3/30/23, 5:19 PM 117888

Official reprint from UpToDate®

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

Pneumothorax: Definitive management and prevention

of recurrence
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: Jul 13, 2021.

INTRODUCTION

Pneumothorax (gas in the pleural space) is considered spontaneous when it presents in the
absence of an external factor. Primary spontaneous pneumothorax (PSP) presents in the
absence of clinical lung disease while secondary spontaneous pneumothorax (SSP) presents as
a complication of underlying lung disease or injury ( table 1). The recurrence rate and
therefore management strategies of PSP and SSP differ in their timing and threshold to
perform a definitive procedure to prevent recurrence.

The definitive management and prevention of recurrent pneumothorax is discussed in this

topic review. Our approach expands upon that outlined in published clinical consensus
statements and guidelines from The American College of Chest Physicians (2001), British
Thoracic Society (2010), European Respiratory Society (2015), the Japanese Association for Chest
Surgery (2014), and others [1-6]. The epidemiology and etiology, clinical presentation and
diagnosis, and initial management of 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" and
"Treatment of secondary spontaneous pneumothorax in adults".)

INCIDENCE OF RECURRENCE

https://www.uptodate.com/contents/117888/print 1/23
3/30/23, 5:19 PM 117888

Primary spontaneous pneumothorax — The estimated recurrence rate after the first primary
spontaneous pneumothorax (PSP) is broad, ranging from 0 to 60 percent; however, newer
studies suggest average recurrence rates between 10 and 30 percent at one to five year follow-
up period, with the highest risk occurring in the first 30 days through the first year [1,2,7-9]. In
one of the largest epidemiologic studies of spontaneous pneumothorax, rates of recurrent PSP
for males were 4 percent (<7 days), 8 percent (<30 days), 10 percent (<3 months), 13 percent (<1
year), and 20 percent (<5 years) [10]. Rates in females were similarly 5 percent (<7 days), 9
percent (<30 days), 11 percent (<3 months), 15 percent (<1 year), and 22 percent (<5 years).
However, these rates may have been underestimated since they were calculated from inpatient
admissions and did not include patients treated as outpatients. In contrast, in another
systematic review that included 29 randomized trials and observational series, the pooled one-
year recurrence rate for patients with PSP was 29 percent [11].

Risk factors reported to be associated with an increased risk of recurrence include [11-18]:

● Female gender
● Tall stature in men
● Low body weight
● Failure to stop smoking or presence of respiratory bronchiolitis
● Large initial pneumothorax size
● Blebs or bullae on chest computed tomography (CT) scan
● Previous events

As an example, one study of 176 patients with PSP reported that the risk of ipsilateral
recurrence for patients with blebs and bullae on chest CT was 68 percent compared with 6
percent in patients without blebs and bullae, with the highest risk in those with multiple and
bilateral lesions (75 percent) [13]. The risk of contralateral pneumothorax was also higher in
patients with blebs and bullae on CT (19 versus 0 percent). (See "Pneumothorax in adults:
Epidemiology and etiology", section on 'Primary spontaneous pneumothorax' and
"Pneumothorax in adults: Epidemiology and etiology", section on 'Secondary spontaneous
pneumothorax'.)

The broad range and high incidence of recurrence in subpopulations of patients with PSP, in
particular those found to have blebs or bullae on imaging, has led some experts to propose
that the classification of pneumothorax is not necessarily binary (primary versus secondary) but
rather a continuum with risk of recurrence ranging from low to high. At minimum, a
subpopulation of patients with suspected PSP may actually have undiagnosed lung disease and
this subpopulation may warrant reclassification as secondary spontaneous pneumothorax (SSP)
so that appropriate preventions can be put in place. Future studies should focus on defining
https://www.uptodate.com/contents/117888/print 2/23
3/30/23, 5:19 PM 117888

cutoffs for recurrence risk to distinguish those with high recurrence in whom pleurodesis is
indicated after a first event, from those with a low recurrence in whom pleurodesis is not
justified until pneumothorax recurs. (See "Pneumothorax in adults: Epidemiology and etiology",
section on 'Pathogenesis and risk factors'.)

Secondary spontaneous pneumothorax — Data to support high recurrence rates in this

population are largely derived from patients with chronic obstructive pulmonary disease
(COPD). For example, one study reported a 50 percent likelihood of recurrent SSP over three
years among patients with a pneumothorax due to COPD who did not have an intervention to
prevent recurrence [19]. Similar high recurrence rates have been described in other populations
of patients with acute and chronic lung disease including women with
lymphangioleiomyomatosis, and individuals with nontuberculous mycobacteria and Birt-Hogg-
Dubé syndrome [20]. One of the largest epidemiologic studies of spontaneous pneumothorax
suggested that the rates of recurrent SSP may be lower than originally thought [10]; rates of
recurrence for males were 7 percent (<7 days), 14 percent (<30 days), 20 percent (<3 months),
27 percent (<1 year), and 33 percent (<5 years). Rates in females were similarly 6 percent (<7
days), 13 percent (<30 days), 19 percent (<3 months), 25 percent (<1 year), and 31 percent (<5
years). However, these rates may have been underestimated since they were calculated from
inpatient admissions over a 46-year period and adjustments for interventions was not clear.
(See "Sporadic lymphangioleiomyomatosis: Clinical presentation and diagnostic evaluation",
section on 'Pulmonary' and "Birt-Hogg-Dubé syndrome", section on 'Pulmonary
manifestations'.)

