**5. Treatment**

Primary spontaneous pneumothorax can be treated conservatively or by intervention that include simple aspiration, chest tube drainage, thoracoscopy, and thoracotomy [37]. A lot of issues must be taken into consideration in the management of spontaneous pneumothorax. Studies have shown numerous approaches offered by different guidelines and associations. According to the American College of Chest Physicians (ACCP), the British Thoracic Society (BTS), and the Spanish Society of Pulmonology and Thoracic Surgery, the initial management of the primary spontaneous pneumothorax is directed to remove air from the pleural space and prevent recurrences [1, 38]. Treatment options for primary spontaneous pneumothorax go from simple observation, aspiration with a catheter, insertion of a chest tube, pleurodesis, thoracoscopy, video-assisted thoracoscopic surgery (which is one of the most studied approaches) to thoracotomy. Selection of the appropriate approach depends on the size of the pneumothorax, the severity of the symptoms, and the presence or absence or persistent air leak (**Figure 2**). An initial step in the management of primary spontaneous pneumothorax is to evaluate the patient hemodynamic stability and risk. When the patient is hemodynamically unstable and/or the pneumothorax is bilateral, chest drain should be performed. If the patient is hemodynamically stable, different approaches can be chosen [38].

**19**

**Figure 2.**

**5.1 Conservative management**

*Management of primary spontaneous pneumothorax [29].*

Clinically stable patients with small pneumothoraces can be treated with conservative management, and they should stay in the emergency room with a control chest radiograph to perceive the resolution of pneumothorax. Conservative management consists of observing the patient, oxygen therapy, and analgesia [39]. In the case of symptomatic and/or large pneumothoraces, it is indicated to remove the air from the pleural space by simple aspiration or chest tube drainage [40]. Patients with a first episode of primary spontaneous pneumothorax that are hemodynamically stable, with few or no symptoms, and have a small pneumothorax (<2–3 centimeters between the lung and the chest wall or <15% of hemithorax) can be

*Primary Spontaneous Pneumothorax, a Clinical Challenge*

*DOI: http://dx.doi.org/10.5772/intechopen.83458*

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

*Pneumothorax*

**4.3 CT and its indications**

**4.4 Size of pneumothorax**

CT scanning is recommended for uncertain or complex cases and is useful in the detection of small pneumothoraces and size estimation. Emphysema, bullous lung, and another lung pathology are identified [29]. Chest CT is helpful in understanding the extent of the underlying lung parenchyma distraction. Some patients

The clinical manifestations and evaluation are more important than the size of pneumothorax and do not correlate with the proportion of the pneumothorax [29].

presented a loculated pneumothorax or pulmonary air cysts [34].

The size of a pneumothorax is classified into three groups:

• Small is defined as small rim of air around the lung.

• Moderate is defined as collapsed halfway toward the heart border.

by CT scanning but are only recommended for difficult cases [36].

• Complete is defined as airless lung, separate from the diaphragm [2].

The difference of a small or large pneumothorax depends on the presence of visible rim <2 cm between the lung margin and the chest wall [29]. PA chest X-ray has been used to quantify the size of the pneumothorax. A commonly used method for estimating pneumothorax size is the light index. This method assumes that the volume of a pneumothorax approximates to the ratio of the cube of the lung diameter to the hemithorax diameter. This volume of pneumothorax can be calculated in percentage [36]. Some guidelines from the USA estimated the volume of a pneumothorax by measuring the distance from the lung apex to the cupola, and some British guidelines estimated the volume by measuring the interpleural distance at level of the hilum [29]. Pneumothorax size calculations are best achieved

Primary spontaneous pneumothorax can be treated conservatively or by intervention that include simple aspiration, chest tube drainage, thoracoscopy, and thoracotomy [37]. A lot of issues must be taken into consideration in the management of spontaneous pneumothorax. Studies have shown numerous approaches offered by different guidelines and associations. According to the American College of Chest Physicians (ACCP), the British Thoracic Society (BTS), and the Spanish Society of Pulmonology and Thoracic Surgery, the initial management of the primary spontaneous pneumothorax is directed to remove air from the pleural space and prevent recurrences [1, 38]. Treatment options for primary spontaneous pneumothorax go from simple observation, aspiration with a catheter, insertion of a chest tube, pleurodesis, thoracoscopy, video-assisted thoracoscopic surgery (which is one of the most studied approaches) to thoracotomy. Selection of the appropriate approach depends on the size of the pneumothorax, the severity of the symptoms, and the presence or absence or persistent air leak (**Figure 2**). An initial step in the management of primary spontaneous pneumothorax is to evaluate the patient hemodynamic stability and risk. When the patient is hemodynamically unstable and/or the pneumothorax is bilateral, chest drain should be performed. If the patient is hemodynamically stable, different approaches can be chosen [38].

**18**

**5. Treatment**

**Figure 2.** *Management of primary spontaneous pneumothorax [29].*
