Primary spontaneous pneumothorax is an abnormal accumulation of air in the space between the lungs and the chest cavity (called the pleural space) that can result in the partial or complete collapse of a lung. This type of pneumothorax is described as primary because it occurs in the absence of lung disease such as emphysema. Spontaneous means the pneumothorax was not caused by an injury such as a rib fracture. Primary spontaneous pneumothorax is likely due to the formation of small sacs of air (blebs) in lung tissue that rupture, causing air to leak into the pleural space. Air in the pleural space creates pressure on the lung and can lead to its collapse. A person with this condition may feel chest pain on the side of the collapsed lung and shortness of breath. Blebs may be present on an individual's lung (or lungs) for a long time before they rupture. Many things can cause a bleb to rupture, such as changes in air pressure or a very sudden deep breath. Often, people who experience a primary spontaneous pneumothorax have no prior sign of illness; the blebs themselves typically do not cause any symptoms and are visible only on medical imaging. Affected individuals may have one bleb to more than thirty blebs. Once a bleb ruptures and causes a pneumothorax, there is an estimated 13 to 60 percent chance that the condition will recur.

1. SPONTANEOUS
PNEUMOTHORAX

2. Directed by
DR.Karar .A.Ali
kararbenign@gmail.com

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12. • After the first episode of PSP, recurrence varies,
ranging from 16% to 54%. Most studies indicate an
average of 30%.14,15 Recent research indicates that the
presence of subpleural blebs on high-resolution CT
confers a recurrence risk of up to 68.1%, whereas the
absence of blebs carries a recurrence risk of only 6.1%.16
Most recurrences develop between 6 months and 2 years
after the initial episode.15 Men who are tall and have a
history of smoking are at the greatest risk of recurrence.
Counseling for smoking cessation should be strongly
encouraged.15 After the second episode of PSP, the likelihood
of recurrence increases markedly and can reach as
high as 83%

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14. • A giant bulla mimicking pneumothorax on a radiograph in a 67-year-old man. He has
chronic obstructive pulmonary disease and a cigarette smoking habit. a A giant bulla
appears as an oval radiolucency (black arrows) in the right lung apex on an erect
radiograph. It resembles pneumothorax in the apicolateral space. Bullous emphysema
exists in both lungs, and a large bulla is observed in the left lung apex (arrowhead). b A
coronal CT image reveals a giant bulla (black arrows) in the right lung apex. A large bulla
(black arrowhead) also exists in the left lung apex in addition to bullous changes in both
lungs

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16. • Learning points
• Bullous emphysema is typically seen in patients with chronic obstructive
pulmonary disease, and when bullae occupy more than 30% of hemithorax,
they are called ‘giant bullae.’2
• Giant bullae can mimic pneumothorax and a CT scan is required in such
cases to avoid misdiagnosis and unnecessary procedures.
• An important differentiating factor between these two entities on imaging
is that the lung collapses towards the ipsilateral hilum unless there are
adhesions in case of pneumothorax, while the lung is draped around the
bulla with the giant pulmonary bulla.3

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18. • Observation
Small pneumothoraces are those that are less than 3 cm
in distance between the apical parietal pleura and the
thoracic cupula, with no lateral component. Asymptomatic patients
should be managed expectantly26-28 by close
monitoring, physical examination, continuous pulse
oximetry, and repeated chest radiography within 3 to 6
hours.

19. • Residual apical
pleural space was
determined by
measuring the
lung apex-to-
cupola distance
(double-headed
arrow), which is
the vertical
distance from the
1st costovertebral
joint to the tip of
apical lung.

20. • The ACCP recommends against the placement of
chest tubes, or aspiration of small pneumothoraces. Our
practice is to monitor patients in the hospital for a
minimum of 24 hours. Even though some patients with
stable radiographic features may be discharged from the
hospital with follow-up within 12 to 24 hours,16,26 the
potential for catastrophic consequences from a missed
tension pneumothorax is a great risk.29 Small
pneumothoraces usually resolve without intervention, but
recurrence is possible. If chest radiography reveals that
the SP is enlarging, immediate intervention is crucial

