**3. Indications of intervention according to the guidelines**

The European Respiratory Society task force [6] for management of primary spontaneous pneumothorax has suggested five indications for definitive management: second-attack pneumothorax, persistent air leak 3–5 days, haemopneumothorax, bilateral pneumothorax and special occupations (divers and pilots).

The BTS guidelines [5, 8] agree with the same indications. The 2003 guidelines [8] had specified persistent air leak for 5 days in PSP and 3 days in SSP, but the 2010 [5] guidelines mention 5–7 days as an arbitrary number for persistent air leak for both PSP and SSP. The reason for giving a longer time period in PSP to wait for in the 2003 guidelines is that there is a better chance of healing of a ruptured bullae/ bleb with the underlying normal lungs with PSP, while in SSP, the diseased lungs have a lower chance of sealing the leaking lesion if they have not done so in the first 3 days. The guidelines also add pregnancy as an indication for intervention.

The ACCP guidelines [7] mention 4 days of conservative treatment in patients with persistent air leak after drain insertion for spontaneous pneumothorax before surgical intervention. Again, the same indications mentioned by other guidelines are considered in the Delphi consensus statement.

The main indication in all guidelines for definitive intervention in cases of PSP and SSP is recurrence. The reason behind this is that the chances of a pneumothorax not recurring after the first attack are usually more than the chances recurring, and hence patients after the first attack are given a chance of no intervention provided their first pneumothorax has healed. Chances of recurrence after a second attack (ipsilateral or contralateral) are in the range of 60–80%, and hence patients are not usually offered the conservative option. Opponents of this opinion would argue that the chances of recurrence after the first attack are still too high to be acceptable for any logical patient. Estimates of the incidence of recurrent PSP range from 25 to more than 50%, with most recurrences seen within the first year [17]. As an example, a study of 153 patients with PSP found a recurrence rate of 54% [18].

Female gender, tall stature in men, low body weight and failure to stop smoking have been associated with an increased risk of recurrence [18, 19]. Unfortunately, most patients have a very unpleasant experience with their first attack of pneumothorax. The sensation of chest pain with breathlessness sounds like 'I felt I am going to die' as patients may express. The other unpleasant experience is insertion of a

**Figure 1.**

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

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 intervention to treat it carries a very low risk.

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