Secondary Spontaneous Pneumothorax in Adults

Secondary spontaneous pneumothorax in adults - UpToDate
04/10/2016, 6:02 AM
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Secondary spontaneous pneumothorax in adults

Author: Richard W Light, MD
Section Editor: V Courtney Broaddus, MD
Deputy Editor: Geraldine Finlay, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Mar 31, 2015.
INTRODUCTION A secondary spontaneous pneumothorax (SSP) is defined as a pneumothorax that occurs
as a complication of underlying lung disease [1,2]. In contrast, primary spontaneous pneumothorax occurs
without a precipitating event in the absence of clinical lung disease.
The causes, clinical manifestations, diagnosis, and management of secondary spontaneous pneumothorax will
be reviewed here. Primary spontaneous pneumothorax and catamenial pneumothorax (due to thoracic
endometriosis) are discussed separately. (See "Primary spontaneous pneumothorax in adults" and "Clinical
features, diagnostic approach, and treatment of adults with thoracic endometriosis".)
ETIOLOGIES Nearly every lung disease can be complicated by secondary spontaneous pneumothorax
(SSP), although the most commonly associated diseases are chronic obstructive pulmonary disease, cystic
fibrosis, primary or metastatic lung malignancy, and necrotizing pneumonia (eg, bacterial or fungal pneumonia,
Pneumocystis jirovecii pneumonia, and tuberculosis) [2,3].
Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is the most
common cause of SSP, with 50 to 70 percent of SSP in case series attributed to COPD [2-4]. Rupture of apical
blebs is the usual cause. (See "Chronic obstructive pulmonary disease: Definition, clinical manifestations,
diagnosis, and staging".)
Severity of COPD correlates with the likelihood of developing SSP. As an example, more than 30 percent of
patients with SSP due to COPD have a forced expiratory volume in one second (FEV1) less than one liter and an
FEV1 to forced vital capacity (FEV1/FVC) ratio less than 40 percent [5].
Cystic fibrosis SSP is relatively common in cystic fibrosis (CF). Approximately 3 to 4 percent of all patients
with CF will have an episode of SSP; in those who survive to age 18, the incidence is 16 to 20 percent [6,7]. CFrelated SSP is usually due to rupture of apical subpleural cysts. (See "Cystic fibrosis: Overview of the treatment
of lung disease", section on 'Spontaneous pneumothorax' and "Cystic fibrosis: Clinical manifestations and
diagnosis", section on 'Respiratory tract involvement'.)
The risk of pneumothorax in CF is inversely related to the FEV1. In one report, nearly half of all patients with CF
who had an FEV1 less than 20 percent of predicted experienced at least one SSP [6]. Other factors associated
with an increased risk of pneumothorax included infection with Pseudomonas aeruginosa, Burkholderia cepacia
complex, or Aspergillus species, as well as a prior episode of massive hemoptysis. These factors may reflect
disease severity, rather than being independent risk factors.
Lung malignancy Both primary and metastatic lung malignancy have been associated with SSP. Among 168
patients with SSP, malignancy was the underlying cause in 16 percent; the underlying malignancy was more
commonly primary than metastatic [3]. Potential mechanisms include tumor necrosis and endobronchial
obstruction with air trapping. As COPD often co-exists with lung malignancy, COPD may contribute to the risk of
pneumothorax in these patients.
Necrotizing pneumonia SSP can complicate the course of necrotizing pneumonia due to bacterial infection,
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Pneumocystis jirovecii, tuberculosis, and less often fungi [3]. The relative frequency of these etiologies depends
on the frequency of these diseases in the population.
Bacterial pneumonia SSP has been associated with bacterial pneumonias caused by Staphylococcus,
Klebsiella, Pseudomonas, Streptococcus pneumoniae, and anaerobic organisms. Among 168 patients with SSP,
bacterial pneumonia was the etiology in 11 percent [3]. In this setting, SSP can be associated with extension of
bacterial infection into the pleura and development of empyema.
