TOC | Pulm

Spontaneous Pneumothorax
Steven A. Sahn, John E. Heffner  
NEJM March 23, 2000 -- Vol. 342, No. 12
              See pneumothorax2001.pdf  

Classification of Pneumothorax

Primary Spontaneous Pneumothorax

Pathophysiology - subpleural bullae in most patients.

Clinical Presentation


Recurrence Rate



Secondary Spontaneous Pneumothorax

It is a potentially life-threatening event, because patients with this condition have associated lung disease and limited cardiopulmonary reserve.

The major causes of secondary spontaneous pneumothorax :

Chronic obstructive pulmonary disease and Pneumocystis carinii pneumonia related to infection with the human immunodeficiency virus (HIV) are the most common conditions associated with secondary pneumothorax.

Pneumothorax related to menses typically occurs in women who are 30 to 40 years old and who have a history of pelvic endometriosis. Such a catamenial pneumothorax usually affects the right lung and occurs within 72 hours after the onset of menses.  Since the rate of recurrence among women receiving hormonal treatment is 50 percent at one year, pleurodesis should be recommended.

Pathophysiology: - the ruptured alveolus.

Clinical Presentation

Diagnosis: Clinical symptoms & signs, chest x-ray or CT scan.

Recurrence: The rates of recurrence ranging from 39 percent to 47 percent.

The management of pneumothorax centers on evacuating air from the pleural space and preventing recurrences.

Available therapeutic options include

The selection of an approach depends on the size of the pneumothorax, the severity of symptoms, whether there is a persistent air leak, and whether the pneumothorax is primary or secondary.

Reexpansion of the Lung

With a small primary spontaneous pneumothorax (one involving <15 percent of the hemithorax), patients may have minimal symptoms. Supplemental oxygen accelerates by a factor of four the reabsorption of air by the pleura, which occurs at a rate of 2 percent per day in patients breathing room air. Young patients who are likely to comply with treatment plans may be managed at home after six hours of observation in the emergency department if such patients can obtain emergency services quickly.

Primary spontaneous pneumothoraxes that are large (involving greater than or equal to 15 percent of the hemithorax) or progressive may be drained by simple aspiration with a plastic intravenous catheter, thoracentesis catheter, or small-bore (7 to 14 French) catheter or by the insertion of a chest tube. Simple aspiration is successful in 70 percent of patients with moderate-sized primary spontaneous pneumothorax. If the patient is more than 50 years old, or if more than 2.5 liters of air is aspirated, this method is likely to fail. Successfully treated patients can be discharged from emergency departments with follow-up within several days if a chest radiograph obtained six hours after aspiration shows resolution of the pneumothorax and if such patients can obtain emergency services quickly. If aspiration through a catheter fails to expand the lung, the catheter can be attached to a one-way Heimlich valve or a water-seal device and used as a chest tube.

Primary spontaneous pneumothorax may also be managed with a chest tube that is left in place for one or more days. Because air leakage is usually minimal, a small-bore (7 to 14 French) chest catheter usually suffices. The catheter can be attached to a one-way Heimlich valve, which allows ambulation, or to a water-seal device. Routine application of suction (with a pressure of 20 cm of water) has not been shown to improve the outcome. Drainage through a chest tube has a success rate of 90 percent for treatment of a first pneumothorax, but the rate decreases to 52 percent for treatment of a first recurrence and to 15 percent for treatment of a second recurrence. Large air leaks and pleural effusions that clog the catheter contribute to failure.

Secondary spontaneous pneumothorax should be managed with a chest tube (20 to 28 French) attached to a water-seal device, and patients should be hospitalized, because of the risk of respiratory compromise. Suction can be reserved for patients with ongoing air leaks and those in whom the lung fails to reexpand after drainage through a water-seal device.

Complications of chest-tube drainage include pain, pleural infection, incorrect placement of the tube, hemorrhage, and hypotension and pulmonary edema due to lung reexpansion.

Persistent Air Leaks

Persistent air leaks are more common with secondary pneumothorax than with primary pneumothorax.

Seventy-five percent of air leaks in primary spontaneous pneumothorax and 61 percent of air leaks in secondary spontaneous pneumothorax resolve after 7 days of chest drainage, but 100 percent and 79 percent, respectively, resolve after 15 days. Another study reported a lower likelihood of eventual resolution of air leaks that persist for longer than two days.

We reassure patients with a first primary spontaneous pneumothorax, at the time the chest tube is inserted, that surgery is usually unnecessary. However, surgery does become a consideration if an air leak persists for four to seven days. On the seventh day of an air leak, we discuss the available surgical alternatives with the patient. Most of our patients request surgical intervention after seven days of a persistent air leak.

or an initial secondary spontaneous pneumothorax, we recommend surgery for patients who are suitable candidates. It is important to prevent recurrences, regardless of the presence or absence of an air leak, because of the seriousness of this condition. Some centers, however, maintain drainage through a chest tube for two weeks before undertaking a surgical intervention.

Preventing Recurrences

We recommend interventions to prevent recurrence after the second ipsilateral pneumothorax. Some centers, however, recommend such measures for all patients with a first primary spontaneous pneumothorax. Patients who plan to continue activities that increase the risk that complications will result from a pneumothorax (e.g., flying or diving) should undergo preventive treatment after the first episode. We still caution against such activities, however, because of the risk of a contralateral pneumothorax.

