New insights and improved strategies for the management of primary spontaneous pneumothorax

Abstract

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema‐like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta‐analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of ‘at risk patients’ is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost‐effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice.

Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial

“…The management of PSP is based on two principles: first, the initial management of the pneumothorax with symptom control and re-expansion of the lung and secondly, reducing recurrence rate [4]. The recurrence rate is reported to be between 17 and 54% [5,6], with the majority of recurrences in the first year after the primary event [7].…”

“…Recurrence rate can be reduced by surgical pleurectomy or thoracoscopic pleurodesis [8]. Initial management of PSP has been subject of ongoing debate [4,8], with a trend towards a more conservative approach using manual aspiration and outpatient treatment [4,6,[8][9][10][11][12]. Manual aspiration has been shown to be effective in approximately two-thirds of patients [8] and is as equally effective as chest tube drainage [8].…”

Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial

“…The management of PSP is based on two principles: first, the initial management of the pneumothorax with symptom control and re-expansion of the lung and secondly, reducing recurrence rate [4]. The recurrence rate is reported to be between 17 and 54% [5][6], with the majority of recurrences in the first year after the primary event [7].…”

“…Recurrence rate can be reduced by surgical pleurectomy or thoracoscopic pleurodesis [8]. Initial management of PSP has been subject of ongoing debate [4,8], with a trend towards a more conservative approach using manual aspiration and outpatient treatment [4,6,[8][9][10][11][12]. Manual aspiration has been shown to be effective in approximately two-thirds of patients [8] and is as equally effective as chest tube drainage [8].…”

Thematic series: Novel insights in pleural diseases

“…Yet, there is evidence in favour of fine‐needle aspiration instead of chest tube insertion when the patient is symptomatic . Whether this is due to diffuse pleural inflammation or other factors, still remains to be established, as well as the optimal management of patients with PSP and Plojoux and associates …”