**4. Classification and treatment**

Eighty percent of pneumothoraces are secondary to trauma, and 20% spontaneous without provocation. Two big categories of spontaneous pneumothorax (SP) exist, with bimodal age distribution: primary SP 15–35 years of age and secondary SP +55 years of age. Pneumothorax is distinctly rare among children less than 15 years. Wilcox et al. reported 17 cases in 12 years [11]. Primary SP occurs on a background of normal lungs, whereas secondary SP is associated with diseased lungs, such as emphysema, chronic obstructive pulmonary disease (COPD), lung fibrosis and cystic fibrosis. Secondary SP is strongly related to cigarette smoking and associated with a higher morbidity and mortality compared to primary SP. Primary pneumothorax has been associated with rupture of apical bullae or blebs (**Figure 1**) and has a 54.2% chance of recurring after the first episode [12]. In the UK the male-to-female ratio is 3:1 [7].

The British Thoracic Society (BTS) has published an updated summary of the management of pneumothorax in 2010 [10]. Similar guidelines were published earlier by the American College of Physicians in 2001 [13] and later by the European Task Force in 2015 [14]. Breathlessness and the size of pneumothorax influence the management of SP. There is a general consensus that conservative management should be tried in the first episode, as conservative management of small pneumothoraces has been shown to be safe [10, 15]. Surgery proved that recurrence is less, and video-assisted

**Figure 1.** *Single apical bulla, a common cause of primary spontaneous pneumothorax.*

thoracoscopic surgery (VATS) has opened the option of treating even the first-time pneumothorax on semi-urgent basis [16–18]. However, there has been no general agreement on the most effective type of surgery or that which is most accepted by patients. Ostensibly such a choice should result in the least incidence of recurrence. Axillary thoracotomy, full posterolateral thoracotomy, limited lateral muscle sparing mini-thoracotomy and triportal, biportal and needlescopic uniportal VATS have all been utilised [10, 18, 19]. A subxiphoid approach has also been tried and reported [20]. These operations have two objectives: firstly, to deal with the source of air leak (pneumostasis) by bullectomy/blebectomy, etc. and, secondly, to obliterate the pleural space leading to permanent adherence of the lung to the chest wall (pleurodesis or symphysis). In essence, we strive to emulate the elephant pleural space and prevent recurrence.

In the 1950s and 1960s, the treatment varied from extremely conservative bed rest only to early insertion of a Malecot catheter through the second intercostal space anteriorly (very painful!) and thoracotomy or bilateral thoracotomies for nonresolving cases [4]. Today's management is nowhere near that, and minimal access surgery or VATS has taken up the management of pneumothorax to a new level [19].

Several randomised and non-randomised trials (RCT) looked into the difference between the optimal surgical techniques in SP [21]. There is no evidence to support the superiority of either VATS or open thoracotomy in the treatment of pneumothorax because the number of randomised trials is sparse and they are underpowered to detect any meaningful difference. Barker et al. published an important metaanalysis of four randomised and 25 non-randomised studies performed in 2007 comparing VATS to open thoracotomy [22]. Complex statistical tests of homogeneity and sensitivity analysis with a hypothetical model biased against open surgery were undertaken. RCT without comparative control groups were excluded. They reported a worrying fourfold increase in the recurrence of pneumothorax following VATS procedure compared to thoracotomy. Their relative risk (RR) favours open surgery; however, postoperative pain could not be assessed since most studies did not report this outcome. Neither did they report on length of hospital stay, due to severe heterogeneity in reporting. A similar previous study by Sedrakyan et al. looking only at the randomised trials did not show this difference [23]. The conclusion is that recurrence following VATS averaged 4.5%, whereas that following mini-thoracotomy was 2.3%. Waller et al. randomised 30 patients to VATS and 30 to open thoracotomy [24]. They concluded that VATS is superior to thoracotomy in the treatment of primary SP but had a higher recurrence rate in secondary SP. Ayed et al. in a randomised trial found VATS superior to thoracotomy but reported higher recurrence rates [25]. A best evidence topic by Vohra et al. reiterated on the superiority of VATS insofar as pain control, less hospital stay and better early lung functions [26]. It stopped short of recommending open thoracotomy for the treatment of this condition, quoting the Barker study. It is hard to imagine that any contemporary surgeon or clinician would recommend open thoracotomy over VATS to their patients, based on this evidence. VATS is the most favoured approach by patients. The Barker study, despite their extensive heterogeneity tests, has lumped together widely heterogeneous approaches to the previously described objectives of pneumostasis and pleurodesis. Great variations exist when it comes to what surgeons do inside the chest, a fact not factorised in the meta-analysis. In our opinion, it should not matter in any way or form how one enters the chest, whereas it matters what one does once inside the chest. Indeed, the Barker study showed that in studies that did the same pleurodesis through two different forms of access, the relative risk (RR) of recurrences in patients undergoing VATS compared with open surgery was similar [22].

