Semin Respir Crit Care Med 2023; 44(04): 426-436
DOI: 10.1055/s-0043-1769615
Review Article

Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions

Eleanor C. Barton
1   Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
,
Nick A. Maskell
1   Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
,
Steven P. Walker
1   Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
› Author Affiliations
› Further Information
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Abstract

For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.

Keywords

pneumothorax - pleural porosity - conservative management - ambulatory management - persistent air leak


Publication History

Article published online:
15 June 2023

© 2023. Thieme. All rights reserved.

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  • References

  • 1 Noppen M, Baumann MH. Pathogenesis and treatment of primary spontaneous pneumothorax: an overview. Respiration 2003; 70 (04) 431-438
    CrossrefPubMedGoogle Scholar
  • 2 Bense L, Lewander R, Eklund G, Hedenstierna G, Wiman LG. Nonsmoking, non-alpha 1-antitrypsin deficiency-induced emphysema in nonsmokers with healed spontaneous pneumothorax, identified by computed tomography of the lungs. Chest 1993; 103 (02) 433-438
    CrossrefPubMedGoogle Scholar
  • 3 Haynes D, Baumann MH. Pleural controversy: aetiology of pneumothorax. Respirology 2011; 16 (04) 604-610
    CrossrefPubMedGoogle Scholar
  • 4 Cardillo G, Carleo F, Giunti R. et al. Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: a single-institution experience in 861 cases. J Thorac Cardiovasc Surg 2006; 131 (02) 322-328
    CrossrefPubMedGoogle Scholar
  • 5 Walker SP, Bibby AC, Halford P, Stadon L, White P, Maskell NA. Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis. Eur Respir J 2018; 52 (03) 1800864
    CrossrefPubMedGoogle Scholar
  • 6 Ohata M, Suzuki H. Pathogenesis of spontaneous pneumothorax. With special reference to the ultrastructure of emphysematous bullae. Chest 1980; 77 (06) 771-776
    PubMedGoogle Scholar
  • 7 Noppen M, Stratakos G, Verbanck S, D'Haese J, Meysman M, Vincken W. Fluorescein-enhanced autofluorescence thoracoscopy in primary spontaneous pneumothorax. Am J Respir Crit Care Med 2004; 170 (06) 680-682
    CrossrefPubMedGoogle Scholar
  • 8 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 (01) 26-30
    CrossrefPubMedGoogle Scholar
  • 9 Min X, Huang Y, Yang Y. et al. Mechanical pleurodesis does not reduce recurrence of spontaneous pneumothorax: a randomized trial. Ann Thorac Surg 2014; 98 (05) 1790-1796 , discussion 1796
    CrossrefPubMedGoogle Scholar
  • 10 Neudecker J, Malzahn U, Heuschmann P, Behrens U, Walles T. Pulmonary wedge resection plus parietal pleurectomy (WRPP) versus parietal pleurectomy (PP) for the treatment of recurrent primary pneumothorax (WOPP trial): study protocol for a randomized controlled trial. Trials 2015; 16 (01) 540
    CrossrefPubMedGoogle Scholar
  • 11 Chee CBE, Abisheganaden J, Yeo JKS. et al. Persistent air-leak in spontaneous pneumothorax–clinical course and outcome. Respir Med 1998; 92 (05) 757-761
    CrossrefPubMedGoogle Scholar
  • 12 Seaton D, Yoganathan K, Coady T, Barker R. Spontaneous pneumothorax: marker gas technique for predicting outcome of manual aspiration. BMJ 1991; 302 (6771): 262-265
    CrossrefPubMedGoogle Scholar
  • 13 Kiely DG, Ansari S, Davey WA, Mahadevan V, Taylor GJ, Seaton D. Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous pneumothorax. Thorax 2001; 56 (08) 617-621
    CrossrefPubMedGoogle Scholar
  • 14 Brown SGA, Ball EL, Perrin K. et al; PSP Investigators. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med 2020; 382 (05) 405-415
    CrossrefPubMedGoogle Scholar
  • 15 Walker SP, Hallifax R, Rahman NM, Maskell NA. Challenging the paradigm of persistent air leak: are we prolonging the problem?. Am J Respir Crit Care Med 2022; 206 (02) 145-149
    CrossrefPubMedGoogle Scholar
