Spontaneous Pneumothorax

Primary spontaneous pneumothorax is more common in males by approximately 3 to 1.

Chest tubes for primary spontaneous pneumothorax work approximately 50% of the time.

Patients who receive a chest tube, resolve, and go home have approximately a 50% failure rate (recurrence requiring further intervention).

Patients who fail chest tube management in the hospital and subsequently undergo VATS have a recurrence rate of approximately 25-30%.

Patients who undergo immediate VATS have a recurrence rate of approximately 10-15%.

In a multi-institutional retrospective study of 81 patients across 3 institutions over 13 years, no patients with primary spontaneous pneumothorax presented with tension physiology.

In the Midwest Consortium prospective study of 33 patients across 9 institutions over 2 years, 50% of patients failed initial aspiration (recurrent pneumothorax within 6 hours).

Of 12 patients who failed aspiration and were managed with chest tubes, 83% (approximately 10 patients) ultimately failed chest tube management and required VATS or had recurrent pneumothorax.

Of 5 patients who failed aspiration and went directly to VATS, none had recurrence.

Of 16 patients who passed the aspiration test and were discharged, 40% (approximately 6-7 patients) returned with recurrent pneumothorax.

The positive predictive value of aspiration for successful treatment is 83%, with a negative predictive value of 56%.

In the retrospective three-institution study, patients who underwent pleurodesis had the same recurrence rate as those who underwent VATS without pleurodesis.

CT scans may identify blebs that are incidental findings and not clinically relevant, similar to traumatic pneumatoceles which rarely rupture.

For patients with multiple recurrences after VATS, thoracoscopic pleurectomy (stripping parietal pleura from apex to near-diaphragm) is performed; this is a bloody, painful operation requiring epidural analgesia and hospitalization for a week to 10 days.

Aerosolized talc pleurodesis is delivered via a canister with a straw inserted through a trocar site, creating a snow-like appearance in the chest.

For a patient with a small (2 cm) apical pneumothorax after previous pleurodesis, if asymptomatic and stable on repeat imaging at 48 hours, observation is appropriate; aspiration carries risk of lung injury and worsening the air leak.