Consensus Statements
Consensus Panel on the Management
of Spontaneous Pneumothorax
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Consensus Panel Recommendations
Secondary Spontaneous Pneumothorax
Clinically Stable Patients With a Small Pneumothorax
Hospitalize the patient (Good Consensus) rather than managing the pneumothorax in the emergency department with observation or simple aspiration only (Very Good Consensus).
Observe the hospitalized patient (Good Consensus), or treat with a chest tube (Some Consensus), depending on the extent of symptoms and course of the pneumothorax.
Thoracoscopy should not be performed before the patient is stablized with a chest tube (Very Good Consensus).Clinically Stable Patients With a Large Pneumothorax
Hospitalize the patient, and place a chest tube to re-expand the lung (Very Good Consensus).
Thoracoscopy should not be performed before the patient is stablized with a chest tube (Very Good Consensus).
Clinically Unstable Patients With a Pneumothorax of Any Size
Hospitalize the patient, and place a chest tube to re-expand the lung (Very Good Consensus).
Thoracoscopy should not be performed before the patient is stable (Very Good Consensus).
Chest Tube Management
Clinical circumstances dictate the size of chest tubes.
Unstable patients (Very Good Consensus) and patients supported by mechanical ventilation at risk for large pleural air leaks (Good Consensus) require a 24F to 28F chest tube.
Stable patients not at risk for large air leaks require a 16F to 22F chest tube (Good Consensus). A small-bore (<14F) catheter may be acceptable in certain circumstances, including small pneumothoraces and patient preference (Good Consensus).
Attachment of the chest tube to a water seal device with (Some Consensus) or without (Good Consensus) suction is acceptable management for most patients. Patients treated with water seal alone should be managed with suction if the lung fails to re-expand (Good Consensus). A Heimlich valve may be used (Good Consensus), but a water seal device is preferred for most patients.
Prevention of Pneumothorax Recurrence
Most (81%) panel members recommend an intervention to prevent pneumothorax recurrence after the first pneumothorax because of the potential lethality of secondary pneumothoraces. The other 19% of panel members recommend an intervention to prevent recurrence after the second spontaneous pneumothorax.
Surgical management is preferred to prevent pneumothorax recurrence (Very Good Consensus); surgery has a lower recurrence rate than use of a sclerosing agent. Instillation of a sclerosant through a chest tube may be used in certain circumstances (Good Consensus) based on patients’ contraindications to surgery, management preferences, and underlying poor patient prognosis (see below for sclerosant choice).
Medical or surgical thoracoscopy is preferred (Very Good Consensus), but a muscle-sparing (axillary) thoracotomy is acceptable (Good Consensus).
Standard thoracotomy through a lateral or medial sternotomy is not appropriate for most patients (Good Consensus).
Bullectomy and a procedure to produce pleural symphysis should be performed during the surgical intervention. Staple bullectomy is preferred (Very Good Consensus). Parietal pleurectomy or parietal pleural abrasion limited to the upper half of the hemithorax is preferred to produce pleural symphysis in most patients (Good Consensus).
For producing pleural symphysis by instillation of a sclerosing agent through a chest tube, preferred agents are talc slurry (Very Good Consensus) and doxycycline (Good Consensus).
Assessment of Pulmonary Function
Performance of pulmonary function tests (PFTs) to assist management decisions is not appropriate (Perfect Consensus) for patients with secondary pneumothoraces. Expiratory maneuvers performed during the acute phase of a pneumothorax may produce inaccurate results. However, results from previous PFTs may assist in patient selection for an intervention to prevent pneumothorax recurrence in special circumstances (Good Consensus).
Persistent Air Leaks
For a patient with persistent air leaks and prolonged chest tube drainage who initially refuses surgery, continue observation for 5 days. After 5 days of observation, the patient should be urged to accept surgical intervention. More prolonged delay may limit the effectiveness of thoracoscopy. Instillation of sclerosing agents through a chest tube to produce a pleural symphysis in managing persistent air leaks is acceptable for patients who are not surgical candidates (Good Consensus).
Chest Tube Removal
For patients treated with a chest tube without referral for surgical intervention to prevent pneumothorax recurrence, management of chest tube removal is similar to management in patients with a primary pneumothorax.
Chest Imaging With CT
Obtaining a chest CT scan is acceptable management for patients with pneumothorax recurrence (Good Consensus), during management of a persistent air leak (Some Consensus), and for planning a surgical intervention (Some Consensus).
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