Risk factors for recurrence may be similar to those in patients with PSP (eg, smoking) [14] (see
'Primary spontaneous pneumothorax' above) but are less well studied since most patients with
SSP proceed with a definitive measure to prevent recurrence after their initial event.

INDICATIONS

Once patients have undergone initial management for pneumothorax, clinicians should assess
the risk of recurrence to evaluate whether definitive management (usually pleurodesis) is
indicated. Several indications for the prevention of recurrence exist ( algorithm 1).

Primary spontaneous pneumothorax at high risk of recurrence — Since the risk of

recurrence is considered low in patients with primary spontaneous pneumothorax (PSP; ie,
pneumothorax without underlying lung disorder), most patients with a first episode of PSP do
not typically undergo definitive treatment until it recurs. However a small percentage of
patients need a preventive intervention. These include patients with a prolonged (persistent) air

https://www.uptodate.com/contents/117888/print 3/23
3/30/23, 5:19 PM 117888

leak (PAL; typically defined as air leak >5 days), patients with a high risk occupation or hobby
(eg, airline pilot, deep sea diver), patients with large, bilateral, or life-threatening PSP in whom
tube thoracostomy was required for management, and patients with a high burden of cysts,
desire to avoid recurrence, or undergoing thoracoscopy for another indication (eg, hemothorax,
lung biopsy). Further details are provided separately. (See "Treatment of primary spontaneous
pneumothorax in adults", section on 'Indications for definitive procedure after first event'.)

First episode of secondary spontaneous pneumothorax — Since the recurrence rate is

considered high (eg, >50 percent), most patients with a first episode of secondary spontaneous
pneumothorax (SSP; ie, spontaneous pneumothorax due to underlying lung disorder) should
undergo a definitive intervention to prevent recurrence. Individual exceptions may be applied
to patients with very small loculated pneumothoraces (eg, patients with cystic fibrosis [6]) or
patients who decline definitive treatment. Further details are provided separately. (See
"Treatment of secondary spontaneous pneumothorax in adults", section on 'Preventing
recurrence and follow-up'.)

Prolonged air leak — Any pneumothorax that presents with a PAL beyond five days should be
assessed for a definitive procedure based upon the rationale that the underlying defect is large
and unlikely to heal rapidly on its own. In such cases a definitive procedure is both a therapeutic
(to seal the leak) and a preventative measure. PALs are more commonly encountered in patients
with SSP than PSP.

High risk professions or hobbies — The risk of recurrence is considered high in patients with
certain professions or hobbies (eg, airline pilot, scuba diver) in whom there is also the potential
for devastating consequences such that a definitive procedure is justified. (See "Pneumothorax
and air travel" and "Complications of SCUBA diving".)

Recurrent pneumothorax — Any patient with recurrent pneumothorax should undergo a

definitive procedure since the likelihood of future events, particularly life-threatening ones, is
high. (See 'Incidence of recurrence' above.)

Concomitant indication for thoracoscopy — Patients with hemothorax or need for lung
biopsy may be considered for pleurodesis at the time of surgery. (See "Overview of minimally
invasive thoracic surgery".)

Other populations — The risk of recurrence should be individualized in other patient

populations (eg, trauma, iatrogenic). Among these causes, iatrogenic and traumatic
pneumothorax are the most common, and a definitive procedure is not typically necessary
unless a prolonged air leak develops. In contrast, patients with a structural abnormality that is
irreversible, such as Marfans syndrome, may potentially benefit from definitive treatment to
https://www.uptodate.com/contents/117888/print 4/23
3/30/23, 5:19 PM 117888

prevent recurrence. (See "Treatment of secondary spontaneous pneumothorax in adults",

section on 'Other pneumothorax types' and "Treatment of secondary spontaneous
pneumothorax in adults", section on 'Pneumothorax and pregnancy'.)

Factors for decision-making — Factors that should be taken into consideration that need
discussion with the patient include:

● The assessed risk of recurrence

● Patient values and preferences
● Ability to tolerate a surgical procedure (eg, surgery or conscious sedation)
● Access to healthcare facility in the event of a recurrence

The potential for lung transplantation is much higher in patients with SSP than PSP. Although
pleurodesis can increase the morbidity associated with subsequent lung transplantation (eg,
bleeding, requirement for transfusion, length of surgery), it should not affect the decision to
proceed with the definitive intervention itself when indicated, but it may affect the type of
definitive procedure chosen. (See 'Pleurodesis' below.)

DEFINITIVE MEASURES

Options for preventing recurrence include surgical and nonsurgical approaches:

● In most cases, we prefer video-assisted thoracic surgery (VATS) pleurodesis based upon its
high efficacy when compared with nonsurgical approaches. The chosen method of
pleurodesis (eg, chemical, abrasion, pleurectomy) and the inclusion of a procedure to treat
blebs (eg stapling, ligation) is usually at the discretion of the surgeon, although we
acknowledge that significant variability exists among institutions and countries. Medical
thoracoscopy can allow talc poudrage but is unsuitable for treating underlying lung blebs
and should only be considered if VATS is contraindicated. (See 'Surgical candidates (VATS)'
below and "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications".)

● For those unable or unwilling to undergo VATS, chemical pleurodesis via chest tube is
preferred. (See 'Nonsurgical candidates (chemical pleurodesis)' below.)

