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

*Pneumothorax*

**5.2 Aspiration**

this method is likely to fail [38].

**5.3 Thoracostomy only**

**5.4 Pleurodesis**

treated by supplemental oxygen, which accelerates the process of reabsorption of air by the pleura. The observation period should be at least 6 hours; after this time, the patient can be discharged if three conditions are met: absence of progression of the pneumothorax confirmed by a control chest radiograph, compliance of the outpatient treatment plans, and ease of access to emergency medical services. In these cases, the follow-up after discharge should be from 2 to 4 weeks [41].

Patients with a first episode of primary spontaneous pneumothorax episode, which are hemodynamically stable and have a large pneumothorax (more than 2–3 centimeters of air in chest X-ray or more than 15% of the hemithorax) or those who have a progressive pneumothorax, or symptomatic with chest pain, or dyspnea should undergo needle aspiration [29, 42]. Several methods are used to perform simple aspiration, ranging from intravenous catheters in the second intercostal space in the midclavicular line with 16–18G cannula to chest tubes that can be removed once re-expansion of the lung is confirmed [43]. When the procedure is successful (less than 2 centimeters of air in the chest X-ray and improving in the breathing pattern), the patient can be discharged, with follow-up from 2 to 4 weeks. Simple aspiration is successful in 70% of the patients with moderate-sized primary pneumothorax; in patients older than 50 years or aspirations bigger than 2.5 liters,

Primary spontaneous pneumothorax may also be managed with a chest tube that is left in place for 1 or more days or by attaching the catheter to a one-way Heimlich valve or water-seal device and using it as a chest tube. The last method is reserved for patients in whom Heimlich valves fail or those who have coexisting respiratory conditions that reduce the ability to tolerate a recurrent pneumothorax [38]. After treatment, persistent air leaks are not common in primary spontaneous pneumothorax. Seventy five percent of air leaks resolve after 7 days, and 100% resolve after 15 days [38]. When the air leak persists for 4 to 7 days, surgery comes to consideration. In a study from Kim, selection of patients with primary spontaneous pneumothorax and persistent air leaks for immediate surgery must be done according to the presence or absence of bullae, detected by

high-resolution chest computed tomographic (HRCT) scanning [44].

**5.5 Video-assisted thoracoscopic surgery (VATS)**

The American College of Chest Physicians, British Thoracic Society, and the Belgian Society of Pulmonology recommended surgical pleurodesis via thoracoscopy for air leak that persists more than 4 days or recurrence prevention at second occurrence [45]. Methods of pleurodesis have included mechanical abrasion with gauze or Marlex, instillation of tetracycline, pleural irritation with laser or cautery, and instillation of talc [46]. The addition of pleurodesis agents reduces the rate of recurrence in PSP. Alayouty et al. in a randomized controlled trial studied the efficacy of different pleurodesis agents. They reported that chemical pleurodesis is associated with less recurrence rate than mechanical abrasion (P < 0.001, evidence level 1b) [47, 48].

The thoracoscopic surgery for primary spontaneous pneumothorax has been proposed and studied by a lot of clinicians as the main treatment for recurrent or

**20**

persistent spontaneous pneumothorax. Surgical treatment is more invasive and has a lower recurrence rate than the conservative treatment [49–51] but increases patient discomfort, which has restricted the application of open thoracotomy. Video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax has been proposed as a new surgical technique and has taken over the role of open thoracotomy, due to its minimal invasiveness and low morbidity [52]. This technique has been used not only for prolonged air leak or recurrence but also in patients at the first episode of pneumothorax, when blebs or bullae are identified with CT scan. A study conducted at the Chest Diseases Hospital in Kuwait treated spontaneous pneumothorax in 72 patients using VATS technique. The study included 67 male and 5 female patients from 15 to 40 years with a recurrent episode of pneumothorax. Surgeons performed VATS unilateral technique in all cases, with gauze abrasion and apical pleurectomy to remove subpleural blebs or bullae and excision of the apex of the upper lobe in the absence of any identifiable lesion. They concluded that thoracoscopic surgery could be carried out safely and effectively in the treatment of recurrent or persistent spontaneous pneumothorax, allowing inspection of the entire lung, identification of bullae, and resection of the bullous disease [29]. Another study compared the results of conservative treatment, open thoracotomy, and VATS. The authors studied 281 patients who had primary spontaneous pneumothorax, finding recurrences in 56.4% of the patients with the conservative treatment, 3% for open thoracotomy and 11.7% for VATS with a hospital stay length of 14.5, 22.2, and 8.3 days, respectively. At the end, they concluded VATS was significantly superior to open thoracotomy measuring length of operation, bleeding volume, and length of hospital stay. In terms of morbidity, low invasive and cosmetic issue VATS is superior to open thoracotomy [52]. Conventional three-port VATS has advantage in hospital stay, postoperative pain, and chest drainage time. In 2005, Dr. Gaetano Rocco used simple-port VATS for the first time, a technique that requires a minimum incision of approximately 3 cm and facilitates the postoperative recovery of the patient, compared with three-port VATS [53].
