Pneumothorax—Time for New Guidelines?

Abstract

Pneumothorax is a common pathology, but optimal management strategies are not yet defined. There are significant differences in international guidelines and therefore variation in clinical practice.There is increasing interest in pneumothorax research, particularly primary spontaneous pneumothorax (PSP), with evidence of lung abnormalities in this group without clinically apparent lung disease and recently completed clinical trials aiming to optimize management. The most robust evidence base is that of the equivalence of needle aspiration and chest tube insertion for initial management of PSP; although, patients with secondary spontaneous pneumothorax may also benefit. A convincing case for surgical intervention or thoracoscopy and talc poudrage to prevent recurrence at first episode in PSP has yet to be made. Clinicians should be vigilant for PSP being the first manifestation of a systemic disease, and should have a low threshold for onward referral. Time to change guidelines? First, chest tube drainage and hospitalization without recurrence prevention should no longer be standard treatment, as this has no advantage over the less invasive manual aspiration, which moreover can be performed on an outpatient basis in an important number of patients. The results of recent trials in conservative and ambulatory management are eagerly awaited. Second, shared decision-making should become more important with the well-informed patient, who may want to avoid a 1 in 3 recurrence rate and therefore will have the possibility to choose treatment including recurrence prevention even after the first episode of PSP. Third, surgical research should urgently make clear if the current practice of resection of emphysema-like changes is routinely necessary, alongside pleurodesis. Future studies should utilize risk stratification by clinical and radiological parameters (e.g., high-resolution computed tomography scanning and digital air leak monitoring) to predict short- and long-term outcomes, and hence personalize management.

Spontaneous pneumomediastinum, pneumothorax and subcutaneous emphysema in critically ill COVID-19 patients: A systematic review

“…The ongoing use of ventilation strategies to protect the lungs and interventions to prevent secondary bacterial infections will also be helpful. 30 …”

“…The ongoing use of ventilation strategies to protect the lungs and interventions to prevent secondary bacterial infections will also be helpful. 30 The present systematic review is the largest study that analyzes the results from reports on cases of pneumothorax, pneumomediastinum, and subcutaneous emphysema cited in case report or case series studies on COVID-19 that include non-ventilated patients as well. Limitations: There were several limitations in the present study.…”

The Natural History and Treatment of Cardiac Implantable Electronic Device Associated Pneumothorax—A 10-Year Single-Centre Experience

“…Furthermore, variation exists in guidelines and consensus statements, including the definition of what constitutes a severe pneumothorax. 7 Knowledge of the appropriate treatment of this condition is important given the consequences of chest tube insertion. 8 In response to the heterogeneity of management strategies, a recent multicentre, open-label, randomized trial was undertaken to evaluate an initial conservative strategy vs invasive (with chest tube) management of patients with primary spontaneous pneumothorax.…”

Risk factors related to the recurrence of pneumothorax in patients with emphysema

“…Hence, followup of the patients who underwent suboptimal treatment is very important. However, no standardized strategies have been established regarding the observation protocols and periodic examinations for the prevention of recurrent pneumothorax in such patients (8). According to the previous guidelines, patients with SSP should be followed up by a respiratory physician to evaluate and manage the underlying lung disease (11).…”

“…The most common underlying structural lung disease, which leads to SSP, is chronic obstructive pulmonary disease (COPD), followed by interstitial lung disease (ILD), malignancy, tuberculosis, cystic fibrosis, and necrotizing pneumonia (6)(7)(8). Compared with PSP, SSP is more closely associated with higher morbidity, mortality, and recurrence rates, because of the aforementioned advanced age and underlying structural lung diseases (9,10).…”