The choice of chemical sclerosing agent is highly variable among experts.

Surgical candidates (VATS) — In those with primary or secondary spontaneous pneumothorax

with an indication for a definitive procedure, we suggest VATS based upon the high efficacy and
lower adverse effect profile when compared with open thoracotomy [16,21-34].

https://www.uptodate.com/contents/117888/print 5/23
3/30/23, 5:19 PM 117888

Although pleurodesis via open thoracotomy has higher success rates, VATS has largely
supplanted open thoracotomy for the management of spontaneous pneumothorax in most
centers [35,36]. Thoracotomy is recommended only if VATS is unavailable or has failed. This
recommendation is based upon meta-analyses comparing open thoracotomy with VATS that
have consistently shown lower recurrence rates with open procedures (approximately 1 percent
with open versus 5 percent with VATS), but with greater blood loss, more postoperative pain,
and longer hospital stays [5,37,38].

The two most common procedures that are performed during surgical thoracoscopy are
pleurodesis and blebectomy/bullectomy. Many surgeons choose to perform both at the time of
surgery since some data suggest that the recurrence rate is lower when both procedures are
performed simultaneously. However, some surgeons perform pleurodesis without
blebectomy/bullectomy or vice versa based upon data that suggest combining both procedures
worsens the adverse effects. We prefer combining blebectomy/bullectomy with pleurodesis
since it makes biologic sense that recurrence is lower when both procedures are used. These
data are discussed below. (See 'Bleb/bulla closure' below.)

Pleurodesis — We prefer mechanical pleurodesis using pleural abrasion with dry gauze as the
initial procedure, since it is both simple and effective. Talc is associated with high success rates,
and should be included in those considered at highest risk of recurrence or those with
recalcitrant pneumothorax in whom avoidance of recurrence is critical. In patients considered
at high risk of recurrence, some surgeons also choose to combine an apical pleurectomy (ie,
partial pleurectomy to the region of lung most affected by blebs) with abrasion to the visceral
pleura over the rest of the lung. (See 'Talc' below.)

● Techniques – Several surgical techniques have been reported to induce pleural symphysis
(ie, pleurodesis) with significant variation in practice among surgeons, institutions, and
countries. These include:

• Parietal or full pleurectomy (usually unilateral, occasionally bilateral) [14,39-41]

• Intrapleural insufflation of talc or a tetracycline derivative (ie, chemical pleurodesis)
[42]
• Pleural abrasion to visceral and parietal pleura with dry gauze [43]
• Laser abrasion of the parietal pleura [44,45]
• Cellulose mesh with fibrin glue [46,47]
• Combinations of the above (eg, abrasion with partial pleurectomy and chemical
pleurodesis)

https://www.uptodate.com/contents/117888/print 6/23
3/30/23, 5:19 PM 117888

● Choosing a technique – Choosing among these options is often at the discretion of the
surgeon but also dependent upon factors including the following:

• Presenting manifestations of the patient (eg, severe, life-threatening symptoms versus

asymptomatic)
• Preferences and values of the patient
• Potential future need for lung transplantation
• Number of previous recurrences of pneumothorax
• Severity of underlying lung disease or burden of cysts
• Risk associated with VATS
• Previous pleurodesis

There is also considerable variability among countries, with mesh and fibrin glue being
popular in Japan while mechanical abrasion or chemical pleurodesis is popular in the
United States; similarly, talc is often the preferred sclerosant used in Europe, while a
tetracycline derivative is preferred by some United States institutions.

Performing lung transplants in patients who have undergone pleurodesis is technically

challenging and associated with increased blood loss due to dissection of the scarred
pleural membrane. Although previous pleurodesis is not a contraindication for lung
transplantation, we prefer a targeted/partial approach to pleurodesis in transplant
candidates using VATS-directed closure of the site of air leak and/or blebectomy and
consideration of mechanical abrasion of the apical pleural surface to achieve apical
pleurodesis. This approach in theory provides enough pleurodesis to prevent large
pneumothoraces while avoiding the formation of dense thick pleural symphysis, typical of
chemical pleurodesis, which can be difficult to dissect. When feasible, we avoid full
pleurodesis with chemicals, unless the frequency and degree of recurrence indicates the
need for more aggressive measures (eg, bilateral life-threatening recurrence, recalcitrant
pneumothorax) [48]. (See "Lung transplantation: General guidelines for recipient
selection", section on 'Previous cardiothoracic surgery'.)

Bleb/bulla closure — Although ill-defined, blebs are considered “blisters” that are visible to
the naked eye on the surface of the pleura (typically 1 to 2 cm in size) while bullae are typically
intraparenchymal and >1 cm in size, often large. Consistent with the practice of many surgeons,
we suggest VATS apical blebectomy/bullectomy simultaneously with pleurodesis based upon
retrospective data that report recurrence rates <5 percent using this combined approach
[26,38,49-51]. However, data are conflicting and some surgeons perform pleurodesis alone
based upon data that report lower recurrence rates in patients with VATS-directed insufflation
of talc compared with bullectomy alone (0.3 versus 3.8 percent) [16,52], while others perform
https://www.uptodate.com/contents/117888/print 7/23
3/30/23, 5:19 PM 117888

blebectomy/bullectomy alone based upon data that report recurrence rates <9 percent with
bullectomy alone [53].

