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BTS guidelines for the management of spontaneouspneumothoraxM Henry, T Arnold, J Harvey, on behalf of the BTS Pleural Disease Group, a subgroupof the BTS Standards of Care Committee. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .

Thorax2003;58(Suppl II):ii39ii52

1 INTRODUCTIONPneumothorax is defined as air in the pleural

spacethat is, between the lung and the chestwall.1 Primary pneumothoraces arise in otherwise

healthy people without any lung disease. Second-ary pneumothoraces arise in subjects with under-

lying lung disease. The term pneumothorax was

first coined by Itard, a student of Laennec, in1803,2 and Laennec himself described the clinical

picture of pneumothorax in 1819.2 He described

most pneumothoraces as occurring in patientswith pulmonary tuberculosis, although he recog-

nised that pneumothoraces also occurred in

otherwise healthy lungs, a condition he describedas pneumothorax simple. The modern descrip-

tion of primary spontaneous pneumothoraxoccurring in otherwise healthy people was pro-

vided by Kjaergard in 1932.3 Primary pneumotho-rax remains a significant global problem, occur-

ring in healthy subjects with a reported incidence

of 1828/100 000 per year for men and 1.26/100 000 per year for women.4 5 Secondary pneu-

mothorax is associated with underlying lung dis-

ease, whereas primary pneumothorax is not. Bydefinition, there is no apparent precipitating

event in either. Hospital admission rates for com-

bined primary and secondary pneumothorax arereported in the UK at between 5.8/100 000 per

year for women and 16.7/100 000 per year for

men. Mortality rates in the UK were 0.62/millionper year for women and 1.26/million per year for

men between 1991 and 1995.6 This guidelinedescribes the management of spontaneous pri-

mary and secondary pneumothorax. It excludesthe management of trauma. Algorithms for the

management of spontaneous primary and sec-

ondary pneumothorax are shown in figs 1 and 2.

Strong emphasis should be placed on therelationship between the recurrence ofpneumothorax and smoking in an effortto encourage patients to stop smoking.[B]

Despite the absence of underlying pulmonarydisease in patients with primary pneumothorax,

subpleural blebsand bullae arelikely to play a rolein the pathogenesis since they are found in up to90% of cases of primary pneumothorax at thora-

coscopy or thoracotomy and in up to 80% of caseson CT scanning of the thorax. 7 8 The aetiology of

such bullous changes in otherwise apparently

healthy lungs is unclear. Undoubtedly, smokingplays a role911; the lifetime risk of developing a

pneumothorax in healthy smoking men may beas much as 12% compared with 0.1% in non-

smoking men.11 This trend is also present, though

to a lesser extent, in women.11 There does notappear to be any relationship between the onset

of pneumothorax and physical activity.5 Small

airway obstruction, mediated by an influx ofinflammatory cells, often characterises pneumo-

thorax and may become manifest in the smaller

airways of men at an earlier stage. 12 Patients withprimary pneumothoraces tend to be taller than

control patients.13 14 The gradient in pleural

pressure increases from the lung base to theapex,1 thus alveoli at the lung apex in tall

individuals are subject to significantly greaterdistending pressure than those at the base of the

lung and, theoretically, are more predisposed to

the development of subpleural blebs.15 Strongemphasis should be placed on the relationship

between smoking and pneumothorax in an effortto deter those smokers who have developed apneumothorax from smoking. Despite the appar-

ent relationship between smoking and pneumo-

thorax, 8086% of young patients continue tosmoke after their first primary pneumothorax.16

The risk of recurrence of primary pneumothoraxis 54% within the first 4 years, with isolated risk

factors including smoking, height in male

patients,14 17 and age over 60 years.17 Risk factors

for secondary pneumothorax recurrence include

age, pulmonary fibrosis, and emphysema.17 18

In an effort to standardise treatment ofprimary and secondary pneumothoraces, theBritish Thoracic Society (BTS) published guide-lines for the treatment of both in 1993.19 Several

studies suggest that compliance with the 1993guidelines, though improving, remains at only2040% among non-respiratory and A&Estaff.2022 Clinical guidelines have been shown toimprove clinical practice23 24; compliance withguidelines is related to the complexity of practicalprocedures that are described25 and is strength-

ened by an evidence base.26 Steps in the 1993guidelines which may need clarification include:

(1) simple aspiration (thoracocentesis) versus

intercostal tube drainage (tube thoracostomy) asthe first step in the management of primary and

secondary pneumothoraces, (2) treatment of eld-erly pneumothorax patients or patients with

underlying lung disease, (3) when to refer

patients with a difficult pneumothorax to a chestphysician or thoracic surgeon for persistent air

leak or failure of re-expansion of the lung, and (4)

treatment of the recurrent pneumothorax. Thisguideline addresses these issues. Its purpose is to

provide a comprehensive evidence based review

of the epidemiology, aetiology, and treatment ofpneumothorax to complement the summary

guidelines for diagnosis and treatment.

2 CLINICAL EVALUATION AND IMAGING

Expiratory chest radiographs are not rec-ommended for the routine diagnosis ofpneumothorax. [B]

See end of article forauthors affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Dr M Henry, The GeneralInfirmary at Leeds, GreatGeorge Street, LeedsLS1 3EX, UK;[email protected]. . . . . . . . . . . . . . . . . . . . . . .

ii39

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Figure 1 Recommended algorithm for the treatment of primary pneumothorax.

P r i m a r y

p n e u m o t h o r a x

S t a r t

B r e a t h l e s s a n d / o r r i m o f a i r > 2 c m

o n c h e s t r a d i o g r a p h ?