Pneumocystis jirovecii Among patients with acquired immunodeficiency syndrome (AIDS) who develop
SSP, greater than 80 percent have current or previous P. jirovecii pneumonia (PCP). In the era of potent
antiretroviral therapy (ART), the frequency of pneumothorax complicating PCP is approximately 5 to 10 percent,
although data are limited [8]. The pathogenesis of SSP in PCP is likely alveolar and pleural tissue invasion and
rupture of large subpleural cysts that are caused by tissue necrosis. The clinical presentation, diagnosis, and
management of Pneumocystis pneumonia and pneumothorax are discussed separately. (See "Clinical
presentation and diagnosis of Pneumocystis pulmonary infection in HIV-infected patients" and "Pneumothorax in
HIV-infected patients", section on 'Pneumocystis jirovecii'.)
Tuberculosis SSP occurs in 1 to 3 percent of patients hospitalized with pulmonary tuberculosis [9]. The
pneumothorax is usually due to rupture of a tuberculous cavity into the pleural space. (See "Diagnosis of
pulmonary tuberculosis in HIV-uninfected patients" and "Clinical manifestations and complications of pulmonary
tuberculosis", section on 'Pneumothorax'.)
Catamenial pneumothorax Catamenial pneumothorax refers to a pneumothorax occurring in association
with menses due to thoracic endometriosis and is discussed separately. (See "Clinical features, diagnostic
approach, and treatment of adults with thoracic endometriosis".)
Less common causes Less common causes of SSP include ankylosing spondylitis, asthma, pulmonary
Langerhans cell histiocytosis, interstitial lung disease (eg, idiopathic pulmonary fibrosis),
lymphangioleiomyomatosis, Birt Hogg Dub syndrome, Sjgren's syndrome, Marfan syndrome, metastatic
sarcoma, rheumatoid arthritis, and sarcoidosis [2,10-12]. (See "Clinical manifestations of ankylosing spondylitis
in adults" and "Clinical manifestations, pathologic features, and diagnosis of Langerhans cell histiocytosis" and
"Sporadic lymphangioleiomyomatosis: Epidemiology and pathogenesis" and "Genetics, clinical features, and
diagnosis of Marfan syndrome and related disorders" and "Overview of lung disease associated with rheumatoid
arthritis" and "Clinical manifestations and diagnosis of pulmonary sarcoidosis" and "Birt-Hogg-Dub syndrome".)
CLINICAL FEATURES The clinical presentation of secondary spontaneous pneumothorax (SSP) depends
upon the volume of air in the pleural space, rapidity of onset, tension within the pleural space, and the patient's
age and respiratory reserve.
History Most patients with SSP complain of dyspnea and report chest pain on the same side as the
pneumothorax [13]. Symptoms due to SSP are generally more severe than those associated with primary
spontaneous pneumothorax, presumably because patients with SSP have less pulmonary reserve due to
underlying lung disease. Thus, any impairment of pulmonary function has a more noticeable effect. The intensity
of dyspnea can range from a mild increase over baseline to impending cardiopulmonary failure when a tension
pneumothorax develops. Patients with an infectious cause of SSP may also have cough, fever, chills, or fatigue.
Usually, the patient has a known underlying lung disease, although occasionally the SSP is the presenting
manifestation, as with a malignancy.
Physical examination In patients with a small SSP, physical examination findings may be limited to those of
the underlying lung disease. In contrast, characteristic physical findings of a large pneumothorax include
decreased chest excursion, diminished breath sounds, absent fremitus, and hyperresonance to percussion on
the affected side. Subcutaneous emphysema may be present. Labored breathing and hemodynamic
compromise (eg, tachycardia, hypotension) may suggest a possible tension pneumothorax, which necessitates
emergency decompression. Tracheal deviation from the midline is a rare and typically late finding in
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pneumothorax.
Arterial blood gases Arterial blood gases are typically obtained when a patient demonstrates tachypnea,
accessory muscle use, a pulse oxygen saturation <92 percent, or has a history of hypercapnia. In patients with
SSP, arterial blood gases are frequently abnormal. In one study, the arterial oxygen tension (PaO2) was below 55
mmHg in 17 percent of patients and below 45 mmHg in 4 percent, while the arterial tension of carbon dioxide
(PaCO2) exceeded 50 mmHg in 16 percent and exceeded 60 mmHg in 4 percent [5].