21. • Aspiration
Aspiration allows evacuation of pleural air and complete
reexpansion of the lung. This technique can be applied
even for larger pneumothoraces if the patient is stable.
We prefer the Seldinger technique,30,31 which uses a
small, single-lumen central line placed over the superior
rib edge in the second interspace in the midclavicular
line. A three-way stopcock and large syringe are used to
aspirate until resistance is felt, usually signifying full lung
expansion. Chest radiography is then performed to
confirm the findings, and the catheter is removed.27,28,32-36
Commercially prepared kits with one-way valves (Heimlich valve)7 allow air to exit but
prevent air entry. These
valves can be left in place until full lung expansion is
achieved. For more rapid resolution, however, it is our
preference to perform tube thoracostomy with a small
chest tube. Complications of aspiration, although rare,
may include bleeding and possible lung injury. Reported
success is higher in resolving PSP (66% to 83%) than for
SSP (37%).27,35 SP that does not respond successfully to
aspiration requires tube thoracostomy

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24. • Tube Thoracostomy
Tube thoracostomy is recommended for patients with
large or symptomatic SP and for most patients with SSPs.
Patients with signs of a tension pneumothorax should be
treated without hesitation, even before chest radiography
is performed. Tube placement is through the fifth intercostal
space in the midaxillary line. In our experience, as
with chest tubes placed through port sites following
VATS, there is no need to tunnel chest tubes placed at
bedside

25. • A small chest tube can be difficult to direct to the apex
of the chest, so a 28 Fr is preferable. The chest tube is
left in place for 24 to 48 hours. Our practice is to place
the chest tube on water seal once lung expansion has been
confirmed. If an air leak persists and nonoperative management is
preferred, a Heimlich valve can be placed
The patient can then be discharged for outpatient
management. The efficacy of suction is debated, but
there is no evidence that it speeds the resolution of SP.
If it is used, it should be used judiciously.37
• Tube thoracostomy successfully resolves PSP in approximately 90%
of patients for the first occurrence, 50% for the first
recurrence, and 15% after a second recurrence.38 For
this reason, definitive management of SP recurrences
will require either surgical intervention or chemical
pleurodesis.

26. • Pleurodesis
After tube thoracostomy, chemical pleurodesis may
help
prevent SP recurrence. Sclerosing agents are instilled to
create pleural symphysis. The most commonly used
agents are sterile talc slurry and doxycycline solution.
Because adult respiratory distress syndrome may be
triggered by high doses of talc, use should be limited to

27. • In theory, talc has the potential to induce malignant
transformation after decades of use, but thus far, this
has not been demonstrated in humans.41 Nonetheless,
our agent of preference is doxycycline to sclerose benign
pleural processes. A total of 500 mg of doxycycline combined
with lidocaine is infused through the chest tube,
and the patient’s position is shifted from side to side to
distribute the sclerosant. Suction is then placed for 48
hours. Recurrence of SP in patients treated with bedside
pleurodesis is high, ranging from 8% to 40%.40,42,43 In our
institution, this treatment is reserved for patients who are
not considered good operative candidates, most commonly
patients with SSP.

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29. • Surgery
Surgical indications for PSP are recurrence, large or persistent
air leaks, and incomplete lung expansion after tube
thoracostomy. Other surgical indications include patients
with a history of bilateral SP and patients in occupations
that would place them at high risk if a pneumothorax
recurred, such as commercial pilots and professional
scuba divers.19,26,37,38 Although some thoracic surgeons
recommend surgery in patients with a first-time PSP if
bullae are detected on CT scan,22 we think that this strategy
is highly aggressive, unnecessary, and unproven; thus
we do not incorporate this practice into our treatment
strategies.

30. • VATS is the surgical procedure of choice for SP,
replacing the previous procedure, axillary thoracotomy.44,45 The
goals of surgery are resection of the offending bulla, complete
lung expansion, and pleurodesis to
prevent recurrence. A standard three-port VATS technique is used
with lung isolation through a double-lumen
endotracheal tube. The entire lung is carefully inspected,
with particular attention to the apex and superior segments,
because these are typical bullae locations. Saline
flooding of the hemithorax during gentle lung inflation
can help locate a ruptured bleb. Some surgeons resect the
apex of the lung even if no bleb is located, although our
practice is to perform lung resection only when a bleb is
identified (Fig. 27-1). Buttressed staple lines are not necessary
with otherwise normal lung parenchyma