( s e c t i o n 4 . 1 )

A s p i r a t i o n

C o n s i d e r r e p e a t

a s p i r a t i o n

?S u c c e s s f u l

( s e c t i o n 4 . 2 )

I n t e r c o s t a l d r a i n


( s e c t i o n 4 . 3 )


( s e c t i o n 4 . 2 . 1 )

R e f e r r a l t o c h e s t p h y s i c i a n w i t h i n 4 8 h o u r s

?S u c t i o n ( s e c t i o n 4 . 4 . 1 )

R e f e r r a l t o t h o r a c i c s u r g e o n

a f t e r 5 d a y s ( s e c t i o n 4 . 5 )

C o n s i d e r

d i s c h a r g e

( s e c t i o n 4 . 6 )

R e m o v e 2 4 h o u r s a f t e r

f u l l r e - e x p a n s i o n / c e s s a t i o n

o f a i r l e a k w i t h o u t c l a m p i n g

N O

Y E S

Y E S

Y E S

Y E S

N O

N O

N O

ii40 Henry, Arnold, Harvey

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S e c o n d a r y

p n e u m o t h o r a x

S t a r t

B r e a t h l e s s + a g e > 5 0 y e a r s

+ r i m o f a i r > 2 c m

o n c h e s t r a d i o g r a p h ?

( s e c t i o n 4 . 1 )

I n t e r c o s t a l d r a i n

R e f e r r a l t o c h e s t

p h y s i c i a n a f t e r 4 8 h o u r s

?S u c t i o n ( s e c t i o n 4 . 4 . 1 )


( s e c t i o n 4 . 3 )


E a r l y d i s c u s s i o n w i t h

s u r g e o n a f t e r 3 d a y s

( s e c t i o n 4 . 5 )

C o n s i d e r

d i s c h a r g e

( s e c t i o n 4 . 6 )

A d m i t t o

h o s p i t a l f o r

2 4 h o u r s

A s p i r a t i o n


( s e c t i o n 4 . 2 )

R e m o v e 2 4 h o u r s a f t e r

f u l l r e - e x p a n s i o n / c e s s a t i o n

o f a i r l e a k

Y E S

Y E S

N O

N O

N O

N O

Y E S Y E S

Figure 2 Recommended algorithm for the treatment of secondary pneumothorax.

BTS guidelines for the management of spontaneous pneumothorax ii41

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A lateral chest or lateral decubitus radiographshould be performed if the clinical suspicion ofpneumothorax is high, but a PA radiograph isnormal. [B]

CT scanning is recommended when differentiating apneumothorax from complex bullous lung disease,

when aberrant tube placement is suspected, andwhen the plain chest radiograph is obscured bysurgical emphysema. [C]

The clinical history is not a reliable indicator ofpneumothorax size. [C]

Clinical history and physical examination usually suggest thepresence of a pneumothorax, although clinical manifestations

are not reliable indicators of size.29 30 In general, the clinicalsymptoms associated with secondary pneumothoraces are

more severe than those associated with primary pneumotho-

races, and most patients with a secondary pneumothoraxcomplain of breathlessness which is out of proportion to the

size of the pneumothorax.31 32 Many patients, particularlythose with primary pneumothoraces, do not seek medical

advice for several days, 46% waiting more than 2 days with

symptoms.9 This feature is important because the occurrenceof re-expansion pulmonary oedema (RPO) after re-inflation

may be related to the length of time the lung has been

collapsed (see section 4.4.1).33 34

Arterial blood gas measurements are frequently abnormal

in patients with pneumothorax with the arterial oxygen ten-sion (PaO2) being less than 10.9 kPa (80 mm Hg) in 75% of

patients.35 The presence of underlying lung disease along with

the size of pneumothorax predicts the degree of hypoxaemia.35 Arterial PaO2 was below 7.5 kPa (55 mm Hg)

and PaCO2 above 6.9 kPa (50 mm Hg) in 16% of cases of

secondary pneumothorax in the largest reported series.36 Pul-

monary function tests are weakly sensitive measures of the

presence or size of pneumothorax and are notrecommended.8

In both primary and secondary spontaneous pneumothorax

the diagnosis is normally established by plain chest radio-graphy. In general, expiratory radiographs add little and are

not indicated as a routine investigation, even in the case of a

suspected small apical pneumothorax.37 38

When a pneumo-thorax is suspected but not confirmed by standard postero-

anterior (PA) chest radiographs, lateral radiographs provideadded information in up to 14% of cases. 39 The lateral decubi-

tus radiograph is superior to the erect or supine chest

radiograph and is felt to be as sensitive as CT scanning inpneumothorax detection.40 The upright lateral or lateral decu-

bitus radiograph is clinically helpful where findings on theupright PA radiograph are unclear. While such small

pneumothoraces may not have much clinical relevance in

patients without underlying lung disease, in patients withsuspected secondary pneumothoraces, even small pneumo-

thoraces may have significant implications and here lateral or

lateral decubitus radiographs are probably valuable. Inpatients with severe bullous lung disease CT scanning will dif-

ferentiate emphysematous bullae from pneumothoraces and

save the patient an unnecessary and potentially dangerousaspiration.41

3 SIZE OF PNEUMOTHORAX

The previous classification of the size of a pneumo-thorax tends to underestimate its volume. In thesenew guidelines the size of a pneumothorax is dividedinto small or large depending on the presence ofa visible rim of 2 cm between the lungmargin and the chest wall.

The plain PA radiograph is a poor method of quantifying the

size of a pneumothorax as it usually underestimates it. Exact

methods of estimating size from PA chest radiographs are

cumbersome and generally used only as a research tool. 42 The

size of a pneumothorax, in terms of volume, is difficult toassess accurately from a chest radiograph which is a two

dimensional image. In the 1993 guidelines19 pneumothoraceswere classified into three groups:

small: defined as a small rim of air around the lung;

moderate: defined as lung collapsed halfway towardsthe heart border; and

complete: defined as airless lung, separate from the dia-phragm.