IMAGING AND DIAGNOSIS An upright chest radiograph is typically obtained as part of the evaluation of new
or worsening dyspnea or chest discomfort in a patient with underlying lung disease. The chest radiograph
provides the diagnosis of secondary spontaneous pneumothorax (SSP) with the finding of a visceral pleural line,
which defines the interface of the lung and pleural air (image 1 and image 2). If the diagnosis of SSP is unclear
on the conventional chest radiograph, chest computed tomography is the best modality for determining the
presence, size, and location of intrapleural air. (See "Imaging of pneumothorax", section on 'Chest radiographs'
and "Imaging of pneumothorax", section on 'Computed tomography'.)
Diagnosing pneumothorax in patients with emphysema The diagnosis of a pneumothorax can be
challenging in patients with severe emphysema for the following reasons:
The pleural line may be difficult to visualize because the emphysematous lung appears hyperlucent,
resulting in minimal difference in the radiodensity of the lung and the pneumothorax.
A pneumothorax may be difficult to distinguish from a large, thin-walled, air-containing bulla (image 3). In
general, the pleural line associated with a pneumothorax is convex relative to the lateral chest wall, whereas
the pleural line associated with a large bulla is usually concave relative to the lateral chest wall. The two
conditions can be easily differentiated by computed tomography of the chest [14]. (See "Evaluation and
medical management of giant bullae", section on 'Imaging'.)
Assessing the size of a pneumothorax In addition to confirming the presence of a pneumothorax, the chest
radiograph is used to assess the size of the pneumothorax, which is important for management decisions. The
size of the pneumothorax is generally determined based on the interpleural distance, which is the distance
between the lung margin (visceral pleura) and the chest wall (parietal pleura) at the level of the hilum on a
conventional, upright posterior-anterior chest radiograph [15]. A distance of 2 cm roughly correlates with a 50
percent pneumothorax, which is considered a large pneumothorax [15]. Other methods for estimating the size of
a pneumothorax are described separately. (See "Imaging of pneumothorax", section on 'Size of pneumothorax'.)
TREATMENT Management of secondary spontaneous pneumothorax (SSP) includes supplemental oxygen,
cardiopulmonary stabilization, and removing air from the pleural space, with subsequent management directed at
treating prolonged air leaks and preventing recurrence. In the discussion that follows, we expand upon published
clinical consensus statements [15,16].
Initial management Almost all patients with secondary spontaneous pneumothorax (SSP) should be
hospitalized, because the underlying lung disease increases the risk for an adverse outcome [15,17,18]. An
exception would be stable patients with cystic fibrosis and a small SSP (<1 cm), who may be observed in the
outpatient setting if follow-up and ease of access to health care are good [17].
Supplemental oxygen Supplemental oxygen is administered to virtually all patients with SSP to treat
hypoxemia and facilitate absorption of air from the pleural space [15]. However, the concentration of inspired
oxygen (FiO2) should be increased cautiously in patients who have or are at risk for hypercapnia (eg, moderate
to severe chronic obstructive pulmonary disease [COPD]) [19]. (See "The evaluation, diagnosis, and treatment of
the adult patient with acute hypercapnic respiratory failure", section on 'Titration of oxygen'.)
Indications for pleural drainage The management of SSP is more complicated than that of primary
spontaneous pneumothorax due to the presence of underlying lung disease, which increases the likelihood of
persistent air leakage and further expansion of the pneumothorax. Thus, most patients with a SSP will require
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pleural drainage [15,20].

The following factors are used to determine the necessity for and type of pleural drainage [15]:
For patients who are dyspneic or with a large SSP (pleural line >2 cm from chest wall), prompt drainage by
tube thoracostomy (chest tube placement) is indicated, because of the risk of progressive respiratory
impairment or tension pneumothorax [21]. (See 'Thoracostomy tube size' below and "Placement and
management of thoracostomy tubes".)
For patients with a small SSP (pleural line 1 to 2 cm from chest wall), we typically place a small bore chest
tube in the pleural space for ongoing drainage. However, centers with experience performing needle
aspiration under ultrasound guidance may choose this option. (See 'Tube thoracostomy versus needle
aspiration' below.)
For stable, asymptomatic patients with a very small SSP (pleural line <1 cm from chest wall), we typically
treat with supplemental oxygen and observation for any deterioration in cardiopulmonary status or
enlargement of the pneumothorax; the chest radiograph should be repeated in 12 to 24 hours, or sooner if
symptoms worsen. (See 'Supplemental oxygen' above.)
