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Spontaneous Pneumothorax
With Dr. Dan Osley · hosted by Dr. Alexander Gibbons & Dr. Todd Ponsky
Chapter 1 of 9 · Case-Based Learning
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Primary spontaneous pneumothorax is more common in males by approximately 3 to 1 ratio
CT scan data fairly convincingly shows that it is probably not beneficial with regard to changing treatment parameters or outcomes for spontaneous pneumothorax
In multi-institutional retrospective trial, chest tubes worked about 50% of the time for spontaneous pneumothorax
The failure rate for patients who get a chest tube and resolve is about 50% - they will be back and have to have another operation
Patients who get a chest tube and fail in the hospital and subsequently go on to VATS still have a failure rate of around 25 to 30%
Patients who get immediate VATS have about a 10 to 15% failure rate
Patients who get a chest tube and then VATS have higher failure rates (25%) than those who get immediate VATS, possibly because they are predisposed to recurrence
The Society of Thoracic Surgery in adult patients recommends primary aspiration for spontaneous pneumothorax
In most large studies for primary spontaneous pneumothorax, the mean age is around 20 to 22 years, making this primarily a young adult disease
The average age in pediatric spontaneous pneumothorax studies has been between 15.5 and 16 years
The hole in spontaneous pneumothorax has probably already closed by the time patients come to the hospital
There is no published paper documenting tension physiology for spontaneous pneumothorax
Of 81 patients in retrospective study across 3 institutions over 13 years, none presented with tension physiology from spontaneous pneumothorax
In Midwest Consortium prospective study, 50% of patients who got aspiration failed within 6 hours
In the aspiration study, 33 patients presented across 9 institutions over 2 years
Of 17 patients who failed aspiration, 12 received chest tubes and 83% of those had persistent air leak requiring VATS or had recurrent pneumothorax
Of 5 patients who went directly to VATS after failed aspiration, none recurred
Of 16 patients who passed aspiration and went home, 40% came back with recurrent pneumothorax
The positive predictive value of aspiration in treating pneumothorax was 83% with negative predictive value of 56%
There is good data suggesting that pleurodesis is not beneficial in preventing recurrence of spontaneous pneumothorax
In three-institution retrospective data, patients who underwent VATS with pleurodesis had the same recurrence rate as those who underwent VATS alone
A large Chinese trial of 289 patients over 3 years (average age 22) randomized patients to wedge resection with or without mechanical pleurodesis using standardized sandpaper abrasion and showed identical recurrence rates
Chemical pleurodesis with talc is probably more effective than mechanical pleurodesis but creates a treacherous reoperative field
CT scans may identify blebs that are incidental findings in patients who never develop pneumothorax, similar to traumatic pneumatoceles that rarely rupture
For patients with multiple recurrences after VATS, thoracoscopic pleurectomy of parietal pleura from apex down to a couple ribs above diaphragm is performed
Pleurectomy is an arduous, bloody operation that is super painful for children, usually requiring epidurals, with patients hospitalized for a week or 10 days
For recurrent recurrent pneumothorax cases, talc pleurodesis would be used if available because it is an appropriate population where preventing reoperation is critical
Aerosolized talc comes in a can with a straw, is inserted down the trocar site, and when sprayed looks like it is snowing inside the chest
For small apical pneumothorax after pleurodesis where lung is fixed to chest wall and patient is asymptomatic, observation with repeat chest X-ray in 48 hours is appropriate rather than operation