This attempt to quantify a pneumothorax tends to underesti-

mate the volume of anything greater than the smallest of

pneumothoraces.1 Since the volume of a pneumothorax

approximates to the ratio of the cube of the of the lung diam-

eter to the hemithorax diameter, a pneumothorax of 1 cm onthePAchest radiograph occupies about 27%of thehemithorax

volume if the lung is 9 cm in diameter and the hemithorax

10 cm: (103 93)/103 = 27%. Similarly, a 2 cm radiographicpneumothorax occupies 49% of the hemithorax on the same

basis (fig 3).In viewof the proximity ofthe lung surface to the chest wall

in a pneumothorax of


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If a patient with a pneumothorax is admittedovernight for observation, high flow (10 l/min) oxy-gen should be administered, with appropriate cau-tion in patients with COPD who may be sensitive tohigher concentrations of oxygen. [B]

Breathless patients should not be left without inter-vention regardless of the size of the pneumothoraxon a chest radiograph. [C]

4.1.1 Primary pneumothoraces, minimal symptomsObservation alone is advised for small, closed, mildly sympto-matic spontaneous pneumothoraces.21 30 4648 7080% of pneu-

mothoraces estimated at smaller than 15% have no persistentair leak and recurrence in those managed with observation

alone is less than in patients treated with intercostal tube

drainage.48 Patients with small primary pneumothoraces andminimal symptoms do not require hospital admission, but it

should be stressed before discharge that they should returndirectly to hospital in the event of developing breathlessness.

Most patients in this group who fail this treatment and

require intercostal tube drainage have secondarypneumothoraces.48

4.1.2 Secondary pneumothoraces, minimal symptomsObservation alone is only recommended in patients with small

secondary pneumothoraces of less than 1 cm depth or isolatedapical pneumothoraces in asymptomatic patients. Hospitalisa-

tion is recommended in these cases. All other cases will

require active intervention (aspiration or chest drain inser-tion, see later sections).

4.1.3 Symptomatic pneumothoraces, primary orsecondaryObservation alone is inappropriate and active intervention is

required. Marked breathlessness in a patient with a small

(


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4.2.1 Repeat aspiration and catheter aspiration of simplepneumothorax

Repeated aspiration is reasonable for primary pneu-mothorax when the first aspiration has been unsuc-cessful (i.e. patient still symptomatic) and a volumeof 2.5 l was

aspirated during the unsuccessful first attempt.56 Catheter

aspiration of simple pneumothorax (CASP) involves a small(8 F) catheter being passed over a guidewire into the pleural

space. A three way stopcock is attached and air may be

aspirated via a 50 ml syringe. This controls up to 59% of all

pneumothoraces. Addition of a Heimlich valve and suctionmay improve success rates further.5759

4.3 Intercostal tube drainage

If simple aspiration or catheter aspiration drainageof any pneumothorax is unsuccessful in controllingsymptoms, then an intercostal tube should beinserted. [B]

Intercostal tube drainage is recommended in second-ary pneumothorax except in patients who are notbreathless and have a very small (50%, primary failure rates for aspiration are

estimated at >50%.

51 52 66

Age alone is a strong predictor offailure of simple aspiration (>50 years, success 2767%), 51 52

although in those over the age of 50 years with no evidence of

pre-existing lung disease there is no evidence that tube drain-age should be recommended before simple aspiration as

primary treatment.

Analgesic use during the insertion of intercostal tubesremains poorly studied. The injection of intrapleural local

anaesthetic (2025 ml = 200250 mg, 1% lignocaine) given as

a bolus and at eight hourly intervals as necessary after theinsertion of the drain significantly and safely reduced pain

scores without affecting blood gas measurements, either with

or without chemical pleurodesis. There are no data detailingthe incidence of pleural infection with this technique.67 68

Chest tubes frequently (59%) end up in fissures,69 but thesetubes seem to retain their effectiveness. Step by step

guidelines to chest drain insertion are described elsewhere inthese guidelines (page ii53).

4.3.1 Complications of intercostal tube drainageThe complications of intercostal tube drainage includepenetration of the major organs such as lung, stomach, spleen,

liver, heart and great vessels, and are potentially fatal.63 7073

These complications occur more commonly when a sharpmetal trocar is inappropriately applied during the

procedure.63 72 73

In the largest series reviewing complications of tube drain-

age in recent times, Chan and colleagues74 identified

complications in 18% of chest drain insertions for allindications; 64% of these chest tubes (n=373) were inserted

for treatment of pneumothorax. However, 15% of the compli-

cations identified involved failure of resolution of thepneumothorax and only 4% involved aberrant tube place-

ment. Notably, complications related to tube placement

occurred most commonly on medical wards. CT assessmentsuggests a higher rate of incorrect tube placement. Baldt and

colleagues75 identified 3% of tubes placed extrathoracicallyand 6% placed within the lung during the treatment of pneu-

mothoraces. This highlights the need for correct training in

chest tube placement. In some circumstances, thoracic CTscanning is valuable for assessing chest tube positionfor

example, when misplacement is suspected but not confirmed

on a plain radiograph.75

Pleural infection is another complication of intercostal tube

drainage. The rate of empyema after chest tube insertion has


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been estimated as 1%.74 Other series have reported anincidence of up to 6% of chest tube related empyema intrauma cases and suggested that the administration ofprophylactic antibiotics should be considered, particularly

where a prolonged period of chest tube drainage might beanticipated.76 77 This highlights the need for full aseptictechnique in the insertion or manipulation of any chest drain-age system.