Tube thoracostomy versus needle aspiration Tube thoracostomy is generally preferred over needle
aspiration for drainage of SSP because it is more likely to be successful [15,22]. In one trial, 28 patients with SSP
were randomly assigned to receive tube thoracostomy and 33 patients to needle aspiration [23]. The tube
thoracostomy group was more likely to have their pleural air completely evacuated than the needle aspiration
group (93 versus 67 percent). The lower success rate of pleural aspiration in SSP than primary spontaneous
pneumothorax may be due to a higher rate of persistent air leakage [24]. The technique of needle aspiration of a
pneumothorax is discussed separately. (See "Primary spontaneous pneumothorax in adults", section on
'Aspiration' and "Placement and management of thoracostomy tubes".)
If the decision is made to proceed with pleural needle aspiration, removal of more than 2.5 L of pleural air
suggests a persistent air leak and is an indication for placement of a thoracostomy tube [15].
Guidance by ultrasound or other imaging Ultrasound or other imaging modalities (eg, fluoroscopy,
computed tomography) are used to guide chest tube placement when the pneumothorax is small (but
symptomatic) or loculated. However, if the patient has impending respiratory failure due to SSP, tube
thoracostomy should not be delayed while waiting for imaging availability. (See "Thoracic ultrasound: Indications,
advantages, and technique", section on 'Identification of pneumothorax' and "Imaging of pleural effusions in
adults", section on 'Computed tomography'.)
Thoracostomy tube size Small bore catheters have advantages over larger tubes in terms of ease of
insertion and patient comfort and also appear to be equally efficacious in most patients in retrospective studies.
One retrospective study included 91 patients, 22 of whom were treated with a large bore (20 to 28 Fr) tube and
69 with a small bore (10 to 14 Fr) tube [25]. Successful treatment was reported in 72 percent of both patient
groups. No significant differences were noted in terms of length of hospital stay, extubation time, recurrence rate,
and complications. In a separate case series that included 114 patients with SSP, placement of a small bore
catheter (12 Fr) was associated with a low (7 percent) overall failure rate and a mean duration of drainage of 4.4
days [26].
One possible exception to the use of small bore tubes for SSP would be patients receiving mechanical
ventilation. The choice is generally made on a case-by-case basis, depending on the severity of the underlying
lung disease and the anticipated rate of air leakage. Traditionally, large bore tubes (24 to 28 Fr) have been used
to decompress pneumothoraces in patients receiving mechanical ventilation, because of concerns about small
bore tubes not being adequate for large volume air leaks during positive pressure ventilation. However, in a
retrospective study of 62 patients with pneumothoraces complicating mechanical ventilation, small bore tubes
were successful in 69 percent of pneumothoraces [27]. In this study, small bore tubes were less likely to be
successful when treating barotrauma-induced pneumothoraces, when compared with pneumothoraces caused
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by lung puncture during procedures such as central line insertion. Thus, patients who are clinically unstable (eg,
tension pneumothorax) or who have barotrauma complicating mechanical ventilation are generally managed with
a 24 to 28 French (Fr) chest tube, due to the increased risk for a large air leak.
Chest tube management The chest tube or catheter should be connected to a water seal device,
generally without application of suction due to the risk of re-expansion pulmonary edema [15]. Failure of the
pneumothorax to resolve should lead to the initiation of suction if it was not initially applied. A Heimlich valve can
also be used, although a water seal device is preferable because it allows monitoring of the rate of air leakage.
(See "Placement and management of thoracostomy tubes", section on 'Drainage system'.)
In general, the chest tube should remain in place until a procedure is performed to prevent recurrent SSP.
However, patients who decline preventive interventions can have their chest tube clamped twelve hours after the
lung has expanded radiographically and no further air leak is detected via the chest tube. A chest radiograph
should be performed 12 to 24 hours after the chest tube is clamped and, if the pneumothorax has not recurred,
the chest tube can be removed. Caution is required in clamping a chest tube, because there is now no egress for
air and, if an air leak resumed, a tension pneumothorax could develop. If the patient should become
symptomatic, the chest tube should be promptly unclamped. However, if the tube is removed the same risks are
present. (See "Placement and management of thoracostomy tubes", section on 'Removal'.)
An alternative approach for stable patients whose lung is at least 90 percent expanded, but who have a
persistent air leak, is to attach a Heimlich valve to the chest tube and discharge the patient to home [28-30]. The
advantage of this regimen is that it allows the patient to avoid a long-term hospitalization. However, a separate
procedure to prevent a recurrent SSP is typically performed in patients who are surgical candidates. (See
'Preventing recurrence' below.)