The rationale for blebectomy/bullectomy is that patients with secondary spontaneous

pneumothorax (SSP) and, less often, patients with primary spontaneous pneumothorax (PSP),
have underlying subpleural blebs or bullae (cysts ≥1 cm) that are considered the most likely
cause of spontaneous pneumothorax.

Blebs/bullae are typically apical in location. While some defects (with or without air leaks) are
visible to the naked eye (or on imaging), others are not apparent. Thus, many surgeons choose
to resect the apex of the lung based upon the observation that even in the absence of obvious
blebs/bullae, patients with pneumothorax have subclinical blebs noted on pathologic analysis
of resected tissue. In support, many high grade blebs have been detected by fluorescein-
enhanced autofluorescence thoracoscopy (FEAT) in areas that appear normal during white light
thoracoscopy [54]. When blebs or bullae are so numerous that resection of all blebs is not
feasible, the surgeon may choose to resect only those that are large and leave smaller ones
intact before proceeding with pleurodesis.

The optimal surgical technique to treat underlying blebs/bullae is uncertain and, in most cases,
the decision is typically left to the discretion and experience of the surgeon. In our experience,
most surgeons resect blebs/bullae using a stapling technique since data support low
recurrence rates with stapling [50], and both pneumostasis and hemostasis can be achieved
with this method. Other techniques include suturing, staple reinforcement at the suture line,
ligation, or coagulation of visible lesions. (See "Bullectomy for giant bullae".)

Lung volume reduction — 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. (See "Lung volume reduction surgery in COPD", section on 'Patient
selection'.)

Nonsurgical candidates (chemical pleurodesis) — In patients who are unable or unwilling to

undergo VATS or medical thoracoscopy, we suggest intrapleural injection of a chemical irritant,
either graded talc or a tetracycline derivative (doxycycline or minocycline), if available [5]. Other
sclerosants have been used (eg, iodopovidone and blood). While many experts, including
contributors of this topic prefer talc due to its consistent high efficacy, especially in malignant
pleural effusion, others, including contributors of this topic, prefer the tetracycline derivative,
doxycycline, on the basis of a potentially lower adverse profile, specifically lung injury. However,
there is evidence that graded talc, which is now available in the United States, rarely, if ever,
causes lung injury due to the larger size of its particles compared with ungraded talc, which

https://www.uptodate.com/contents/117888/print 8/23
3/30/23, 5:19 PM 117888

may ultimately minimize the most worrisome adverse effect of talc (ie, lung injury) [55].
Regardless of the sclerosant chosen, chemical pleurodesis via tube thoracostomy is not as
effective as VATS pleurodesis or pleurodesis with medical thoracoscopy since rates of
recurrence are about 25 percent [19,56].

Tetracycline derivatives — Chemical pleurodesis with tetracycline derivatives decreases the

recurrence rate of pneumothorax to rates as low as 13 percent (range 13 to 25 percent). In two
large trials of 442 patients with PSP, pleurodesis with the intrapleural instillation of a
tetracycline derivative (tetracycline or minocycline) was compared with aspiration and drainage
without pleurodesis [19,57]. Over a one to five year follow-up period, the rates of recurrent PSP
fell from 41 to 25 percent (tetracycline) in one study [19] and from 33 to 13 percent
(minocycline) in another study [57]. In those that failed, thoracoscopic evaluation by VATS
revealed loose intrapleural adhesions only, suggesting that an intense inflammatory response
was not initiated in some patients at the outset.

Other than post-pleurodesis pain, tetracycline derivatives are well-tolerated. Respiratory failure
due to an apparent allergic reaction to intrapleural instillation of doxycycline has been reported
[58]. Additional technical details regarding tetracycline derivative administration are provided
separately. (See "Chemical pleurodesis".)

Talc — Talc is a cheap sclerosant that induces an intense inflammatory response. Talc
pleurodesis is the most commonly preferred sclerosant in Europe but is also used frequently in
the United States. Talc is consistently, among studies and in all populations, an effective
sclerosant. In patients with PSP, recurrence rates vary between 2 and 8 percent after medical
thoracoscopy, a rate that reflects that seen in other populations.

Several studies support the safety and efficacy of talc pleurodesis for the prevention of
recurrent pneumothorax, when graded talc is chosen [30,59-61]. However, most data are
derived from patients with malignant pleural effusion rather than pneumothorax and delivery is
thoracoscopic rather than via a chest tube thoracotomy.

However, intrapleural injection of talc has been associated with more adverse effects than
tetracycline (tachycardia, fever, pain, respiratory failure). For example, the development of the
acute respiratory failure/acute respiratory distress syndrome (ARDS) has been reported in 0 to
3.8 percent of patients and, although some cases are transient, other rare cases may be fatal
[62-66]. Small retrospective studies have suggested that small particle size, old age, and
interstitial abnormalities may increase the risk of ARDS, although not all data were derived in
patients with pneumothorax [67,68]. Another case of extensive pleural thickening with

https://www.uptodate.com/contents/117888/print 9/23
3/30/23, 5:19 PM 117888

calcifications has also been reported [69]. Further details regarding talc pleurodesis are
provided separately. (See "Talc pleurodesis".)

There exists concerns that talc already creates an intense pleural reaction thus combination
with other methods of pleurodesis (eg, abrasion) is unnecessary. In addition, concerns exist in
using talc in those with significant intraparenchymal disease burden, who may not have
significant reserve to tolerate an episode of ARDS or respiratory failure. There are insufficient
data to support or disprove these concerns at present.