Finally, surgical emphysema is a well recognised complica-tion of intercostal tube drainage.78 This is generally of cosmetic

importance only, subsiding after a few days. The developmentof surgical emphysema associated with pneumothorax in-

volves an air filled space, not formerly in communication withthe subcutaneous tissue, being brought into communication

with the subcutaneous tissues. This may occur in the presenceof a malpositioned, kinked, blocked, or clamped tube.Likewise, a small tube in the presence of a very large leak maypotentially cause surgical emphysema. Occasionally, theresulting acute airway obstruction or thoracic compressionmay lead to respiratory compromise.78 79 The treatment isusually conservative but, in life threatening situations,tracheostomy, skin incision decompression, and insertion oflarge bore modified subcutaneous chest drains have all beenused.78

4.3.2 Size of tube

There is no evidence that large tubes (2024 F) areany better than small tubes (1014 F) in the manage-ment of pneumothoraces. The initial use of large(2024 F) intercostal tubes is not recommended,although it may become necessary to replace a smallchest tube with a larger one if there is a persistent airleak. [B]

Although one study suggested that success rates for the treat-ment of pneumothoraces with small chest tubes (13 F) were

poor and that larger sized catheters should be used,80

subsequent studies have not confirmed this and suggest thatsmaller calibre chest tubes are just as effective.8184 Primary

success rates of 8497% were recorded in these studies usingdrains of 79 F gauge. Recent technical developments have

allowed the addition of a Heimlich flutter valve to small tubes

as well as to larger bore tubes.Factors which might predispose to small tube failure, thus

favouring the choice of a larger tube, would be the presence ofpleural fluid and the presence of a large air leak which exceedsthe capacity of the smaller tubes.82 The use of an indwellingsmall lumen Teflon catheter (2 mm) inserted over needle andguidewire attached to a flutter valve after partial aspiration

with a 60 ml syringe proved successful in 27 of 28 patientswith a mean drainage time of 48 hours.59 Using a small calibrechest drain system, the median duration of drainage rangedfrom 2 to 4 days, which compares very favourably with largerintercostal tube drainage systems.59 82 83 Difficulties with tubeblockage were not encountered in any of these studies.Chemical pleurodesis is still possible through smaller tubesincluding indwelling catheter systems.

If the decision is made to insert a chest drain, small(1014 F) systems should be used initially. The use of catheterover guidewire systems (Seldinger technique) may prove to beas safe and effective as small calibre tubes, although they aremore expensive. They are being used with increasingfrequency, but further evidence is required before they can berecommended for initial use.

4.4 Referral to respiratory specialists

Pneumothoraces which fail to respond within 48hours to treatment should be referred to a respira-tory physician. [C]

Failure of a pneumothoraxto re-expand or a persistent airleakexceeding 48 hours duration should prompt referral to a res-

piratory physician. Such patients may require sustained chestdrainage with complex drain management (suction, chest

drain repositioning) and thoracic surgery decisions. These

issues will be better managed by physicians with specifictraining and experience in these problems and established

relationships with a thoracic surgeon. Drain management isalso best delivered by nurses with substantial experience in

this area.

4.4.1 Chest drain suction

Suction to an intercostal tube should not be applieddirectly after tube insertion, but can be added after48 hours for persistent air leak or failure of apneumothorax to re-expand. [B]

High volume, low pressure (10 to 20 cm H2O)suction systems are recommended. [C]

Patients requiring suction should only be managedon lung units where there is specialist medical andnursing experience. [C]

There is no evidence to support the routine initial use of suc-

tion applied to chest drain systems in the treatment of spon-

taneous pneumothorax.80 85A persistent air leak, with or with-

out incomplete re-expansion of the pneumothorax on a chest

radiograph, is the usual reason for applying suction to an

intercostal tube system. A persistent air leak is usuallyarbitrarily defined as a continued air bubbling through an

intercostal tube 48 hours after insertion. Mathur andcolleagues86 retrospectively reviewed 142 cases of spontaneous

pneumothorax requiring chest drain insertion. The median

time to resolution was 8 days (19 days in those withunderlying lung disease), which was not related to the initial

size of the pneumothorax. Most of the patients (30/43) with apersistent air leak had suction applied, but without standardi-

sation of the degree of suction or of the point of initiation (the

first 4 days in the majority). Normal intrapleural pressures are8 cm H2O during inspiration and 3.4 cm H2O during expira-

tion. During intercostal tube drainage various factors influ-ence the amount of suction applied to the pleural space. 63 87 It

has been suggested that, because the magnitude of these

physiological factors varies, it is desirable to apply 10 to

20 cm H2O suction to all pneumothoraces which are slow tore-expand, and the system used should have the capacity to

increase the suction with an air flow volume of 1520 l/min. 88

Over 40 years ago Roe89 stressed the importance of high

volume vacuums to drain the pleural space during pneumot-horaces. The use of high pressure, high volume suction is not,

however, recommended because of the ease with which it can

generate high air flow suction which may lead to air stealing,hypoxaemia, or the perpetuation of persistent air leaks.90 Like-

wise, high pressure, low volume systems should be avoided.64

High volume, low pressure systems such as a Vernon-Thompson pump or wall suction with an adaptor to reduce

pressure are recommended. Unfortunately, due to the lack ofmore recent randomised controlled trials examining the role

of suction with intercostal tube systems, evidence based

recommendations cannot be applied. The best practice fromprevious studies to date, as above, suggests that suction should

be applied after 48 hours, but that surgical referral for a

persistent air leak in those without pre-existing lung diseaseshould be made at 57 days. Significantly, earlier referral (24

days) should be considered in those with underlying disease,

a large persistent air leak, or failure of the lung tore-expand.9193 If suction is to be applied to a chest drain, it is

recommended that the patient should be situated in an areawhere specialist nursing experience is available.