After initial stabilization After initial stabilization of the SSP, some patients will need an additional
intervention to treat a persistent air leak and most will need a procedure to prevent recurrence (eg, stapling of
blebs, mechanical or chemical pleurodesis) [15]. For those who require an intervention for prolonged air leakage,
the two procedures are typically performed at the same time.
Persistent air leakage Persistent air leaks are more common and tend to persist longer in SSP, compared
to primary spontaneous pneumothorax [31]. Persistent air leaks may be due to subpleural bullae or cysts (eg,
COPD, Pneumocystis pneumonia) or to necrotic lung (eg, pneumonia) [32]. For patients who have a persistent
air leak after three days of tube thoracostomy drainage or failure of the lung to re-expand fully, it becomes
progressively less likely that the leak will close spontaneously and additional interventions may be appropriate
[15,21].
Video-assisted thoracoscopic surgery For surgical candidates with a persistent leak and/or incomplete
lung expansion (<90 percent), the preferred procedure is stapling or resection of blebs and mechanical
pleurodesis via video-assisted thoracoscopic surgery (VATS) or open thoracotomy. As an alternative, VATS
with stapling/resection of blebs and intraoperative chemical pleurodesis can be performed. As pleurodesis is
performed as part of the procedure, the two goals of closure of the air leak and prevention of recurrence are
accomplished with one operation. Additional details of VATS and thoracotomy are discussed below. (See
'Preventing recurrence' below.)
Blood patch or chemical pleurodesis For patients who have a persistent or refractory air leak but are
not candidates for surgery, we suggest bedside application of a blood patch or chemical pleurodesis. A few
case series have described the successful use of a pleural blood patch (also known as blood patch
pleurodesis) for patients with a persistent air leak complicating acute respiratory distress syndrome [33-38].
Blood patch pleurodesis is performed by drawing approximately 100 mL of the patient's venous blood
without anticoagulants under sterile conditions and instilling it immediately into the pleural space through the
chest tube. One review of ten observational studies that utilized the blood patch technique reported
successful cessation of the air leak 92 percent of patients [38]. However, another report suggested that
empyema was a significant complication in 9 percent of patients treated with this modality [36].
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Chemical pleurodesis via the chest tube with a tetracycline derivative or size-calibrated talc is another option
for management of a persistent air leak, although success is much lower than with VATS. The technique is
discussed separately. (See "Chemical pleurodesis", section on 'Technique'.)
Conservative management Some patients with severe underlying lung disease who are poor surgical
candidates may prefer a longer period of conservative management with supplemental oxygen and chest
tube drainage. Spontaneous resolution has been described with conservative management after as long as
14 days [15,20].
Preventing recurrence Once the patient has been stabilized and initial drainage of pleural air established,
we advocate performing an intervention to prevent recurrence in almost all patients treated for an initial SSP [15].
This advice is based on the observation that recurrence of SSP is common and frequently life-threatening. One
study reported a 50 percent likelihood of recurrent SSP over three years among patients with a SSP due to
COPD, who did not have an intervention to prevent recurrence [5].
As noted above, for patients with a persistent air leak, an intervention to control the leak and prevent recurrence
(pleurodesis) is performed within a few (eg, three to five) days of hospitalization [15]. For patients with full reexpansion and no evidence of persistent air leak, surgery to prevent recurrence is typically performed during the
same hospitalization prior to removal of the chest tube, because SSP tends to recur relatively early.
The three main options are thoracotomy, video-assisted thoracoscopic surgery (VATS), and chemical
pleurodesis. The decision among these options depends on the preferences of the surgical team and whether
the patient is an operative candidate at present or a lung transplant candidate in the future. (See 'Lung transplant
candidates' below.)
Surgical options Meta-analyses comparing open thoracotomy with VATS have shown lower recurrence
rates with open procedures (approximately 1 percent with open versus 5 percent with VATS), but with
greater blood loss, more postoperative pain, and longer hospital stays [15,39,40]. Due to the potential for
lower morbidity, VATS with stapling of blebs followed by obliteration of the pleural space is the preferred
intervention in most patients [15,41,42].