Others — One study reported similar efficacy between iodopovidone and talc when delivered
thoracoscopically [70].

Timing — When a definitive procedure is indicated, it is usually performed during the same
hospitalization (three to five days), since the risk of recurrence is greatest in the first month,
although this is not always feasible.

POST-PLEURODESIS PAIN

Despite the intrapleural administration of anesthetic (eg, lidocaine) pre-procedurally, moderate

to severe pain is a common complication after pleurodesis that may last for two weeks,
sometimes longer [59,71,72]. It generally dissipates slowly (weeks to months). Although the
pain can arise from ongoing pleural inflammation, chronic post-thoracoscopy intercostal
neuralgia is common with prevalence reported as high as 40 percent, and half of these cases
are neuropathic in character. (See "Overview of cancer pain syndromes", section on
'Postsurgical pain syndromes'.)

Importantly, the severity of the pain is often underestimated by physicians. Accordingly,

postoperative pain should be addressed in institutional protocols. Frequently, narcotic
medication is needed in the short-term. Nonsteroidal agents were avoided in the immediate
postoperative period since it was thought that nonsteroidal anti-inflammatory drugs (NSAIDs)
might interfere with the inflammation that is required to ensure effective pleural membrane
symphysis. However, a study comparing opioids with NSAIDs for pain reported no difference in
the efficacy of pleurodesis in patients with malignant pleural effusion [73]. (See "Talc
pleurodesis", section on 'Concomitant medications'.)

FOLLOW-UP

https://www.uptodate.com/contents/117888/print 10/23
3/30/23, 5:19 PM 117888

Following a definitive procedure, the chest tube remains in place and patients are assessed
daily for pain and for closure of the air leak. Frequent radiographs or ultrasonograms are
performed to check for lung expansion. (See "Thoracostomy tubes and catheters: Management
and removal", section on 'Management of thoracostomy tubes'.)

Sealed air leak — Once the air leak has been sealed, the chest tube can be removed, and the
patient can be discharged and followed up in an outpatient clinic, similar to that described
elsewhere. (See "Treatment of primary spontaneous pneumothorax in adults", section on
'Follow-up thoracostomy management (one to five days)' and "Treatment of primary
spontaneous pneumothorax in adults", section on 'Outpatient follow-up'.)

Prolonged air leak or refractory pneumothorax — If an air leak persists or pneumothorax

recurs despite pleurodesis, management may be complex due to loculations from the previous
attempt at pleurodesis. In such cases, a multidisciplinary approach is advised where discussion
of several options should be undertaken, including catheter-directed pleurodesis, thoracoscopic
revision, or conservative management. A rare patient is left with residual chronic
pneumothorax.

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: Pneumothorax".)

PATIENT INFORMATION

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.)

https://www.uptodate.com/contents/117888/print 11/23
3/30/23, 5:19 PM 117888

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

PATIENT PERSPECTIVE TOPIC

Patient perspectives are provided for selected disorders to help clinicians better understand the
patient experience and patient concerns. These narratives may offer insights into patient values
and preferences not included in other UpToDate topics. (See "Patient perspective:
Lymphangioleiomyomatosis (LAM)".)

SUMMARY AND RECOMMENDATIONS

● Primary spontaneous pneumothorax (PSP) presents in the absence of clinical lung disease,
while secondary spontaneous pneumothorax (SSP) presents as a complication of
underlying lung disease ( table 1). Recurrence rates vary but, in general, the risk of
recurrence is higher with SSP (>30 to 50 percent) than with PSP (10 to 30 percent). (See
'Introduction' above and 'Incidence of recurrence' above.)

● Once patients have undergone initial management, clinicians should assess the risk of
recurrence to evaluate whether definitive management is indicated. Indications include
patients with PSP assessed to be at high risk of recurrence, patients with high risk
professions or hobbies (eg, airplane pilot or deep sea diver), patients with a prolonged
(persistent) air leak (typically >5 days), patients with SSP or recurrent pneumothorax, or
patients with a concomitant indication for thoracoscopy (eg, hemothorax or lung biopsy)
( algorithm 1). (See 'Indications' above.)

● For most patients in whom a definitive procedure is indicated, we recommend surgical

approaches rather than nonsurgical approaches (Grade 1B). This preference is based
upon the high efficacy of surgery in this population who are at a high risk of recurrence.

• Among the available surgical approaches, we suggest video-assisted thoracic surgery

(VATS) rather than open thoracotomy due to the shorter length of hospital stay and
lower morbidity (pain and blood loss) associated with VATS (Grade 2C). An alternative is
medical thoracoscopy. (See 'Surgical candidates (VATS)' above.)

• The method of pleurodesis (chemical sclerosant, abrasion, pleurectomy, mesh, fibrin

glue, combinations) and the inclusion of a procedure to treat blebs/bullae (eg, apical
resection, stapling, ligation, suturing, coagulation) is usually at the discretion of the
surgeon and dependent upon presenting features of the patient, patient preferences,

https://www.uptodate.com/contents/117888/print 12/23
3/30/23, 5:19 PM 117888

future need for lung transplantation, number of previous recurrences, severity of

underlying disease, and surgical risk. We prefer VATS pleurodesis with dry gauze
abrasion, stapling of blebs/bullae or talc insufflation, which are associated with the
highest success rates, especially in those considered at highest risk of recurrence or
those with recalcitrant pneumothorax in whom avoidance of recurrence is critical. (See
'Pleurodesis' above and 'Bleb/bulla closure' above.)

