*Indications of Surgery in Pneumothorax DOI: http://dx.doi.org/10.5772/intechopen.88640*

*Pneumothorax*

**4**

pneumothorax.

**Figure 1.**

alone may be appropriate.

chest drain for drainage which is very frequently painful even with using generous local anaesthesia. These experiences usually form a painful memory scar for the patients and their parents which they would not like to experience again if the

**Figure 1** shows a flowchart summary recommended by the author for the different published guidelines for indications of intervention in primary spontaneous

In recent years there has been a trend towards a more conservative approach to management of primary spontaneous pneumothorax, based on the principle that intrapleural air does not necessarily require a therapeutic intervention and that management depends on the clinical symptoms and not on the size of the pneumothorax [20]. This conservative approach may be appropriate as tension pneumothorax from a PSP is extremely rare [21]. In selected patients with minimal or no symptoms and good access to medical care in case of deterioration, observation

**4. Guidelines for management of first-attack pneumothorax**

*Simple flowchart summary for management of primary spontaneous pneumothorax.*

intervention to treat it carries a very low risk.

Within the current British Thoracic Society guidelines (from 2010), there is a significant emphasis on a conservative approach to treatment [5] with management predominantly based on clinical symptoms. In contrast, the American College of Chest Physicians Delphi consensus statement (from 2001) recommended a more aggressive approach, with intercostal drain placement recommended in any pneumothorax larger than 20% of the hemithorax, irrespective of the symptoms [7].

Patients with an attack of tension pneumothorax (quite rare in PSP) and more commonly patients with a first attack associated with complete lung collapse should be counselled about the benefits of definitive intervention with VATS due to the life-threatening condition of a tension pneumothorax or the higher than usual risk of recurrence associated with a complete collapsed lung. This is probably due to an associated larger bulla with a completely collapsed lung, and hence the chances of re rupture seem higher than a simple smaller size pneumothorax attack which is usually associated with a bleb or small bulla.

It is in the previous context that current clinical practice guidelines for management of spontaneous pneumothorax tend to avoid use of surgery for patients with only a single episode of PSP. The trauma—considering not only physical but also perhaps psychological—of receiving such major surgery for a simple benign disease in a young patient was considered quite excessive if the recurrence rate of attacks is not high. The 2003 British Thoracic Surgery Guidelines for the management of spontaneous pneumothorax specifically referred to an open thoracotomy as the 'gold standard' for surgical management [8].

With this in mind, it would be unsurprising that clinicians are reluctant to offer such aggressive surgery. This is reflected in those guidelines listing the indications for surgery to only be first contralateral pneumothorax, second ipsilateral pneumothorax, synchronous bilateral spontaneous pneumothorax, single attack of tension pneumothorax, a persistent air leak after chest drain insertion, and spontaneous significant haemothorax [5–8]. First episode PSP is deliberately excluded. In a similar context back in 2001, the American College of Chest Physicians consensus statement on the management of spontaneous pneumothorax explicitly states that 'procedures to prevent the recurrence of a primary spontaneous pneumothorax should be reserved for the second pneumothorax occurrence' [7].

It is therefore evident that views on surgical indications are influenced by the perceived harm from surgery, the aggression of intervention and the simplicity of the disease. Over the past decade or more since the above guidelines, the trauma from thoracotomy remains existing. What we think has changed, though, is the current view of whether an open thoracotomy remains the surgical approach of choice across the world.

The combination of lowered morbidity with equivalent efficacy at preventing recurrence means that open thoracotomy should no longer be regarded as the firstline approach for the surgical management of PSP [22, 23]. Today, VATS has become the approach of choice by surgeons throughout the world, and it is rare to find traumatic open thoracotomy being offered to young patients with PSP especially that many are young patients and could be manual workers where thoracotomy would be an obstacle to perform their job satisfactorily. Compared to the 2003 version, the latest British Thoracic Surgery Guidelines for the management of spontaneous pneumothorax published in 2010 pointedly no longer uses the words 'gold standard' in relation to open thoracotomy [5, 8]. Instead, it is very noticeable that when the latest guidelines advised surgical pleurodesis for specific circumstances (such as pregnancy), VATS is the only approach named, and open thoracotomy is nowhere to be seen.

In summary, the management of a first-attack pneumothorax according to the current guidelines is debatable and incoherent. Advice will range from conservative


**Table 2.** *Studies using video-assisted thoracoscopy for management of first-attack spontaneous pneumothorax.*

**7**

recommendation) [

details of relevant insurance.

8].

*Indications of Surgery in Pneumothorax DOI: http://dx.doi.org/10.5772/intechopen.88640*

VATS for first-attack pneumothorax.

recurrence. **Table**

management of 'doing nothing' up to a VATS intervention on the next available list. Needle aspiration and chest tube drainage are commonly used modalities, but CTD will remain the most common and classic intervention for an attack of pneumo

thorax worldwide. It is the author's preference to send patients for a VATS interven

tion on the next available list without inserting a chest tube (provided there is no respiratory compromise) to allow a shorter hospital stay, allow patients to return to work or school as early as possible and most importantly avoid the high risk of

A conservative approach with follow-up or needle aspiration seems as a reason

able first-line option in a first-attack small-sized pneumothorax. In patients with a large pneumothorax who are not keen for surgery or with hospital logistics that would hinder the availability of VATS intervention on the next morning list due to lack of facilities or personnel, a chest drain insertion is the most reasonable option. Further intervention will then be guided by the time of resolution of the pneumothorax, availability of a VATS intervention service and patient wishes after

**5. Guideline recommendations for lifestyle changes post pneumothorax**

rax was largely based on anecdotal case reports [30, 31]. A pneumothorax, espe

stress that patients should not fly until resolution has been confirmed [

cially an undrained one, is however an absolute contraindication to all commercial air travels [32]. Travelling with a chest drain inserted for pneumothorax had no published guidelines or recommendations. It is theoretically safe, but most airlines would not be willing to accept such a risk and would need documented medical

Recommendations for passengers travelling by air after an attack of pneumotho

According to the BTS guidelines, commercial airlines advise individuals to avoid air travel for 6 weeks after an episode of primary spontaneous pneumothorax and

Although there is no evidence that recurrence is caused by flying, the conse

quences of a pneumothorax occurring during a flight could be serious because of the lack of medical care. Restrictions on flying may be more justified in patients for whom pneumothorax is associated with higher risk, such as smokers and patients with underlying lung disease (secondary spontaneous pneumothorax). In patients with secondary pneumothorax who have not been treated surgically, air travel should be avoided for 1 year after an episode (grade C recommendation). Patients with a history of pneumothorax who have not been treated surgically should also be advised against practising high-risk sports, such as diving (grade C

The performance of a VATS procedure can offer patients more safety to fly or practise diving sports. This makes patients with occupations as pilots and scuba divers candidates for a VATS intervention even with a first-attack pneumothorax. Definitive treatment significantly reduces the risk of recurrence and makes air travel safer from an airline point of view [30]; however, an individual clinical deci

sion is usually made by the treating clinician, considering both airline policy and

There are no specific guidelines regarding lifestyle modification to prevent patients from having another attack of pneumothorax apart from advising all patients to stop smoking. Despite the apparent relationship between smoking and pneumothorax, 80–86% of young patients continue to smoke after their first epi

sode of PSP [33]. Smoking cessation remains the only reversible risk factor known

understanding the risks of recurrence after the first attack.

input and insurance approval to allow patients to travel.

**2** shows studies starting more than two decades ago considering









8].