The addition of suction too early after the insertion of a

chest tube, particularly in the case of a primary pneumo-thorax which may have been present for a few days, may

precipitate re-expansion pulmonary oedema (RPO) and is


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contraindicated. RPO is probably caused by the increased per-

meability of capillaries damaged during a pneumothorax. This

becomes manifest as oedema during re-expansion due to fur-ther mechanical stresses applied to the already leaky

capillaries.94 Clinically, these patients manifest symptoms ofcoughing and breathlessness or chest tightness after insertion

of the chest tube. In those whose symptoms persist, a repeat

chest radiograph after 24 hours will often show pulmonaryoedema in the treated lung, although pulmonary oedema may

also develop in the contralateral lung.95 The incidence of RPO

may be up to 14% and is higher in those with larger primarypneumothoraces and in younger patients (


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persistent air leaks had resolved their air leaks by 14 days with

no mortality. However, considering the efficacy and relatively

lowlevels of morbidityand recurrence associated with surgeryfor pneumothorax,109112 earlier surgical intervention has been

advocated for persistent air leak or failure of re-expansion,particularly in cases of secondary pneumothorax.92 113 Several

authors have recommended operative referral/intervention as

early as 3 days for a persistent air leak. However, these studieswere not controlled.91 93 Despite the reduction in the incidence

of late recurrence of pneumothorax in many of these studies,

surgical referral for a persistent air leak in a first primarypneumothorax within the first 45 days is not supported by

the literature. However, best practice suggests that protracted

chest tube drainage is not in the patients interest. It is there-fore recommended that patients with difficult pneumothora-

ces should receive care from a respiratory physician and that athoracic surgical opinion will be an early part of management.

According to the statistical and perceived risk of recurrence,accepted indications for operative intervention are as follows:

Second ipsilateral pneumothorax

First contralateral pneumothorax

Bilateral spontaneous pneumothorax

Persistent air leak (>57 days of tube drainage; air leak orfailure to completely re-expand)

Spontaneous haemothorax Professions at risk (e.g. pilots, divers)108 110 114116

4.5.1 Surgical strategiesThere are two objectives in the surgical management of a

pneumothorax. The first widely accepted objective is resection

of blebs or the suture of apical perforations to treat the under-lying defect. The second objective is to create a pleural

symphysis to prevent recurrences. There is debate between

those who favour surgical pleurodesis or pleural abrasion ver-sus those who favour partial or total pleurectomy as a defini-

tive treatment to prevent recurrence of pneumothorax, 109 117 118

although a relatively recent comprehensive review of this area

suggests a slight advantage of pleurectomy over pleural abra-

sion with a recurrence rate of 0.4% after pleurectomy (n=752)and 2.3% after pleural abrasion (n=301).109 Operative tech-

niques have tended towards minimally invasive procedures

over the last few years. In order to be considered effective,these techniques should yield results comparable to the gold

standard open thoracotomy procedurethat is, the operative

morbidity should be less than 15% and the pneumothoraxrecurrence rate should be less than 1%.37 99 112

Open thoracotomyIn 1941 Tyson and Crandall119 described pleural abrasion as a

treatment for pneumothorax and in 1956 Gaensler 117 intro-

duced parietal pleurectomy for recurrent pneumothorax. Thisprocedure produces uniform adhesions between the pleura

and the chest wall. Both of these techniques are designed to

obliterate the pleural space by creating symphysis between thetwo pleural layers or between the visceral pleura and subpleu-

ral plane, in the case of parietal pleurectomy. In order to pre-vent recurrence, however, an appropriate closure at the site ofthe pleural airleak is essentialeither by cauterisation, ligation,

or suture of accompanying blebs.116 Open thoracotomy yieldsthe lowest postoperative recurrence results. Bulla ligation/

excision, thoracotomy with pleural abrasion, and either apical

or total parietal pleurectomy all have failure rates under0.5%.48 110 Morbidity from thoracotomy for pneumothorax has

an overall incidence of 3.7%, mostly in the form of sputumretention and postoperative infection.110 Open thoracotomy is

generally performed using single lung ventilation, a limited

posterolateral thoracotomy allowing parietal pleurectomy,excision, or stapling of bullae or pleural abrasion.120 Isolated

lung ventilation during open thoracotomy facilitates full visu-

alisation of the visceral pleura. This may not be possible dur-

ing a VATS procedure, increasing the risk of missing a leaking

bulla.121123 Open thoracotomy may be associated with in-creased postoperative respiratory dysfunction and hospital

stay compared with VATS procedures.120 It is suggestedthat thesuccess rates with the open procedure are higher.124 Thus, sur-

gical authorities suggest open thoracotomy in patients with

secondary pneumothoraces who may have extensive pleuraldisease requiring more extensive pleurectomy, subpleural

bullectomy, or pleural abrasion.110 114 125

Surgical chemical pleurodesis

Surgical chemical pleurodesis is best achieved with5 g sterile talc. Side effects such as ARDS andempyema are reported but rare. [A]

The use of talc pleurodesis is now a subject of renewed inter-

est because of the potential unavailability of tetracycline, its

low cost, and a record of successful pleurodesis (8592%) thatis similar to alternative thoracoscopic techniques for compli-

cated pneumothorax.99 114 126 127While talc slurry inserted undermedical supervision via intercostal tube drainage tends to be

less favoured than thoracoscopic talc poudrage, both methods

have been shown to be effective. The overall success rate fortalc pleurodesis reviewed by meta-analysis is 91%.126 Surgical

pleurodesis with tetracycline is not generally felt to be a satis-

factory alternative, with recurrence rates of 16% in a series of390 patients who underwent surgical pleurodesis using

tetracycline.98 There are no controlled trials comparing painduring talc pleurodesis with that using other agents, although

it is suggested that talc pleurodesis is no more difficult or

painful a procedure than tetracycline pleurodesis.128132 Dos-ages of talc ranging from 2 g to 10 g have been used, but the

suggestion that higherdosages aremore effective has not been

established by controlled trials. On the basis of a meta-analysis of uncontrolled data, 5 g talc by VATS is recom-

mended with a success rate of 87%, which is very close to thesuccess rates using more extensive operative approaches.126

