Spontaneous pneumothorax: stop chest tube as first-line therapy

Abstract

Spontaneous pneumothorax is traditionally divided between primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) when there is some underlying lung disease. For decades management of spontaneous pneumothorax has remained highly debatable despite different published guidelines [1][2][3], many of which contradict each other. Our task force, comprising a multidisciplinary panel of pulmonologists, thoracic surgeons and epidemiologists, recently published a consensus statement [4] on PSP to highlight new findings on the clinical approach, pathophysiology and management strategies of this disease. Pneumothorax remains an under-researched area. The epidemiology of PSP is still poorly documented regarding risk factors or rates of recurrence of PSP. Although smoking remains the principal and well-established risk factor [5], advice for quitting smoking [6] should be routinely given. This disease affects young patients in good health. They are therefore an ideal target population for receiving preventive advice. The pathophysiology of PSP is better understood because of many recent findings. The old concept [7] of PSP because of a localised rupture of a bleb or a bulla is obsolete and has been questioned by many recent studies. We now have robust evidence that the occurrence of PSP is mainly the result of a diffuse histopathological change of the lung parenchyma under the visceral pleura known as emphysema-like changes [8,9]. There is also a diffuse decrease in the lung density measured by computed tomography (CT) [10] and diffuse increased porosity [11] at the periphery of both lungs. These recent findings explain why a localised surgical approach is less effective than a diffuse pleurodesis, whatever the method of pleurodesis used [12,13,14]. Most patients with PSP have no or minimal symptoms, and the entire panel of this European task force [4] agreed that the clinical evaluation of patients with PSP should be more symptom driven and not based only on the measurement of the size of pneumothorax on plain chest radiography or CT, which have little clinical value [15,16]. Tension pneumothorax is very rare [17]. Most patients with spontaneous pneumothorax commonly experience minimal or no symptoms.In recent years, there has been a change in the management strategy of spontaneous pneumothorax leading to more use of a conservative approach [1,3] based on the idea that air in the pleural cavity is well supported. This is not surprising. Chest physicians historically were familiar with inducing artificial pneumothorax in cases of tuberculosis and using the same apparatus for aspirating pneumothorax on an ambulatory basis. With the advent of the chest tube, the use of chest tube drainage (CTD) became widespread although such an approach required hospitalisation and was mainly practised by surgeons [18] and not by pulmonologists. 50 years ago, STRADLING and POOLE [19] had already recommended a conservative and outpatient treatment of pneumothorax. Later on, many randomised studies [20][21][22][23][24...

Short term association between air pollution (PM10, NO2 and O3) and secondary spontaneous pneumothorax

“…A diffuse histopathological change in the lung parenchyma under the visceral pleural could lead to the occurrence of a pneumothorax. Diffuse increased porosity at the periphery of both lungs has been identified, which could be associated with localized rupture of a bleb, or a bulla 25,26 . Short-term O 3 exposure could induce airway hyperresponsiveness, increase oxidant stress and stimulate inflammatory responses in the respiratory system associated with a chronic inflammatory disease, which could lend credence to the hypothesis of a stronger link between SSP and air pollutants 27 .…”

Does Air Pollution Really Impact the Onset of Spontaneous Pneumothorax? A French Case-Crossover Study

“…The pathophysiology of PSP is actually better understood. The concept of PSP associated with a localised rupture of a bleb, or a bulla has been discussed (Tschopp and Marquette, 2017). The occurrence of PSP could be the result of a diffuse histopathological change in the lung parenchyma under the visceral pleura.…”

Selected Disorders of the Respiratory System

“…Primary spontaneous pneumothorax (PSP) has long thought to occur due to spontaneous rupture of a subpleural bleb (small thin-walled air pockets); however, recent evidence points to diffuse emphysema-like changes of the lung parenchyma as the more likely cause [7]. The classic patient with PSP is a tall, thin male.…”

“…If air evacuation is necessary, needle aspiration and chest drain insertion are both options; however, no consensus guidelines exist on recommended treatment. Recent evidence suggests that needle aspiration is effective for the initial management of PSP [7]. A large pneumothorax or significant symptoms increase the likelihood that simple aspiration will not be sufficient, thus requiring chest tube placement for definitive management [8].…”