  • 16 Chopra A, Doelken P, Judson MA, Huggins T. The pressure-dependent air leak after partial lung resection. Thorax 2017; 72 (03) 290-291
    CrossrefPubMedGoogle Scholar
  • 17 Chopra A, Hu K, Judson MA. et al. Association between drainage-dependent prolonged air leak after partial lung resection and clinical outcomes: a prospective cohort study. Ann Am Thorac Soc 2022; 19 (03) 389-398
    CrossrefPubMedGoogle Scholar
  • 18 Kjaergaard H. Spontaneous pneumothorax in the apparently healthy. Lancet 1938; 232 (6002): 632-633
    CrossrefPubMedGoogle Scholar
  • 19 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. 02) ii18-ii31
    PubMedGoogle Scholar
  • 20 Baumann MH, Strange C, Heffner JE. et al; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119 (02) 590-602
    CrossrefPubMedGoogle Scholar
  • 21 Hallifax RJ, Goldacre R, Landray MJ, Rahman NM, Goldacre MJ. Trends in the incidence and recurrence of inpatient-treated spontaneous pneumothorax, 1968-2016. JAMA 2018; 320 (14) 1471-1480
    CrossrefPubMedGoogle Scholar
  • 22 Mitlehner W, Friedrich M, Dissmann W. Value of computer tomography in the detection of bullae and blebs in patients with primary spontaneous pneumothorax. Respiration 1992; 59 (04) 221-227
    CrossrefPubMedGoogle Scholar
  • 23 Cheng Y-L, Huang T-W, Lin C-K. et al. The impact of smoking in primary spontaneous pneumothorax. J Thorac Cardiovasc Surg 2009; 138 (01) 192-195
    CrossrefPubMedGoogle Scholar
  • 24 Stefani A, Aramini B, Baraldi C. et al. Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: a case-control study. PLoS One 2020; 15 (03) e0230419
    CrossrefPubMedGoogle Scholar
  • 25 Hallifax RJ, McKeown E, Sivakumar P. et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet 2020; 396 (10243): 39-49
    CrossrefPubMedGoogle Scholar
  • 26 Alifano M. Catamenial pneumothorax. Curr Opin Pulm Med 2010; 16 (04) 381-386
    CrossrefPubMedGoogle Scholar
  • 27 Alifano M, Legras A, Rousset-Jablonski C. et al. Pneumothorax recurrence after surgery in women: clinicopathologic characteristics and management. Ann Thorac Surg 2011; 92 (01) 322-326
    CrossrefPubMedGoogle Scholar
  • 28 Legras A, Mansuet-Lupo A, Rousset-Jablonski C. et al. Pneumothorax in women of child-bearing age: an update classification based on clinical and pathologic findings. Chest 2014; 145 (02) 354-360
    CrossrefPubMedGoogle Scholar
  • 29 Ng AW, Chan KW, Lee SK. Simple aspiration of pneumothorax. Singapore Med J 1994; 35 (01) 50-52
    PubMedGoogle Scholar
  • 30 Archer GJ, Hamilton AA, Upadhyay R, Finlay M, Grace PM. Results of simple aspiration of pneumothoraces. Br J Dis Chest 1985; 79 (02) 177-182
    CrossrefPubMedGoogle Scholar
  • 31 Thelle A, Gjerdevik M, SueChu M, Hagen OM, Bakke P. Randomised comparison of needle aspiration and chest tube drainage in spontaneous pneumothorax. Eur Respir J 2017; 49 (04) 1601296
    CrossrefPubMedGoogle Scholar
  • 32 Bobbio A, Dechartres A, Bouam S. et al. Epidemiology of spontaneous pneumothorax: gender-related differences. Thorax 2015; 70 (07) 653-658
    CrossrefPubMedGoogle Scholar
  • 33 Onuki T, Ueda S, Yamaoka M. et al. Primary and secondary spontaneous pneumothorax: prevalence, clinical features, and in-hospital mortality. Can Respir J 2017; 2017: 6014967
    CrossrefPubMedGoogle Scholar
  • 34 Ichinose J, Nagayama K, Hino H. et al. Results of surgical treatment for secondary spontaneous pneumothorax according to underlying diseases. Eur J Cardiothorac Surg 2016; 49 (04) 1132-1136
    CrossrefPubMedGoogle Scholar
  • 35 Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir Crit Care Med 2002; 165 (09) 1240-1244
    CrossrefPubMedGoogle Scholar
  • 36 Harvey J, Prescott RJ. British Thoracic Society Research Committee. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with normal lungs. BMJ 1994; 309 (6965): 1338-1339
    CrossrefPubMedGoogle Scholar
  • 37 Klassen KP, Meckstroth CV. Treatment of spontaneous pneumothorax: prompt expansion with controlled thoracotomy tube suction. JAMA 1962; 182 (01) 1-5