● For patients in whom a definitive procedure is indicated who are poor candidates for or
are unwilling to undergo VATS, we suggest chemical pleurodesis via tube thoracostomy
rather than tube thoracostomy drainage alone (Grade 2C). This procedure reduces the
recurrence rate to <25 percent when a tetracycline compound is used as the sclerosant.
Success may be higher when graded talc is used as the sclerosant; choosing the sclerosant
is individualized and should weigh the risk of adverse effects against the efficacy. (See
'Nonsurgical candidates (chemical pleurodesis)' above.)

● Despite the intrapleural administration of anesthetic pre-procedurally, moderate to severe

thoracic pain (especially intercostal neuralgia) is a common complication after VATS
pleurodesis that may last for two weeks or longer. (See 'Post-pleurodesis pain' above.)

● Once the air leak has been sealed, the chest tube can be removed, and the patient can be
discharged and followed up in outpatient clinic. However, if an air leak persists or
pneumothorax recurs despite pleurodesis, a multidisciplinary approach is advised where
discussion of several options should be undertaken including catheter-directed
pleurodesis, thoracoscopic revision, or conservative management. Rarely, some patients
are left with residual chronic pneumothorax. (See 'Follow-up' above and "Treatment of
primary spontaneous pneumothorax in adults", section on 'Follow-up thoracostomy
management (one to five days)' and "Treatment of primary spontaneous pneumothorax in
adults", section on 'Outpatient follow-up'.)

Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. 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.
2. Henry M, Arnold T, Harvey J, Pleural Diseases Group, Standards of Care Committee, British
Thoracic Society. BTS guidelines for the management of spontaneous pneumothorax.
Thorax 2003; 58 Suppl 2:ii39.

https://www.uptodate.com/contents/117888/print 13/23
3/30/23, 5:19 PM 117888

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. 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.
5. MacDuff A, Arnold A, Harvey J, BTS Pleural Disease Guideline Group. Management of
spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010.
Thorax 2010; 65 Suppl 2:ii18.

6. 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.

7. Light RW. Pleural Diseases, 6th ed, Lippincott, Williams and Wilkins, Philadelphia 2013.
8. Light RW. Management of spontaneous pneumothorax. Am Rev Respir Dis 1993; 148:245.
9. Kepka S, Dalphin JC, Parmentier AL, et al. Primary Spontaneous Pneumothorax Admitted in
Emergency Unit: Does First Episode Differ from Recurrence? A Cross-Sectional Study. Can
Respir J 2017; 2017:2729548.
10. Hallifax RJ, Goldacre R, Landray MJ, et al. Trends in the Incidence and Recurrence of
Inpatient-Treated Spontaneous Pneumothorax, 1968-2016. JAMA 2018; 320:1471.
11. Walker SP, Bibby AC, Halford P, et al. Recurrence rates in primary spontaneous
pneumothorax: a systematic review and meta-analysis. Eur Respir J 2018; 52.

12. Sadikot RT, Greene T, Meadows K, Arnold AG. Recurrence of primary spontaneous
pneumothorax. Thorax 1997; 52:805.
13. Casali C, Stefani A, Ligabue G, et al. Role of blebs and bullae detected by high-resolution
computed tomography and recurrent spontaneous pneumothorax. Ann Thorac Surg 2013;
95:249.
14. Guo Y, Xie C, Rodriguez RM, Light RW. Factors related to recurrence of spontaneous
pneumothorax. Respirology 2005; 10:378.
15. Hofmann HS, Suttner T, Neu R, et al. Burden between Undersupply and Overtreatment in
the Care of Primary Spontaneous Pneumothorax. Thorac Cardiovasc Surg 2018; 66:575.
16. Cardillo G, Bintcliffe OJ, Carleo F, et al. Primary spontaneous pneumothorax: a cohort study
of VATS with talc poudrage. Thorax 2016; 71:847.

17. Cheng YL, Huang TW, Lin CK, et al. The impact of smoking in primary spontaneous
pneumothorax. J Thorac Cardiovasc Surg 2009; 138:192.

https://www.uptodate.com/contents/117888/print 14/23
3/30/23, 5:19 PM 117888

18. Light RW. Talc should not be used for pleurodesis. Am J Respir Crit Care Med 2000;
162:2024.
19. Light RW, O'Hara VS, Moritz TE, et al. Intrapleural tetracycline for the prevention of
recurrent spontaneous pneumothorax. Results of a Department of Veterans Affairs
cooperative study. JAMA 1990; 264:2224.
20. Ueyama M, Asakura T, Morimoto K, et al. Pneumothorax associated with nontuberculous
mycobacteria: A retrospective study of 69 patients. Medicine (Baltimore) 2016; 95:e4246.

21. Hwong TM, Ng CS, Lee TW, et al. Video-assisted thoracic surgery for primary spontaneous
hemopneumothorax. Eur J Cardiothorac Surg 2004; 26:893.
22. Sawada S, Watanabe Y, Moriyama S. Video-assisted thoracoscopic surgery for primary
spontaneous pneumothorax: evaluation of indications and long-term outcome compared
with conservative treatment and open thoracotomy. Chest 2005; 127:2226.
23. Ayed AK, Al-Din HJ. The results of thoracoscopic surgery for primary spontaneous
pneumothorax. Chest 2000; 118:235.