Side effects reported with talc pleurodesis include five cases of

adult respiratory distress syndrome (ARDS), although the riskof ARDS may be related to the size of talc particles used 133;

empyema, although this is rare when properly sterilised talc isused126 134 135; pneumonia; and respiratory failure.134 In view of

these potential side effects, standard first line usage of talc

poudrage or talc slurry pleurodesis should be approached withcaution since surgery not dependent on introducing a foreign

agent is usually an option. Lower dosages of 25 g should be

used until dosage schedules and effectiveness have been clari-fied. Long term safety does not appear to be an issue if

asbestos-free talc is used. The success rates with talc poudrage

and talc slurry pleurodesis are similar, so either approach canbe recommended. Because of the relatively high failure rates

of over 9% with talc pleurodesis compared with surgical pleu-

ral stripping procedures, talc pleurodesis should not beconsidered as initial treatment for primary spontaneous

pneumothorax requiring surgical intervention. In thosepatients who are either unwilling or too unwell to undergo

general anaesthesia, medical pleurodesis with either tetra-

cycline or talc (via an intercostal tube) is recommended.

Transaxillary minithoracotomyBecker and Munro136 pioneered this technique in the 1970s.

The procedure is considered a minimally invasive procedure.

The incision in the axillary margin measures 56 cm. Apicalpleurectomy or abrasion may be performed and the apex care-

fully inspected for pleural blebs or bullae which may be

stapled. The largest series examining this technique reporteda mean hospital stay of 6 days, a recurrence rate of 0.4%, and

a complication rate of 10%, most of which were minor.125 Theseresults make this procedure a realistic alternative to open


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thoracotomy for the treatment of complicated spontaneous

pneumothorax.

Video assisted thoracoscopic surgery (VATS)The evaluation of VATS for spontaneous pneumothorax is lim-

ited by the small number of randomised trials comparing it

with alternative surgical approaches. To date, there have onlybeen two randomised studies which have attempted to define

the role of VATS in the treatment of spontaneouspneumothorax.120 137 In a comprehensive review, Massard and

colleagues99

have suggested that the impression that VATS issuperior to open procedures in terms of morbidity, time inhospital, and cost may not be wholly correct. Minimally

invasive surgery may have a complication rate similar to open

procedures at about 810%.120 122 138 Recurrence rates of

pneumothorax after VATS are 510%,114 127 which are higher

than the 1% rates reported after open procedures.110 Whilebullectomy, pleurectomy, pleural abrasion, and surgical pleu-

rodesis have all been shown to have reasonable success rates

when carr ied out thoracoscopically,120 122 128 139141 there are con-cerns associated with VATS performed under local anaesthetic

supplemented by nitrous oxide inhalation. These arise from

the inability to obtain isolated single lung ventilation andinclude difficulties in inspecting the entire visceral pleural

surface, increasing the risk of missing a leaking bleb orbulla.123 142 It is also suggested that a less intense pleural

inflammatory reaction is induced by VATS procedures leading

to a less effective pleurodesis.143 Several authors suggest thatVATS offers significant advantages over open thoracotomy

including a shorter postoperative hospital stay,114 120 127 138 142

significantly less postoperative pain,120 125 143 144 and better

pulmonary gas exchange in the postoperative period. 145 How-

ever, Kim and colleagues in their randomised controlled trialdid not confirm a shorter postoperative stay in the VATS

groups.137

Further randomised trials comparing VATS with transaxil-lary and open thoracotomies are required and, until these data

are available, VATS cannot be considered to be established asbeing superior to thoracotomy.144 Waller and colleagues146 sug-

gested that, while VATS may be the preferred surgical

procedure for young fit people with complicated or recurrent

primary pneumothoraces, it is less reliable in cases of second-ary pneumothorax.In cases of secondary pneumothorax, open

thoracotomy and repair is still the recommended approachand VATS procedures should be reserved for those who might

not tolerate an open procedure because of poor lung function.

4.6 Discharge and follow up

Patients discharged without intervention shouldavoid air travel until a chest radiograph has con-firmed resolution of the pneumothorax. [C]

Diving should be permanently avoided after a pneu-mothorax, unless the patient has had bilateral surgi-cal pleurectomy. [C]

Primary pneumothorax patients treated successfullyby simple aspiration should be observed to ensure

clinical stability before discharge. Secondary pneu-mothorax patients who are successfully treated withsimple aspiration should be admitted for 24 hoursbefore discharge to ensure no recurrence. [C]

Patients with spontaneous pneumothoraces who are dis-

charged without active intervention should be advised toreturn for a follow up chest radiograph after 2 weeks. These

patients should be cautioned against flying until a follow up

chest radiograph confirms full resolution of the pneumotho-rax. Commercial airlines currently arbitrarily advise that there

should be a 6 week interval between having a pneumothoraxand travelling by air. A recent chest radiograph should confirm

resolution of the pneumothorax. A patient with a current

closed pneumothorax should not travel on a commercialflight. There is no evidence that air travel precipitates

recurrence of a pneumothorax, but recurrence during a flight

may have serious repercussions. The BTS Air Travel WorkingParty stress that patients may travel safely 6 weeks after a

definitive surgical procedure or resolution of the pneumotho-

rax on the chest radiograph. Otherwise, there is still a signifi-cant risk of recurrence for up to 1 year, depending on whether

the patient has underlying lung disease or not. Patients,

particularly those who have suffered a secondary spontaneous

pneumothorax, may decide to avoid the risk by avoiding flyingfor a year in the absence of a definitive surgical procedure.147

After a pneumothorax, diving should be discouraged per ma-nently unless a very secure definitive prevention strategy such

as surgical pleurectomy has been performed.148 The BTS

guidelines on respiratory aspects of fitness for diving149 dealwith this in greater detail.