Since most recurrences occur within three years of the first pneumothorax and risk decreases after the age of 40 years, younger patients are at risk for a longer period and have a greater likelihood of benefiting from preventive procedures after a first pneumothorax than older patients.

Interventions to Prevent Recurrences

The instillation of sclerosing agents through chest tubes in the absence of air leaks is associated with a recurrence rate of 8 to 25 percent, which is higher than the rate associated with other available methods.

Thoracoscopy through a single chest port performed under direct visualization allows the resection of small apical bullae (those approximately <2 cm in diameter) and pleurodesis by mechanical pleural abrasion or insufflation of talc. Two grams of talc is used, in contrast with the 5 g recommended for pleurodesis of malignant pleural effusions. The treatment of patients found at thoracoscopy to have bullae greater than or equal to 2 cm in diameter can be switched to video-assisted thoracoscopic surgery or thoracotomy (for the resection of bullae and pleurodesis). The success rate for thoracoscopy with insufflation of talc is approximately 97 percent, with a recurrence rate of 5 to 9 percent. There is concern about the use of talc, however, because of reports of acute lung injury and respiratory failure.





American College of Chest Physicians  -  Consensus Statements

Consensus Panel on the Management of Spontaneous Pneumothorax 2009  

Spontaneous pneumothorax that occurs in the absence of thoracic trauma is classified as primary or secondary:

  1. Primary pneumothorax occurs in patients who have no clinically apparent lung disorder.
  2. Secondary pneumothorax occurs in patients with an underlying pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD).

Primary and secondary pneumothorax occurs in more than 20,000 patients annually in the United States.

Pneumothorax size Determined by distance from the lung apex to the ipsilateral thoracic cupola at the parietal surface as determined by upright standard radiograph.

Stable patient

Unstable patient


Primary Spontaneous Pneumothorax  

Clinically Stable Patients With a Small Pneumothorax (< 3 cm apex-to-cupola distance)

Clinically Stable Patients With a Large Pneumothorax (> 3 cm apex-to cupola distance)

Clinically Unstable Patients With a Large Pneumothorax

Chest Tube Removal

The panel had divided opinion on the question "Should the chest tube be clamped to detect an air leak after re-expansion of the lung?"

The panel had divided opinion on the question: "When should chest radiography be repeated after the last evidence of an air leak to ensure that the pneumothorax has not recurred before the chest tube is removed?"

Persistent Air Leak

Prevention of Pneumothorax Recurrence

The panel had divided opinion on the question: "Should patients with their first primary spontaneous pneumothorax be offered an intervention to prevent recurrence?"

The occupational and recreational interests of patients (eg, flying, scuba diving) should be considered in timing an intervention.

Thoracoscopy is the preferred procedure for preventing pneumothorax recurrence (Very Good Consensus).
Thoracoscopy can be performed with or without video assistance. Intraoperative bullectomy should be performed (Very Good Consensus) by staple bullectomy (Very Good Consensus) in patients with apical bullae visualized at surgery.

Chemical pleurodesis through a chest tube is an acceptable alternative to thoracoscopy in certain patients (Good Consensus), although thoracoscopy has a higher success rate.
Intraoperative pleurodesis should be performed in most patients, with parietal pleural abrasion limited to the upper half of the hemithorax (Good Consensus).


Secondary Spontaneous Pneumothorax

Clinically Stable Patients With a Small Pneumothorax

Clinically Unstable Patients With a Pneumothorax of Any Size

Chest Tube Management

Prevention of Pneumothorax Recurrence

Most (81%) panel members recommend an intervention to prevent pneumothorax recurrence after the first pneumothorax because of the potential lethality of secondary pneumothoraces. The other 19% of panel members recommend an intervention to prevent recurrence after the second spontaneous pneumothorax.

Surgical management is preferred to prevent pneumothorax recurrence (Very Good Consensus); surgery has a lower recurrence rate than use of a sclerosing agent. Instillation of a sclerosant through a chest tube may be used in certain circumstances (Good Consensus) based on patients’ contraindications to surgery, management preferences, and underlying poor patient prognosis (see below for sclerosant choice).

Medical or surgical thoracoscopy is preferred (Very Good Consensus), but a muscle-sparing (axillary) thoracotomy is acceptable (Good Consensus).

Standard thoracotomy through a lateral or medial sternotomy is not appropriate for most patients (Good Consensus).

Bullectomy and a procedure to produce pleural symphysis should be performed during the surgical intervention. Staple bullectomy is preferred (Very Good Consensus). Parietal pleurectomy or parietal pleural abrasion limited to the upper half of the hemithorax is preferred to produce pleural symphysis in most patients (Good Consensus).

For producing pleural symphysis by instillation of a sclerosing agent through a chest tube, preferred agents are talc slurry (Very Good Consensus) and doxycycline (Good Consensus).

Assessment of Pulmonary Function

Performance of pulmonary function tests (PFTs) to assist management decisions is not appropriate (Perfect Consensus) for patients with secondary pneumothoraces. Expiratory maneuvers performed during the acute phase of a pneumothorax may produce inaccurate results. However, results from previous PFTs may assist in patient selection for an intervention to prevent pneumothorax recurrence in special circumstances (Good Consensus).

Persistent Air Leaks

Chest Tube Removal

Chest Imaging With CT