**4. Guidelines for management of first-attack pneumothorax**

In recent years there has been a trend towards a more conservative approach to management of primary spontaneous pneumothorax, based on the principle that intrapleural air does not necessarily require a therapeutic intervention and that management depends on the clinical symptoms and not on the size of the pneumothorax [20]. This conservative approach may be appropriate as tension pneumothorax from a PSP is extremely rare [21]. In selected patients with minimal or no symptoms and good access to medical care in case of deterioration, observation alone may be appropriate.

**5**

to be seen.

across the world.

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

usually associated with a bleb or small bulla.

'gold standard' for surgical management [8].

Within the current British Thoracic Society guidelines (from 2010), there is a significant emphasis on a conservative approach to treatment [5] with management predominantly based on clinical symptoms. In contrast, the American College of Chest Physicians Delphi consensus statement (from 2001) recommended a more aggressive approach, with intercostal drain placement recommended in any pneumothorax larger than 20% of the hemithorax, irrespective of the symptoms [7]. Patients with an attack of tension pneumothorax (quite rare in PSP) and more commonly patients with a first attack associated with complete lung collapse should be counselled about the benefits of definitive intervention with VATS due to the life-threatening condition of a tension pneumothorax or the higher than usual risk of recurrence associated with a complete collapsed lung. This is probably due to an associated larger bulla with a completely collapsed lung, and hence the chances of re rupture seem higher than a simple smaller size pneumothorax attack which is

It is in the previous context that current clinical practice guidelines for management of spontaneous pneumothorax tend to avoid use of surgery for patients with only a single episode of PSP. The trauma—considering not only physical but also perhaps psychological—of receiving such major surgery for a simple benign disease in a young patient was considered quite excessive if the recurrence rate of attacks is not high. The 2003 British Thoracic Surgery Guidelines for the management of spontaneous pneumothorax specifically referred to an open thoracotomy as the

With this in mind, it would be unsurprising that clinicians are reluctant to offer such aggressive surgery. This is reflected in those guidelines listing the indications for surgery to only be first contralateral pneumothorax, second ipsilateral pneumothorax, synchronous bilateral spontaneous pneumothorax, single attack of tension pneumothorax, a persistent air leak after chest drain insertion, and spontaneous significant haemothorax [5–8]. First episode PSP is deliberately excluded. In a similar context back in 2001, the American College of Chest Physicians consensus statement on the management of spontaneous pneumothorax explicitly states that 'procedures to prevent the recurrence of a primary spontaneous pneumothorax

It is therefore evident that views on surgical indications are influenced by the perceived harm from surgery, the aggression of intervention and the simplicity of the disease. Over the past decade or more since the above guidelines, the trauma from thoracotomy remains existing. What we think has changed, though, is the current view of whether an open thoracotomy remains the surgical approach of choice

The combination of lowered morbidity with equivalent efficacy at preventing recurrence means that open thoracotomy should no longer be regarded as the firstline approach for the surgical management of PSP [22, 23]. Today, VATS has become the approach of choice by surgeons throughout the world, and it is rare to find traumatic open thoracotomy being offered to young patients with PSP especially that many are young patients and could be manual workers where thoracotomy would be an obstacle to perform their job satisfactorily. Compared to the 2003 version, the latest British Thoracic Surgery Guidelines for the management of spontaneous pneumothorax published in 2010 pointedly no longer uses the words 'gold standard' in relation to open thoracotomy [5, 8]. Instead, it is very noticeable that when the latest guidelines advised surgical pleurodesis for specific circumstances (such as pregnancy), VATS is the only approach named, and open thoracotomy is nowhere

In summary, the management of a first-attack pneumothorax according to the current guidelines is debatable and incoherent. Advice will range from conservative

should be reserved for the second pneumothorax occurrence' [7].
