*Controversies in Pneumothorax Treatment DOI: http://dx.doi.org/10.5772/intechopen.87141*

*Pneumothorax*

routine use has been recommended by the National Institute for Health and Clinical Excellence (NICE) after VATS pulmonary resections [70]. For how long should we leave the drain? One day, 1 week or more? Some believe (including the author) that if the drain is not serving its purpose, it should be removed. It is our practice to remove the drain the day following the surgery, provided the digital drain registers absence of air leak and the lung is fully expanded on the chest X-ray. The backdrop of such an approach is to accept reinsertion of the drain in a minority of patients when we get it wrong. The patient is allowed home after a normal chest X-ray has followed the drain removal. Others are more conservative and of the opinion that for the pleurodesis to succeed, the drain should remain in situ 3–7 days. We tend to send patients home with a Heimlich valve (flutter bag) if air leak persists more than 3 days and follow them weekly in the outpatient clinic. There are no RCTs to compare drain dwell times, and therefore general rules apply. In the absence of air leak while suction is off, and the lung is fully expanded on the chest X-ray the drain could safely

be removed, otherwise; recurrence of pneumothorax is guaranteed.

washed away by the reactive effusion, resulting in treatment failure.

and institutions manage chest drains differently" [76].

**6. Pneumothorax and pregnancy**

From the above discussion, it is safe to conclude and agree with Lim that "No single aspect of postoperative care in general thoracic surgery is subject to more variation than the management of chest drains, … yet almost all thoracic surgeons

Spontaneous pneumothorax during pregnancy is rare but not unusual [77, 78]. Notoriously pneumothorax recurs during pregnancy and poses risks to the mother

There is a general consensus that drains should never be clamped [10, 71]. However, some of us do clamp drains and send patients to the radiology department for a chest X-ray, in preparation for removing the drain *despite* the air leak. It must be emphasised that this management should remain selective. This "provocative" approach in removing the drain despite air leak was described before by Kirschner et al. and Cerfolio et al. [72, 73]. If the chest X-ray shows the lung stuck to the chest wall after 2 weeks of tube time, we clamp the tube and send the patient for another X-ray. If the patient is clinically well and there is no change in lung expansion, then the drain is safely removed without bothering to close the drain site, which is usually either infected or has necrotic margins that take stitches badly. A pressure dressing is all that is needed. The stuck lung does not collapse, and the drain site closes in a week or two by secondary intention. The patient has to be reassured about the hissing sound through the drain site, which stops within a week or so. To complicate matters further, air could entrain back into the chest at the time of drain removal. This usually leads to a small residual pneumothorax, which does not expand on subsequent radiological examination. It is important to realise the difference between erroneous drain removal and recurrence of genuine air leak. The incidence of this complication is technique-dependant and proportional to the experience of the staff member allocated for this task. Instructions given to the patient at the time of removing the drain are crucial. Again RCT about removing chest drains on full inspiration, full expiration, mid inspiration or Valsalva manoeuvre found no statistical difference, and therefore no evidence-based practice could be extrapolated [73, 74]. The rate of absorption of air in the chest is roughly 1–2% of the volume of the hemithorax every 24 hours, and complete re-expansion usually takes 2–7 weeks [75]. However, this might be too late for pleurodesis. By that time the parietal pleura (in the case of pleurectomy) would have healed, and the partially collapsed lung would not stick to the chest wall. Likewise, pleurodesing agents might be diluted or

**62**

and foetus during labour. In addition, exposure to radiation of the X-rays in the first trimester is tied to foetal deformities and abnormalities. There is no unified evidence-based practice to guide management in this scenario. Historically it was managed by intercostal drainage for the rest of the pregnancy duration, thoracotomy at any stage, premature induction of labour or caesarean section. The clinician must be aware that even in the first trimester, the diaphragm moves cephalad approximately 4 cm. The classical landmarks for drain insertion do not apply.

The most contemporary recommendation of management is a conservative approach. Expectant management is recommended if the mother is not dyspnoeic and there is no foetal distress and the pneumothorax on the chest X-ray is not significant (<2 cm). Symptomatic mothers could have needle aspiration or drain insertion to resolve the pneumothorax. There is no consensus as what to do with non-resolving pneumothorax, but in our centre, we tend to assess the risk in conjunction with the obstetrician's advice and perform a VATS bullectomy and partial parietal pleurectomy. This is safe in the first trimester but should be avoided after that.

With regard to advice to the risk during labour, we adopt the one given by Lal et al. and the BTS guidelines [10, 79]. Elective-assisted delivery (forceps or ventouse extraction) at or near term is recommended, with regional (epidural) anaesthesia. Less maternal effort is required with forceps delivery, which theoretically reduces the chance of recurrence. Close cooperation between the respiratory physician, obstetrician and thoracic surgeon is essential, requiring delivery to be undertaken in a tertiary referral centre with all three specialties under one roof. If a caesarean section is unavoidable, then a spinal anaesthetic is preferable to a general anaesthetic. To avoid desaturation and tension during general anaesthesia, a prophylactic intercostal drain could be considered as a safety measure. It is advisable that the mother should undergo elective VATS procedure after convalescence due to the risk of recurrence in subsequent pregnancies.