Patients with primary pneumothorax treated successfully

by simple aspiration should be observed to ensure clinical sta-bility before discharge. The few patients with secondary

pneumothorax who are successfully treated with simple aspi-

ration should be admitted at least overnight and preferably for24 hours before discharge to ensure no recurrence. The

mortality rate associated with secondary pneumothorax is10%, and many of these patients die after the pneumothorax

has resolved.

18 32

Most patients with secondary pneumothoraxwill require a more protracted admission, including treatmentof their underlying lung disorder.32 All patients discharged

after active treatment or otherwise should be given verbal andwritten advice to return to the Accident and Emergency

department immediately should they develop further breath-

lessness.

5 PNEUMOTHORAX AND AIDS

Early and aggressive treatment of pneumothoracesin HIV patients, incorporating intercostal tubedrainage and early surgical referral, is recommended.[B]

There is evidence that the clinical spectrum of spontaneous

pneumothorax is shifting away from the predominant

subpleural bleb disease as emphasised by most reports sinceKjaergard.3 There are several reports that up to 25% of sponta-neous pneumothoraces in large urban settings with a high

prevalence of HIV infection are AIDS related31 32 150; 25% of

AIDS patients will develop a pneumothorax.151153 Pneumocystis

carinii infection should be considered as the most likely

aetiology in any HIV positive patient who develops a

pneumothorax, although the administration of aerosolisedpentamidine has also been suggested as an independent risk

factor.151 Pneumocystis carinii pneumonia (PCP) is associatedwith a severe form of necrotising alveolitis in which the sub-

pleural pulmonary parenchyma is replaced by necrotic thin

walled cysts and pneumatoceles.154 155 AIDS related spontane-ous pneumothorax is complicated by the refractory nature of

air leaks which tend to occur with the necrotising subpleural

pneumonitis of PCP infection.

156

Such is the relationshipbetween AIDS related pneumothorax and the presence of P

carinii that the occurrence of pneumothorax in AIDS patientsis considered an indicator of treatment for active P carinii

infection.151 AIDS related spontaneous pneumothorax carr ies

a higher hospital mortality, a higher incidence of bilateral(40%) and recurrent pneumothoraces, and more prolonged air

leaks.157 Treatment failures may also reflect the degree ofimmunocompromise of the impaired host as reflected by the

CD4 counts.157 It has also been suggested that systemic

corticosteroids used to treat PCP may increase the risk of mor-bidity from AIDS related pneumothorax.158 Because of the

high rate of primary treatment failures and associated short

survival times reported for such patients,159 160 early and


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aggressive treatment of AIDS related spontaneous

pneumothoraxincorporating early tube drainage and talc

pleurodesis, early VATS assisted talc poudrage, unilateral orbilateral pleurectomyis recommended.150 152 157 158 161 162

6 PNEUMOTHORAX AND CYSTIC FIBROSIS

Early and aggressive treatment of pneumothoracesin cystic fibrosis is recommended. [C]

Surgical intervention should be considered after the

first episode, provided the patient is fit for the proce-dure. [C]

The treatment of pneumothorax for patients with cystic fibro-sis (CF) is similar to that for non-CF patients. A pneumotho-

rax is associated with more severe disease and can be lifethreatening. Median survival after pneumothorax in patients

with CF is 30 months and the occurrence reflects the severity

of the underlying disease rather than being an independentrisk factor.163 Contralateral pneumothoraces occur in up to 40%

of patients.163 164 A small pneumothorax without symptomscan be observed or aspirated. Larger pneumothoraces require

treatment with intercostal tube drainage. The leak is usually

from the upper lobes and it is important to site the tube in thecorrect place. The collapsed lung can be stiff and take a long

time to re-expand. It is important to commence intravenous

antibiotics at the same time to prevent sputum retention,which can delay re-expansion of the collapsed lung. Pleurec-

tomy, pleural abrasion, and talc pleurodesis all have markedly

lower reported recurrence rates than observation or tube tho-racostomy alone, which has an unacceptably high recurrence

rate of 50%.165167 Partial pleurectomy has a success rate of 95%with little reduction in pulmonary function associated with

surgery, and it is generally felt to be the treatment of choice in

CF patients with recurrent pneumothoraces who are fit toundergo surgery.163 In those patients who are too ill to undergo

surgery, it can take 23 weeks for the lung to re-expand withintubation and suction. In this group, talc instillation or

repeated instillation of the patients own blood are effective

alternatives.163 Although not an absolute contraindication totransplantation, sclerosants can make transplantation more

difficult. It takes longer to remove the lungs, prolonging the

ischaemic time for the donor lungs, and is associated withexcessive bleeding.168

7 TENSION PNEUMOTHORAX

If tension pneumothorax is present, a cannula ofadequate length should be promptly inserted intothe second intercostal space in the mid clavicular lineand left in place until a functioning intercostal tubecan be positioned. [B]

Tension pneumothorax occurs when the intrapleural pressure

exceeds the atmospheric pressure throughout inspiration as

well as expiration. It is thought to result from the operation ofa one way valve system, drawing air into the pleural space

during inspiration and not allowing it out during expiration.

