*Primary Spontaneous Pneumothorax, a Clinical Challenge DOI: http://dx.doi.org/10.5772/intechopen.83458*

*Pneumothorax*

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**Figure 1.**

infectious lung disease, interstitial lung disease (sarcoidosis), connective tissue disease (Marfan syndrome or Ehlers-Danlos syndrome), cancer, and thoracic endometriosis. Traumatic pneumothorax is caused by penetrating and non-penetrating (blunt) trauma to the chest. Iatrogenic pneumothorax results from a complication

*Classification of pneumothorax. Adapted from Noppen M. European Respiratory Review. 2010;***19***:217–219.*

The most important risk factor of primary spontaneous pneumothorax is tobacco smoking, and the number of cigarettes smoked per day contributes to the increased risk. Cannabis smoking is associated with bullous disease. Smoking suspension is the only modifiable risk factor for recurrence of PSP. Catamenial pneumothorax is a rare condition associated with the presence of thoracic endometriosis and affects women before or after 72 hours of the start of menstruation. Other risks include male gender and age with peaking between 15 and 34 years. Clinical presentation in patients with spontaneous pneumothorax depends on the size of pneumothorax. PSP may be asymptomatic or may be suspected by typical clinical features. The most common symptoms are abrupt onset of chest pain and breathlessness; the findings on physical exam may include absent breath sounds, reduced ipsilateral chest expansion, and hyperresonant percussion [5]. The presence of hypotension and tachycardia may indicate tension pneumothorax that occurs when the intrapleural pressure exceeded atmospheric pressure, caused mediastinal deviation, and reduced venous return and cardiovascular collapse [6]. The diagnosis is suggested by patient's history and findings on examination and is confirmed with chest X-ray;

of a diagnostic or therapeutic intervention [4].

the radiographic sign is the displacement of the pleural line and an absence of lung markings between the edge of the pleura and chest wall. Computed tomography (CT) provides sensitive and specific imaging for the detection of pneumothorax, but it is not recommended routinely except if loculated pneumothorax or lung disease is suspected. The diagnosis may be clearly made on a chest radiograph, and an excess radiation dose should be avoided in this young patient population [7].

The difference between primary, secondary, traumatic, and iatrogenic pneumothorax is important to be defined because of the different management strategies required for their treatment. The goal of treatment is to remove the air from the pleural space and decrease the recurrence. Management options range from observation to aspiration or drainage to thoracic surgical intervention and is guided by presenting symptoms: hemodynamic compromise, size and cause of pneumothorax. As well as it is the first time or recurring pneumothorax. PSP can be treated conservatively; patients with first episode who are asymptomatic and have a small pneumothorax need simple clinical observation, analgesia, and oxygen therapy that increased the rate of reabsorption. The removal of air from the pleural space can be achieved with needle aspiration or chest drain insertion [7, 8]. Simple aspiration and chest tube drainage are the most frequently used methods for the initial treatment of primary spontaneous pneumothorax. Aspiration should be the primary treatment in uncomplicated cases; the insertion of an aspiration catheter is easier and safer than chest tube drainage and is recommended in the guidelines. Chest tube drainage is the most popular and recommended air evacuation technique, but this method does not provide any definitive recurrence prevention [9, 10]. Video-assisted thoracic surgery (VATS) is a minimally invasive procedure, and its advantages include less postoperative pain, better postoperative pulmonary function, shorter length of hospital stay, and less invasive than thoracotomy. Thoracoscopic evaluation of primary pneumothorax shows that this disorder is regularly associated with apical subpleural blebs or bullae. Pleurodesis, either mechanical or chemical, using talc has to be applied to decrease the risk of recurrence of PSP [11, 12]. Open thoracotomy plus pleurectomy are used in the case of recurrent ipsilateral PSP, simultaneous bilateral PSP, an episode of PSP following a previous episode of contralateral PSP, first episode of tension pneumothorax, significant spontaneous hemopneumothorax at first episode, persistent air leak through the chest tube for more than 5–7 days, or failure of the lung to reexpand despite adequate pleural space drainage in the first episode. Open surgery has the lower recurrence rate [13]. The main complication of primary spontaneous pneumothorax is recurrence, which is greater after conservative treatment. Some risk factors for recurrence are younger age, male sex, and low body mass index [14]. A preventive procedure like thoracotomy or thoracoscopy plus pleurodesis may be recommended after the first episode of pneumothorax, with the objective to reduce the rate of recurrence. Some agents have been investigated for pleurodesis, but talc poudrage has presented the best results until now [15].
