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StayCurrentMD
Spontaneous Pneumothorax
With Dr. Dan Ostlie · hosted by Dr. Alexander Gibbons & Dr. Todd Ponsky
Chapter 1 of 9 · Case-Based Learning
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Introduction and Case Presentation
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Primary spontaneous pneumothorax is more common in males by approximately 3 to 1.
In a multi-institutional retrospective study of 81 patients from three institutions over 13 years, chest tubes worked approximately 50% of the time for primary spontaneous pneumothorax.
Patients who receive chest tube treatment and resolve have approximately 50% failure rate (recurrence requiring reoperation).
Patients who fail chest tube management in hospital and subsequently undergo VATS have a failure rate of 25-30%.
Patients who undergo immediate VATS have a failure rate of 10-15%.
The Society of Thoracic Surgery recommends primary aspiration for spontaneous pneumothorax in adult patients.
In most large studies of primary spontaneous pneumothorax, the mean age is around 20-22 years, making this primarily a young adult disease.
The average age in pediatric spontaneous pneumothorax studies has been 15.5-16 years.
There is no published documentation of tension physiology occurring with spontaneous pneumothorax.
In the 81-patient retrospective study across three institutions over 13 years, no patients presented with tension physiology from spontaneous pneumothorax.
In the Midwest Consortium prospective study of 33 patients from 9 institutions over 2 years, 50% of patients failed initial aspiration (had recurrent pneumothorax within 6 hours).
Of the 17 patients who failed aspiration, 12 were managed with chest tubes; 83% of those chest tube patients ultimately failed (persistent air leak requiring VATS or recurrent pneumothorax).
Of the 5 patients who failed aspiration and went directly to VATS, none had recurrence.
Of the 16 patients who passed aspiration and went home, 40% returned with recurrent pneumothorax.
The positive predictive value of aspiration for successful treatment is 83%, with a negative predictive value of 56%.
If immediate VATS were performed on all patients, approximately 25-30% would receive an unnecessary operation (those who would have done well with aspiration alone).
Current recommended algorithm: all patients receive initial aspiration; if pneumothorax recurs within 6 hours, proceed directly to VATS rather than chest tube management.
In the three-institution retrospective study, patients who underwent pleurodesis at VATS had the same recurrence rate as those who underwent VATS without pleurodesis.
A Chinese randomized trial of 289 patients (average age 22) comparing wedge resection with versus without mechanical pleurodesis showed identical recurrence rates between groups.
The Chinese pleurodesis study used standardized mechanical pleurodesis with sandpaper, abrading the parietal pleura at the apex until bleeding in all cases.
There is no large study evidence that chemical pleurodesis reduces recurrence rates at initial VATS for spontaneous pneumothorax.
CT scans may identify blebs that are incidental findings in patients who never develop pneumothorax, potentially leading to overtreatment of clinically irrelevant findings.
For patients who fail initial VATS, thoracoscopic pleurectomy (stripping parietal pleura from apex down to a couple ribs above the diaphragm) is a salvage option.
Thoracoscopic pleurectomy is an arduous, bloody operation that is extremely painful, typically requiring epidural analgesia and 7-10 day hospitalization.
Aerosolized talc delivered via cannister through a trocar site is an alternative salvage option for recurrent failures after VATS.
For small apical pneumothorax (2cm) after VATS with pleurodesis where the lung is adherent and patient is asymptomatic, observation with repeat chest X-ray in 48 hours is appropriate rather than reintervention.
By the time patients present to hospital with spontaneous pneumothorax, the hole in the lung has probably already closed and they are not actively leaking.
Talc pleurodesis creates a treacherous reoperative field, making subsequent chest operations extremely difficult.