With regard to pneumostasis, the practice varies widely between doing nothing (if a bulla is not found) and performing a variety of procedures. These include blind wedge of the lung apex (apicoectomy), ligation of bulla, tying, stitching, stapling,

**59**

**Figure 2.**

*Controversies in Pneumothorax Treatment DOI: http://dx.doi.org/10.5772/intechopen.87141*

hiding within an azygos lobe (**Figure 4**).

*obliterates them and forms a scar at the margin.*

*(a) Rosary of marginal blebs (beads), which can lead to recurrent pneumothorax. (b) Contact diathermy* 

diathermy, applying silver nitrate and lasering among other methods [27–29]. Each of these variants might have a subgroup, for example, stapling with or without buttressing or covering the stapling line to reduce postoperative air leak. Should the treated bulla site (staple line) be covered with bioglue or a sealant agent? Which one? Does a pleural tent work? [30–32]. This choice could be an attractive option for ventilated

It is conceivable that some clinical importance is attached to the function of the pleura and the preservation of this function is advocated when a single apical bulla is all that explains the pneumothorax. In addition, pleurodesis is not without its complications. It can induce severe postoperative chest pain and increase the risk of bleeding and unscheduled return to theatre. In addition, it poses difficulties with subsequent thoracic surgery, e.g. if lung transplantation will be required later in life. Following this line of thinking, RCT have looked into the difference between bullectomy alone and bullectomy coupled with pleurodesis [34–36]. The general consensus, bar the Korean trial, is that pleurodesis with bullectomy reduces recurrence. We then come to the second objective of pleurodesis. Several options exist, scratching, abrasion, partial or semitotal pleurectomy and pleural sclerosing agents [37]. Several chemical agents have been described: talc, tetracycline, minocycline, autologous blood, dextrose, etc. [38–41]. The use of chemical pleurodesis is tied to the complication of empyema, which adds insult to injury. The bottom line is that none of these techniques or agents could give a 100% guarantee of freedom from recurrence. Heterogeneity in the methodology of RCT leads to significant differences in outcomes. Nor does the meta-analysis of Barker take into account the human factor of surgical experience and learning curves. It is not useful to lump together trainees at the beginning of their VATS learning curve together with experienced surgeons in this field. Unsupervised trainees are bound to have high recurrence rates, skewing the figures. Familiarity with small details that might avert recurrence is a function of experience. Meticulous examination of the lung surfaces is vital to unveil bullae in other lobes. Seventy percent of postoperative pneumothorax recurrences probably developed because of overlooked bullae and incomplete resection of bullae in the early period of VATS experience [42]. Equally important is to scrutinise the diaphragmatic surface for fenestrations in the child-bearing age of ladies [43]. Identification of the lung margin rosary of blebs and the knowledge of how to deal with them prevent recurrence (**Figure 2**). Detailed knowledge of the stapling devices, their colour code and sizes is mandatory, as well as the realisation that the intersection point of two stapling lines is the weakest link for potential air leak. How many of us perform the bubbling test (underwater testing for air leak before and after pneumostasis)? It seems logical to make sure that there is no air leak by the end of pneumostasis, to ensure the complete expansion of the lung and guarantee pleurodesis (**Figure 3**). Many is the time we found the source of air leak

patients in intensive care and for patients with severe secondary SP [33].