    CrossrefPubMedGoogle Scholar
  • 38 Baronofsky ID, Warden HG, Kaufman JL, Whatley J, Hanner JM. Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Surg 1957; 34 (03) 310-319 , discussion 319–322
    CrossrefPubMedGoogle Scholar
  • 39 Smith WG, Rothwell PPG. Treatment of spontaneous pneumothorax. Thorax 1962; 17 (04) 342-349
    CrossrefPubMedGoogle Scholar
  • 40 Ruckley CV, McCormack RJ. The management of spontaneous pneumothorax. Thorax 1966; 21 (02) 139-144
    CrossrefPubMedGoogle Scholar
  • 41 Hyde L. Spontaneous pneumothorax. Dis Chest 1963; 43 (05) 476-480
    CrossrefPubMedGoogle Scholar
  • 42 Beumer HMA. Ten-year review of spontaneous pneumothorax in an armed forces hospital. Am Rev Respir Dis 1964; 90: 261
    PubMedGoogle Scholar
  • 43 Stradling P, Poole G. Conservative management of spontaneous pneumothorax. Thorax 1966; 21 (02) 145-149
    CrossrefPubMedGoogle Scholar
  • 44 Simpson G, Vincent S, Ferns J. Spontaneous tension pneumothorax: what is it and does it exist?. Intern Med J 2012; 42 (10) 1157-1160
    CrossrefPubMedGoogle Scholar
  • 45 Carson-Chahhoud KV, Wakai A, van Agteren JE. et al. Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev 2017; 9 (09) CD004479
    PubMedGoogle Scholar
  • 46 Lee JH, Kim R, Park CM. Chest tube drainage versus conservative management as the initial treatment of primary spontaneous pneumothorax: a systematic review and meta-analysis. J Clin Med 2020; 9 (11) 3456
    CrossrefPubMedGoogle Scholar
  • 47 Hallifax RJ, Walker S, Walters J, Maskell N, Rahman NM. Management of primary spontaneous pneumothorax: less is more - Authors' reply. Lancet 2021; 396 (10267): 1973-1974
    CrossrefPubMedGoogle Scholar
  • 48 Gerhardy BC, Simpson G. Conservative versus invasive management of secondary spontaneous pneumothorax: a retrospective cohort study. Acute Med Surg 2021; 8 (01) e663
    CrossrefPubMedGoogle Scholar
  • 49 Brims FJH, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax 2013; 68 (07) 664-669
    CrossrefPubMedGoogle Scholar
  • 50 Ho KK, Ong MEH, Koh MS, Wong E, Raghuram J. A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med 2011; 29 (09) 1152-1157
    CrossrefPubMedGoogle Scholar
  • 51 Röggla M, Wagner A, Brunner C, Röggla G. The management of pneumothorax with the thoracic vent versus conventional intercostal tube drainage. Wien Klin Wochenschr 1996; 108 (11) 330-333
    PubMedGoogle Scholar
  • 52 Khan F, Vali Y, Naeem M, Reddy R. Safety and efficacy of ambulatory management of secondary spontaneous pneumothorax: a case series. BMJ Open Respir Res 2019; 6 (01) e000373
    CrossrefPubMedGoogle Scholar
  • 53 Walker SP, Keenan E, Bintcliffe O. et al. Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial. Eur Respir J 2021; 57 (06) 2003375
    CrossrefPubMedGoogle Scholar
  • 54 Maskell N, Rahman N, Roberts M. et al. British Thoracic Society Pleural Disease Guidelines [Internet]. 2022 Accessed December 22 at: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/pleural-disease/
    PubMedGoogle Scholar
  • 55 Pompili C, Salati M, Brunelli A. Chest tube management after surgery for pneumothorax. Thorac Surg Clin 2017; 27 (01) 25-28
    CrossrefPubMedGoogle Scholar
  • 56 Cerfolio RJ, Bass C, Katholi CR. Prospective randomized trial compares suction versus water seal for air leaks. Ann Thorac Surg 2001; 71 (05) 1613-1617
    CrossrefPubMedGoogle Scholar
  • 57 Alphonso N, Tan C, Utley M. et al. A prospective randomized controlled trial of suction versus non-suction to the under-water seal drains following lung resection. Eur J Cardiothorac Surg 2005; 27 (03) 391-394
    CrossrefPubMedGoogle Scholar
  • 58 Dumire R, Crabbe MM, Mappin FG, Fontenelle LJ. Autologous “blood patch” pleurodesis for persistent pulmonary air leak. Chest 1992; 101 (01) 64-66
    CrossrefPubMedGoogle Scholar
  • 59 Cagirici U, Sahin B, Cakan A, Kayabas H, Buduneli T. Autologous blood patch pleurodesis in spontaneous pneumothorax with persistent air leak. Scand Cardiovasc J 1998; 32 (02) 75-78