Several methods are available for obliteration of the pleural space, including pleural abrasion with dry gauze
[43], apical pleurectomy [44], intraoperative insufflation of talc [45], and laser abrasion of the parietal pleura
[46,47]. We prefer mechanical pleurodesis, using pleural abrasion with gauze, because it is effective and
simple to perform.
For surgical candidates who have a persistent air leak, the optimal surgical techniques to ensure closure of
the air leak(s) are uncertain. Most surgeons recommend stapling of blebs, because recurrence rates are
substantially higher if the blebs are not closed [48,49]. In contrast, in one study of patients with AIDS-related
pulmonary infections, VATS-directed insufflation of talc was reported to be successful in seven out of eight
patients without treatment directed to the site of the air leak [50].
For patients with emphysema who meet inclusion and exclusion criteria for lung volume reduction surgery
(LVRS), it may be appropriate to perform LVRS at the time of surgical pleurodesis. (See "Lung volume
reduction surgery in COPD", section on 'Patient selection'.)
Nonsurgical chemical pleurodesis For patients who refuse VATS or are not operative candidates, we
suggest chemical pleurodesis, rather than no further intervention [15]. However, this technique is not as
effective as the VATS with pleurodesis procedure described above [5,51]. Chemical pleurodesis
administered via the chest tube reduces the SSP recurrence rate from 40 to 50 percent to approximately 15
percent [5,15,52]. It is performed by instilling a sclerosant into the pleural space. Although the choice of a
sclerosant is controversial, we prefer doxycycline over talc, because we believe it is the safer option [53-55].
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The usual intrapleural dose of doxycycline is 500 mg. Technical aspects of chemical pleurodesis are
discussed in detail elsewhere. (See "Chemical pleurodesis" and "Talc pleurodesis".)
Lung transplant candidates For lung transplant candidates, we avoid chemical pleurodesis [56].
Chemical pleurodesis increases the risk of excessive bleeding during transplantation, although it does not
preclude future lung transplantation [15]. Instead, VATS-directed mechanical abrasion of the apical pleural
surface is performed to achieve apical pleurodesis. This partial pleurodesis usually prevents large
pneumothoraces without creating full pleurodesis. (See "Lung transplantation: General guidelines for recipient
selection", section on 'Previous cardiothoracic surgery'.)
Air travel The optimal length of time to wait after resolution of a secondary pneumothorax before travelling
by air is not known. The type of treatment the patient received (eg, simple drainage versus pleurodesis) likely
influences the risk of recurrence during air travel, although this has not been studied. In general, air travel is
postponed for at least two weeks following radiographic resolution of a spontaneous pneumothorax. (See
"Pneumothorax and air travel", section on 'Disease-specific management'.)
Patients should be assessed for potential in-flight hypoxemia and supplemental oxygen supplied when
necessary. (See "Traveling with oxygen aboard commercial air carriers", section on 'Screening for in-flight
hypoxemia'.)
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Basics topics (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")
SUMMARY AND RECOMMENDATIONS
Etiologies and clinical features
A secondary spontaneous pneumothorax (SSP) is a pneumothorax that occurs as a complication of
underlying lung disease, most commonly chronic obstructive pulmonary disease (COPD). (See 'Introduction'
above and 'Etiologies' above.)
Patients with SSP usually complain of dyspnea and also chest pain on the same side as the pneumothorax.
(See 'Clinical features' above.)
The diagnosis of SSP is established by detection of a visceral pleural line on the chest radiograph of a
patient with underlying lung disease. If the diagnosis is unclear based on a conventional chest radiograph
(eg, due to underlying bullae, emphysema), chest computed tomography (CT) is obtained for clarification.
(See 'Imaging and diagnosis' above.)
The size of the pneumothorax is estimated on the chest radiograph based on the distance between the
visceral pleural line and the chest wall at the level of the hilum. A pneumothorax is considered large if the
pleural line is more than 2 cm from the chest wall. (See 'Imaging and diagnosis' above.)
Initial management
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We advise initial hospitalization of all patients with SSP because the underlying lung disease increases the
risk for an adverse outcome. (See 'Treatment' above.)
Clinically unstable patients with SSP require a chest tube regardless of the size of the pneumothorax. (See
'Initial management' above.)
