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

*Pneumothorax*

pneumothorax guidelines.

can yield variable results [39].

to reduce the chance of recurrence although we should not neglect the deleterious role of marijuana and cannabis smoking as a risk of PSP. From the author's point of view, cannabis has a more destructive effect on the lung parenchyma exposing patients to a higher risk of first-attack and recurrent pneumothorax. This has also been noted elsewhere [34]. Smoking cessation advice is therefore given to all our patients who smoke after the first episode of spontaneous pneumothorax.

Despite the availability of published guidelines, there has been a recording in the English literature of non-compliance or deviation from the guidelines, which has occasionally resulted in inconsistency or patient harm in management of spontaneous pneumothorax. We have previously published our experience in a large UK tertiary centre [35] where the median time to referral from chest physicians to thoracic surgeons after the 2003 BTS guideline publication was 10 days for a persistent pneumothorax which is longer than any time suggested by all guidelines. This has resulted in a higher incidence of developing empyema and the more frequent need of a thoracotomy rather than VATS treatment for patients with delayed referral. Delayed referral is one of the most common areas of deviation from published

When assessing a pneumothorax, the size will determine the initial step of management, ranging from conservative treatment, needle aspiration up to chest tube drainage in larger pneumothoraces. There is discrepancy in size calculations of pneumothorax between different guidelines, and this has resulted in inconsistency in management. Kelly and Clooney have noticed this with management of 234 patients managed in Australia [36], and patients with a large pneumothorax were treated conservatively. Yoon et al. have studied size calculation of PSP in 87 patients in a tertiary UK centre and found significant discrepancy between the size calculation suggested in the BTS guidelines (resulting in only 70% compliance) and the ACCP guidelines (resulting in only 32% compliance) with consequent inconsistent management [37]. Sole blame on physicians and surgeons applying the guidelines can be unfair as there is obvious inconsistency in size calculation between different pneumothorax guidelines [38], and estimation of the size using only a chest X-ray

The BTS guidelines [8] suggest explicitly inserting a chest drain for simple spontaneous pneumothorax in the 'safe triangle of chest'. We have previously published that knowledge of the guidelines regarding this site of insertion is deficient in surgeons and physicians involved in insertion of chest drains [40]. This resulted in more than 50% of drains inserted being outside the 'safe triangle' exposing patients to an unnecessary risk of higher morbidity associated with this common everyday

To conclude, the current guidelines available for treatment of spontaneous pneumothorax would state that in cases of spontaneous pneumothorax, patients will be assessed for clinical status and size of pneumothorax. In a very small PSP pneumothorax with no clinical complaint, it would be reasonable to discharge the patient and follow up. All patients with SSP require hospital admission. In a sizable pneumothorax with symptoms, the BTS and ERS guidelines would recommend needle aspiration with chest drain insertion if failed. The ACCP guidelines would

**6. Hazards of non-compliance with pneumothorax guidelines**

**8**

procedure.

**7. Summary**

recommend a chest drain straightaway. If the pneumothorax persists for 3–7 days according to different guidelines, definitive treatment is required. The BTS, ACCP and ERS guidelines choose first-attack tension pneumothorax, bilateral pneumothoraces and special occupations (pilots and divers) as indications for definitive intervention after one attack of spontaneous pneumothorax, while the BTS guidelines add pregnancy and previous pneumonectomy as indications.

All guidelines agree that second-attack ipsilateral and first-attack contralateral recurrent pneumothorax are indications for intervention. The management of firstattack pneumothorax is debatable in all guidelines and will range from conservative management up to performing a VATS for definitive treatment. This will depend on the clinical situation, availability of resources/personnel and patient wishing to avoid the relatively high chance of recurrence. With the advancement in VATS techniques and significant reduction in risk of recurrence with a VATS intervention, it could be reasonable to perform the procedure on the next available list. A VATS procedure should be the standard surgical procedure for pneumothorax patients, and an open thoracotomy is no longer considered the 'gold standard' in all guidelines. All patients with an attack of spontaneous pneumothorax need lifestyle modifications regarding their smoking status, sport activity and travelling through air flights.

Physicians and thoracic surgeons should be aware of the current available guidelines for management of spontaneous pneumothorax. Deviation from the guidelines, particularly regarding the time to refer patients for definitive treatment, is associated with higher patient morbidity (particularly developing an empyema), increased hospital stay and higher medical costs.