    CrossrefPubMedGoogle Scholar
  • 60 Ando M, Yamamoto M, Kitagawa C. et al. Autologous blood-patch pleurodesis for secondary spontaneous pneumothorax with persistent air leak. Respir Med 1999; 93 (06) 432-434
    CrossrefPubMedGoogle Scholar
  • 61 Cao Gq, Kang J, Wang F, Wang H. Intrapleural instillation of autologous blood for persistent air leak in spontaneous pneumothorax in patients with advanced chronic obstructive pulmonary disease. Ann Thorac Surg 2012; 93 (05) 1652-1657
    CrossrefPubMedGoogle Scholar
  • 62 Ibrahim IM, Elaziz MEA, El-Hag-Aly MA. Early autologous blood-patch pleurodesis versus conservative management for treatment of secondary spontaneous pneumothorax. Thorac Cardiovasc Surg 2019; 67 (03) 222-226
    Article in Thieme ConnectPubMedGoogle Scholar
  • 63 Shackcloth MJ, Poullis M, Jackson M, Soorae A, Page RD. Intrapleural instillation of autologous blood in the treatment of prolonged air leak after lobectomy: a prospective randomized controlled trial. Ann Thorac Surg 2006; 82 (03) 1052-1056
    CrossrefPubMedGoogle Scholar
  • 64 Travaline JM, McKenna Jr. RJ, De Giacomo T. et al; Endobronchial Valve for Persistent Air Leak Group. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009; 136 (02) 355-360
    CrossrefPubMedGoogle Scholar
  • 65 Zhang HT, Xie YH, Gu X. et al. Management of persistent air leaks using endobronchial autologous blood patch and spigot occlusion: a multicentre randomized controlled trial in China. Respiration 2019; 97 (05) 436-443
    CrossrefPubMedGoogle Scholar
  • 66 Abolnik IZ, Lossos IS, Zlotogora J, Brauer R. On the inheritance of primary spontaneous pneumothorax. Am J Med Genet 1991; 40 (02) 155-158
    CrossrefPubMedGoogle Scholar
  • 67 Scott RM, Henske EP, Raby B, Boone PM, Rusk RA, Marciniak SJ. Familial pneumothorax: towards precision medicine. Thorax 2018; 73 (03) 270-276
    CrossrefPubMedGoogle Scholar
  • 68 Lenler-Petersen P, Grunnet N, Jespersen TW, Jaeger P. Familial spontaneous pneumothorax. Eur Respir J 1990; 3 (03) 342-345
    CrossrefPubMedGoogle Scholar
  • 69 Boone PM, Scott RM, Marciniak SJ, Henske EP, Raby BA. The genetics of pneumothorax. Am J Respir Crit Care Med 2019; 199 (11) 1344-1357
    CrossrefPubMedGoogle Scholar
  • 70 Warner BW, Bailey WW, Shipley RT. Value of computed tomography of the lung in the management of primary spontaneous pneumothorax. Am J Surg 1991; 162 (01) 39-42
    CrossrefPubMedGoogle Scholar
  • 71 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 (01) 249-255
    CrossrefPubMedGoogle Scholar
  • 72 Primavesi F, Jäger T, Meissnitzer T. et al. First episode of spontaneous pneumothorax: CT-based scoring to select patients for early surgery. World J Surg 2016; 40 (05) 1112-1120
    CrossrefPubMedGoogle Scholar
  • 73 Ouanes-Besbes L, Golli M, Knani J. et al. Prediction of recurrent spontaneous pneumothorax: CT scan findings versus management features. Respir Med 2007; 101 (02) 230-236
    CrossrefPubMedGoogle Scholar
  • 74 Martínez-Ramos D, Ángel-Yepes V, Escrig-Sos J, Miralles-Tena JM, Salvador-Sanchís JL. Usefulness of computed tomography in determining risk of recurrence after a first episode of primary spontaneous pneumothorax: therapeutic implications [in Spanish]. Arch Bronconeumol 2007; 43 (06) 304-308
    CrossrefPubMedGoogle Scholar
  • 75 Sihoe ADL, Yim APC, Lee TW. et al. Can CT scanning be used to select patients with unilateral primary spontaneous pneumothorax for bilateral surgery?. Chest 2000; 118 (02) 380-383
    CrossrefPubMedGoogle Scholar
  • 76 Hallifax RJ, Laskawiec-Szkonter M, Rahman NM. RAMPP Trial collaborators. Predicting outcomes in primary spontaneous pneumothorax using air leak measurements. Thorax 2019; 74 (04) 410-412
    PubMedGoogle Scholar
  • 77 Nakanishi K, Shimotakahara A, Asato Y, Ishihara T. A new method to detect air leakage in a patient with pneumothorax using saline solution and multidetector-row spiral CT scan. Chest 2013; 144 (03) 940-946
    CrossrefPubMedGoogle Scholar