24. Freixinet JL, Canalís E, Juliá G, et al. Axillary thoracotomy versus videothoracoscopy for the
treatment of primary spontaneous pneumothorax. Ann Thorac Surg 2004; 78:417.
25. Inderbitzi RG, Leiser A, Furrer M, Althaus U. Three years' experience in video-assisted
thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1994;
107:1410.
26. Cardillo G, Facciolo F, Giunti R, et al. Videothoracoscopic treatment of primary spontaneous
pneumothorax: a 6-year experience. Ann Thorac Surg 2000; 69:357.
27. Hatz RA, Kaps MF, Meimarakis G, et al. Long-term results after video-assisted thoracoscopic
surgery for first-time and recurrent spontaneous pneumothorax. Ann Thorac Surg 2000;
70:253.
28. Lang-Lazdunski L, de Kerangal X, Pons F, Jancovici R. Primary spontaneous pneumothorax:
one-stage treatment by bilateral videothoracoscopy. Ann Thorac Surg 2000; 70:412.

29. Janssen JP, van Mourik J, Cuesta Valentin M, et al. Treatment of patients with spontaneous
pneumothorax during videothoracoscopy. Eur Respir J 1994; 7:1281.
30. Györik S, Erni S, Studler U, et al. Long-term follow-up of thoracoscopic talc pleurodesis for
primary spontaneous pneumothorax. Eur Respir J 2007; 29:757.
31. Nathan DP, Taylor NE, Low DW, et al. Thoracoscopic total parietal pleurectomy for primary
spontaneous pneumothorax. Ann Thorac Surg 2008; 85:1825.

32. Rena O, Massera F, Papalia E, et al. Surgical pleurodesis for Vanderschueren's stage III
primary spontaneous pneumothorax. Eur Respir J 2008; 31:837.
https://www.uptodate.com/contents/117888/print 15/23
3/30/23, 5:19 PM 117888

33. Lee S, Kim HR, Cho S, et al. Staple line coverage after bullectomy for primary spontaneous
pneumothorax: a randomized trial. Ann Thorac Surg 2014; 98:2005.
34. Herrmann D, Klapdor B, Ewig S, Hecker E. Initial management of primary spontaneous
pneumothorax with video-assisted thoracoscopic surgery: a 10-year experience. Eur J
Cardiothorac Surg 2016; 49:854.
35. Hazelrigg SR, Landreneau RJ, Mack M, et al. Thoracoscopic stapled resection for
spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993; 105:389.

36. Urschel JD. Thoracoscopic treatment of spontaneous pneumothorax. A review. J Cardiovasc

Surg (Torino) 1993; 34:535.
37. Barker A, Maratos EC, Edmonds L, Lim E. Recurrence rates of video-assisted thoracoscopic
versus open surgery in the prevention of recurrent pneumothoraces: a systematic review
of randomised and non-randomised trials. Lancet 2007; 370:329.
38. Vohra HA, Adamson L, Weeden DF. Does video-assisted thoracoscopic pleurectomy result
in better outcomes than open pleurectomy for primary spontaneous pneumothorax?
Interact Cardiovasc Thorac Surg 2008; 7:673.
39. Waller DA, Yoruk Y, Morritt GN, et al. Videothoracoscopy in the treatment of spontaneous
pneumothorax: An initial experience. Ann Royal College Surg Eng 1993; 75:23.
40. Ayed AK. Suction versus water seal after thoracoscopy for primary spontaneous
pneumothorax: prospective randomized study. Ann Thorac Surg 2003; 75:1593.

41. Qureshi R, Nugent A, Hayat J, et al. Should surgical pleurectomy for spontaneous
pneumothorax be always thoracoscopic? Interact Cardiovasc Thorac Surg 2008; 7:569.
42. Milanez JR, Vargas FS, Filomeno LT, et al. Intrapleural talc for the prevention of recurrent
pneumothorax. Chest 1994; 106:1162.
43. Fosse E, Fjeld NB, Brockmeier V, Buanes T. Thoracoscopic pleurodesis. Scand J Thorac
Cardiovasc Surg 1993; 27:117.
44. Torre M, Grassi M, Nerli FP, et al. Nd-YAG laser pleurodesis via thoracoscopy. Endoscopic
therapy in spontaneous pneumothorax Nd-YAG laser pleurodesis. Chest 1994; 106:338.
45. Bobbio A, Ampollini L, Internullo E, et al. Thoracoscopic parietal pleural argon beam
coagulation versus pleural abrasion in the treatment of primary spontaneous
pneumothorax. Eur J Cardiothorac Surg 2006; 29:6.
46. Sakamoto K, Takei H, Nishii T, et al. Staple line coverage with absorbable mesh after
thoracoscopic bullectomy for spontaneous pneumothorax. Surg Endosc 2004; 18:478.

47. Mizobuchi T, Kurihara M, Ebana H, et al. A total pleural covering of absorbable cellulose
mesh prevents pneumothorax recurrence in patients with Birt-Hogg-Dubé syndrome.
https://www.uptodate.com/contents/117888/print 16/23
3/30/23, 5:19 PM 117888

Orphanet J Rare Dis 2018; 13:78.