The development of tension pneumothorax is often, but notalways, heralded by a sudden deterioration in the cardiopul-

monary status of the patient related to impaired venous

return, reduced cardiac output, and hypoxaemia.169 170 The

development of tension in a pneumothorax is not dependent

on the size of the pneumothorax and the clinical scenario oftension pneumothorax may correlate poorly with chest radio-

graphic findings. The clinical status is striking. The patient

rapidly becomes distressed with rapid laboured respiration,cyanosis, sweating, and tachycardia. It should be particularly

suspected in those on mechanical ventilators or nasalnon-invasive ventilation who suddenly deteriorate or develop

EMD arrest, and is frequently missed in the ICU setting.171 If a

tension pneumothorax occurs, the patient should be given

high concentration oxygen and a cannula should be intro-

duced into the pleural space, usually in the second anterior

intercostal space mid clavicular line. Air should be removeduntil the patient is no longer compromised and then an inter-

costal tube should be inserted into the pleural space as previ-

ously described. Advanced Trauma Life Support guidelinesrecommend the use of a cannula 36 cm long to perform

needle thoracocentesis for life threatening tensionpneumothorax.172 However, in 57% of patients with tension

pneumothorax the thickness of the chest wall has been found

to be greater than 3 cm. It is therefore recommended that acannula length of at least 4.5 cm should be used in needle

thoracocentesis of tension pneumothoraces.173 174 The cannulashould be left in place until bubbling is confirmed in the

underwater seal system to confirm proper function of the

intercostal tube.169

8 IATROGENIC PNEUMOTHORAXThe incidence of iatrogenic pneumothorax is high, outnum-bering spontaneous pneumothoraces in several large review

series.175 176 Transthoracic needle aspiration (24%), subclavian

vessel puncture (22%), thoracocentesis (22%), pleural biopsy(8%), and mechanical ventilation (7%) are the five leading

causes.173 The two primary risk factors related to the develop-ment of pneumothorax with transthoracic needle aspiration

are the depth of the lesion and the presence of COPD.

177

Todate, no method has been found to prevent pneumothoraxfollowing needle aspiration/thoracocentesis. While it was

hoped that positioning the patient so that the area to be biop-

sied was dependent might reduce the incidence of suchevents, this has not been shown to be the case.178 The

treatment of iatrogenic pneumothorax tends to be simple asthere is less likelihood of recurrence. The majority will resolve

with observation alone. If required, treatment should be by

simple aspiration. Delius and coworkers58 aspirated up to 89%without resorting to tube drainage using a small 8 F teflon

catheter. Patients with COPD who develop an iatrogenic

pneumothorax are more likely to require tube drainage,179 and

patients who develop a pneumothorax while on positive pres-

sure ventilation should be treated with a chest drain unlessimmediate weaning from positive pressure ventilation is pos-

sible, as positive pressure ventilation maintains the air leak. 180

9 CONCLUDING REMARKSThe 1993 BTS pneumothorax guidelines emphasised the place

of simple observation and aspiration, reminded junior doctorsof the potential hazards of chest drain insertion, and encour-

aged shorter, safer and less painful treatment paths for many

patients. Despite their usefulness, recent evidence suggeststhat adherence to these guidelines may be suboptimal. This

revision endorses the main thrust of these guidelines, with

observation for the least severe cases, simple aspiration as theinitial treatment choice, and chest drain insertion as a last

resort. Recently, the American College of Chest Physicians

(ACCP) has published its own guidelines which were arrivedat by the Delphi consensus method.65 These guidelines are

similar to our proposed guidelines in many respects, althoughthere are differences such as the emphasis placed on the value

of simple aspiration in the treatment of primary pneumotho-

rax.Both sets of guidelines will undoubtedly stimulate debate.The evidence for the current BTS recommendations is

incorporated and its weaknesses described. This revision alters

the threshold for aspiration in primary pneumothorax andsuggests a place for re-aspiration. The limitations of aspiration

in secondary pneumothorax are acknowledged, and initialchest drain insertion is recommended for categories of

patients where aspiration is unlikely to succeed. These issues

are already being revisited as the new pneumothorax kitsinserted with a Seldinger technique and containing integral

Heimlich type flutter valves gain popularity. It is likely that


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they will prove to be as successful and possibly replace simpleaspiration followed by immediate removal of the catheter as

recommended in these guidelines.

Several aspects of management that were not previouslycovered are now included. These include the place of CT scan-

ning in diagnosis, which patients to refer for surgery, a discus-

sion of surgical techniques, and issues such as intercostal tubesize and the place of suction and pleurodesis. Complex

scenarios including tension pneumothorax, subcutaneous

emphysema, pneumothorax in HIV disease and adult CF arealso discussed. It is hoped that these changes build on the

clinical benefits produced by the first set of guidelineswhichif adhered toshould, we calculate, prevent approxi-

mately 7000 unnecessary chest drain insertions every year in

the UK.

. . . . . . . . . . . . . . . . . . . . .

Authors affiliationsM Henry, Department of Respiratory Medicine, The General Infirmary atLeeds, Great George Street, Leeds LS1 3EX, UKT Arnold, Medical Chest Unit, Castle Hill Hospital, Cottingham, NorthHumberside HU16 5JQ, UKJ Harvey, Department of Respiratory Medicine, Southmead Hospital,Bristol BS10 5NB, UK

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Audit points

Proportion of patients treated by (a) simple observation, (b)aspiration, and (c) chest drains and their appropriateness(relative to the guidelines) and outcome (in terms ofrecurrence rates, complications, and lengths of stay in hos-pital)

Number of chest drains clamped and the reasons for this. Referral rates to physicians and surgeons and the timing of

such referrals.

Use of analgesics and local anaesthetics. Follow up rates

Future potential areas for research

Prospective randomised controlled trials comparing: simple observation versus aspiration tube drainage

for primary pneumothoraces larger than 2 cm on thechest radiograph;

use of small catheter/Heimlich valve kits versus inter-costal tube drainage following failed aspiration inprimary pneumothoraces;

small catheter aspiration (CASP) versus conventionalaspiration or tube drainage;

VATS versus open thoracotomy for the difficult pneu-mothorax. Use of suction with regard to its timing and optimal mode. Comparison of clamping and non-clamping strategies

after cessation of air leak.


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