical (eg, talc or tatracycline) via

tube or catheter thoracostomy. Recurrence rates are approximately 25 % during
the first year.

Graphic 121365 Version 2.0

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Contributor Disclosures
YC Gary Lee, MBChB, PhD Grant/Research/Clinical Trial Support: Rocket Med Plc [Pleural Effusions]. All of
the relevant financial relationships listed have been mitigated. V Courtney Broaddus, MD No relevant
financial relationship(s) with ineligible companies to disclose. Geraldine Finlay, MD No relevant financial
relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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