For clinically stable patients with a large SSP (pleural line >2 cm from chest wall), we recommend insertion
of a chest tube, rather than observation or simple aspiration, regardless of the presence of symptoms
(Grade 1B). This recommendation is based on the risk of rapid progression to respiratory failure or tension
pneumothorax in these patients. (See 'Initial management' above.)
For patients with a small pneumothorax (pleural line 1 to 2 cm from chest wall) and are minimally
breathless, we suggest drainage of pleural air, rather than observation (Grade 2B). In the setting of SSP,
placement of a small bore catheter (10 to 14 Fr) is generally preferred over needle aspiration. (See 'Initial
management' above.)
For clinically stable, asymptomatic patients with a very small SSP (pleural line <1 cm from chest wall), close
observation may be an acceptable alternative to immediate pleural drainage. Onset of symptoms or an
enlarging pneumothorax would be indications for pleural drainage. (See 'Initial management' above.)
We believe that patients who are clinically unstable or who may have a large air leak (eg, patients with
barotrauma due to mechanical ventilation) are best managed with a 24 to 28 French (Fr) chest tube. For the
majority of other patients who require pleural drainage, a 10 to 14 Fr chest tube should be sufficient. (See
'Initial management' above.)
When managing SSP, the chest tube is usually connected to a water seal device, rather than to a Heimlich
valve. Suction is usually NOT applied to the chest tube initially, but should be applied if the pneumothorax
fails to resolve. (See 'Initial management' above.)
For surgical candidates who have an air leak that persists for more than three days, we suggest video
assisted thoracoscopy (VATS) with stapling or resection of blebs and pleurodesis, rather than ongoing
management with a chest tube (Grade 2B). Alternative approaches for patients who are not surgical
candidates include the performance of a blood patch, chemical pleurodesis through the chest tube, or a
longer period of pleural drainage. (See 'Persistent air leakage' above.)
Preventing recurrence
We recommend that patients undergo a preventive intervention after their initial SSP, rather than waiting for
a second SSP (Grade 1B). For recurrence prevention, we recommend thoracotomy or VATS with stapling of
blebs and pleural abrasion, rather than nonsurgical chemical pleurodesis via the chest tube (Grade 1B).
Thoracotomy is associated with a slightly lower rate of recurrence than VATS, but greater initial morbidity.
(See 'Preventing recurrence' above.)
For patients who are not operative candidates or who refuse VATS, we recommend chemical pleurodesis via
the chest tube, rather than forgoing an intervention (Grade 1B). (See 'Preventing recurrence' above.)
For potential lung transplant candidates, the preferred procedure is VATS-directed mechanical abrasion of
the apical pleural surface to achieve apical pleurodesis without generalized pleurodesis (Grade 2C). (See
'Lung transplant candidates' above.)
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Topic 6691 Version 14.0
Page 11 of 15
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GRAPHICS
Chest radiograph of a pneumothorax after stab wound
This plain chest radiograph shows a left apicolateral pneumothorax with

typical convex white visceral pleural line (yellow arrows).
Courtesy of Paul Stark, MD.
Graphic 56589 Version 5.0
Normal chest radiograph
Posteroanterior view of a normal chest radiograph.

Courtesy of Carol M Black, MD.
Page 12 of 15
04/10/2016, 6:02 AM
Chest radiograph of an atypical pneumothorax
Left inferolateral atypical pneumothorax in patient with emphysema and pleural

adhesions. Left panel: Chest radiograph shows left basilar collection of pleural gas
with concave visceral pleural edge toward the chest wall. At first glance, this
resembles a bulla. Right panel: After drainage of the pneumothorax, no evidence of a
bulla is seen.
Normal chest radiograph
Posteroanterior view of a normal chest radiograph.

Courtesy of Carol M Black, MD.
Page 13 of 15
04/10/2016, 6:02 AM
Chest radiograph of a giant bilateral bullae in young

smoker
Chest radiograph shows large bilateral collections of gas devoid of any

vascular structures with a sharp edge concave laterally, which is a
differentiating feature from pneumothorax. The functioning lung is retracted
to the bases.
Page 14 of 15
04/10/2016, 6:02 AM
Contributor Disclosures
Richard W Light, MD Consultant/Advisory Boards: Care Fusion [Pleural eusions (Tunneled pleural
catheter)]. V Courtney Broaddus, MD Nothing to disclose Geraldine Finlay, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy
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