48. Noyes BE, Orenstein DM. Treatment of pneumothorax in cystic fibrosis in the era of lung
transplantation. Chest 1992; 101:1187.
49. Horowitz MD, Oliva H. Pneumothorax in AIDS patients: operative management. Am Surg
1993; 59:200.
50. Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and efficacy of video-assisted thoracic
surgical techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc
Surg 1995; 109:1198.
51. Asban A, Raza SS, McLeod C, et al. Mechanical or chemical and mechanical pleurodesis for
spontaneous pneumothorax: what is the most effective approach in preventing
recurrence? A systematic review and meta-analysis. Eur J Cardiothorac Surg 2020; 58:682.
52. Wait MA, Dal Nogare AR. Treatment of AIDS-related spontaneous pneumothorax. A decade
of experience. Chest 1994; 106:693.
53. Nakayama T, Takahashi Y, Uehara H, et al. Outcome and risk factors of recurrence after
thoracoscopic bullectomy in young adults with primary spontaneous pneumothorax. Surg
Today 2017; 47:859.
54. Noppen M, Dekeukeleire T, Hanon S, et al. Fluorescein-enhanced autofluorescence
thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects.
Am J Respir Crit Care Med 2006; 174:26.
55. Janssen JP, Collier G, Astoul P, et al. Safety of pleurodesis with talc poudrage in malignant
pleural effusion: a prospective cohort study. Lancet 2007; 369:1535.
56. Alfageme I, Moreno L, Huertas C, et al. Spontaneous pneumothorax. Long-term results
with tetracycline pleurodesis. Chest 1994; 106:347.
57. Chen JS, Tsai KT, Hsu HH, et al. Intrapleural minocycline following simple aspiration for
initial treatment of primary spontaneous pneumothorax. Respir Med 2008; 102:1004.
58. DiBardino DJ, Vanatta JM, Fagan SP, Awad SS. Acute respiratory failure after pleurodesis
with doxycycline. Ann Thorac Surg 2002; 74:257.
59. Tschopp JM, Boutin C, Astoul P, et al. Talcage by medical thoracoscopy for primary
spontaneous pneumothorax is more cost-effective than drainage: a randomised study. Eur
Respir J 2002; 20:1003.
60. Cardillo G, Carleo F, Carbone L, et al. Long-term lung function following videothoracoscopic
talc poudrage for primary spontaneous recurrent pneumothorax. Eur J Cardiothorac Surg
2007; 31:802.

https://www.uptodate.com/contents/117888/print 17/23
3/30/23, 5:19 PM 117888

61. Hunt I, Barber B, Southon R, Treasure T. Is talc pleurodesis safe for young patients
following primary spontaneous pneumothorax? Interact Cardiovasc Thorac Surg 2007;
6:117.
62. de Campos JR, Vargas FS, de Campos Werebe E, et al. Thoracoscopy talc poudrage : a 15-
year experience. Chest 2001; 119:801.

63. Brant A, Eaton T. Serious complications with talc slurry pleurodesis. Respirology 2001;
6:181.

64. Pletinckx P, Muysoms F, De Decker C, et al. Thoracoscopic talc pleurodesis for the treatment
of spontaneous pneumothorax. Acta Chir Belg 2005; 105:504.
65. Gonzalez AV, Bezwada V, Beamis JF Jr, Villanueva AG. Lung injury following thoracoscopic
talc insufflation: experience of a single North American center. Chest 2010; 137:1375.

66. Bridevaux PO, Tschopp JM, Cardillo G, et al. Short-term safety of thoracoscopic talc
pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European
multicentre study. Eur Respir J 2011; 38:770.

67. Shinno Y, Kage H, Chino H, et al. Old age and underlying interstitial abnormalities are risk
factors for development of ARDS after pleurodesis using limited amount of large particle
size talc. Respirology 2018; 23:55.

68. Leuzzi G, Vita ML, Porziella V, et al. Single center experience on talc poudrage morbidity:
focus on high talc dosage. J Cardiothorac Surg 2011; 6:87.
69. Lange P, Mortensen J, Groth S. Lung function 22-35 years after treatment of idiopathic
spontaneous pneumothorax with talc poudrage or simple drainage. Thorax 1988; 43:559.
70. Agarwal R, Paul AS, Aggarwal AN, et al. A randomized controlled trial of the efficacy of
cosmetic talc compared with iodopovidone for chemical pleurodesis. Respirology 2011;
16:1064.
71. Khoshbin E, Prayaga S, Kinsella J, Sutherland FW. Mini-sternotomy for aortic valve
replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of
randomised controlled trials. BMJ Open 2011; 1:e000266.
72. Khoshbin E, Al-Jilaihawi AN, Scott NB, et al. An audit of pain control pathways following
video-assisted thoracoscopic surgery. Innovations (Phila) 2011; 6:248.
73. Rahman NM, Pepperell J, Rehal S, et al. Effect of Opioids vs NSAIDs and Larger vs Smaller
Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant
Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA 2015; 314:2641.
Topic 117888 Version 12.0

https://www.uptodate.com/contents/117888/print 18/23
3/30/23, 5:19 PM 117888

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.

https://www.uptodate.com/contents/117888/print 19/23
3/30/23, 5:19 PM 117888

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

https://www.uptodate.com/contents/117888/print 20/23
3/30/23, 5:19 PM 117888

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.

https://www.uptodate.com/contents/117888/print 21/23
3/30/23, 5:19 PM 117888

¶ 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

https://www.uptodate.com/contents/117888/print 22/23
3/30/23, 5:19 PM 117888

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

https://www.uptodate.com/contents/117888/print 23/23