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33. • Intraoperative pleurodesis should be performed in
addition to blebectomy. Mechanical pleurodesis is our
most common method and is performed with use of a
Bovie scratch pad with aggressive abrasion of the parietal
pleura (Fig. 27-2). It is our practice to infuse doxycycline
as an additional chemical sclerosant, although some
surgeons choose to infuse talc at the time of surgery with
good results and minimal impairment of pulmonary
function over time.46,47 This is in spite of a recent study out
of Korea suggesting that there is no difference in recurrence
with mechanical pleurodesis following bleb
resection

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35. • Another effective method of obtaining pleural symphysis is parietal
pleurectomy, by either VATS or open
techniques. Results are similar to those of mechanical
abrasion.49,50 Surgeons should make every effort to control
air leak before leaving the operating room. Apical chest
tube placement is crucial to full lung expansion. Postoperatively, chest tubes
are placed to water seal as soon as a chest x-ray demonstrates full
expansion, and no air leak
is present. VATS successfully resolves SP and prevents
recurrence in more than 90% of patients.51 Whereas
some studies show that recurrence of SP is slightly higher
with VATS compared with thoracotomy, this small increment does not
justify the discomfort and lost work days
in this generally young population.52 Thoracotomy is
reserved for VATS failures and complex giant bleb resections not
amenable to VATS.

36. • SPECIAL CONSIDERATIONS
Secondary Spontaneous Pneumothorax
Clinical presentation of SSP is similar to that of PSP;
however, dyspnea and respiratory compromise are often
more profound, given the presence of underlying lung disease, even with small
pneumothoraces. In this setting,
intervention should be performed quickly with tube thoracostomy. Major causes of SSP are
COPD with bleb
rupture followed by Pneumocystis infection in patients with
HIV infection, asthma, cystic fibrosis, necrotizing pneumonia, or tuberculosis. Less common
causes are idiopathic pulmonary fibrosis, Langerhans cell histiocytosis,
lung cancer, lymphangioleiomyomatosis, sarcoidosis, and
catamenial pneumothorax.12 SP in patients with COPD
portends poor long-term prognosis.53 Management strategies must be tailored to the
individual patient. Operative
risk in a markedly compromised patient must be weighed
against the potential morbidity and prolonged hospital
course that can accompany nonoperative intervention.
We have found Heimlich valves particularly valuable in
managing patients with prolonged air leak because they
allow easy ambulation and outpatient management.

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39. • Catamenial pneumothorax in a 40-year old woman. (a) Posteroanterior
radiograph shows a right-sided pneumothorax (arrows). (b) Image
obtained at video-assisted thoracoscopic surgery shows round brown
endometrial implants (arrows) on the right hemidiaphragm.

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42. • Conclusions: Catamenial pneumothorax may be suspected in ovulating women with
spontaneous pneumothorax, even in the absence of symptoms associated with pelvic
endometriosis. During video-assisted thoracoscopic surgery, inspection of the dia-
phragmatic surface is paramount. Plication of the involved area alone can be
successful. In complicated cases, hormonal suppression therapy is a helpful adjunct.

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45. • Patient 2
In December 2001, a healthy 32-year-old woman, gravida 0,
had two right-sided spontaneous pneumothoraces and was
treated with a medical talcum pleurodesis. During VATS
after a second recurrence in May 2002, no lesions were
found. We performed an apical pleurectomy down to the
seventh rib. After another recurrence that coincided with her
menses in August 2002, we discovered during reexploration
several perforations in the centrum tendineum of the dia-
phragm, associated with purple nodules. Through a minitho-
racotomy, we excised a perforation with the adjacent nod-
ule, reinforced the perforated portion with a double running
suture, and performed a talcage. Histologic examination
confirmed an endometrial implant (Figure 2). After release,
she had a recurrence in October 2002. To explore the extent
of a possible abdominal endometriosis, we undertook a
rethoracoscopy in combination with laparoscopy. The in-
trathoracic findings were inconclusive, although we did not
mobilize the whole basal portion of the lung. Laparoscopic
exploration confirmed the suspicion of disseminated pelvic
endometriosis. After recovery, luteinizing hormone–releas- ing hormone analog therapy was
started, and the patient has
been symptom free for 17 months.

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