CHAPTER 27 
SPONTANEOUS PNEUMOTHORAX
Neal G. Moores  •  Karl G. Reyes  •  Siva Raja  •  David P. Mason
CHAPTER OUTLINE
EPIDEMIOLOGY
CAUSES
CLINICAL PRESENTATION
IMAGING
MANAGEMENT
Observation
The term pneumothorax was first coined by Jean Marc
Gaspard Itard1 in 1803, when he called attention to five
cases in which free air was found in the thorax after
trauma. Derived from the Greek words pneuma (air) and
thorakos (breastplate or chest), it is an apt description for
the accumulation of air in the pleural space that leads to
partial or total collapse of the affected lung. The clinical
features of pneumothorax were first described in 1819 by
René Laennec,2 who postulated the relationship to pre-
existing blebs and unprovoked rupture and, hence, the
term spontaneous pneumothorax. This pathophysiologic
mechanism was confirmed by Kjærgaard3 in later decades.
Today, the classification of pneumothoraces is based on
clinical presentation and underlying lung disease. Mul-
tiple management strategies range from simple evacua-
tion of air from the pleural space to potential prevention
of future pneumothoraces.
EPIDEMIOLOGY
Spontaneous pneumothorax (SP) may be termed either a
primary or secondary event, dependent on underlying
lung disease. Primary spontaneous pneumothorax (PSP)
typically occurs in young patients with localized blebs but
otherwise normal lungs. Secondary spontaneous pneu-
mothorax (SSP) occurs in patients with marked structural
lung disease and directly contributes to SP. Approxi-
mately 20,000 new cases of PSP are diagnosed annually
in the United States,4 with an estimated economic impact
of $130 million per year in lost wages. The annual esti-
mated incidence of PSP is between 7.4 and 18 cases per
100,000 population among men and between 1.2 and 6
cases per 100,000 population among women.4 Patients
prone to PSP are usually tall and thin and between 10
and 30 years of age.5 A significant factor is cigarette
smoking, which can increase the risk of PSP by a factor
as high as 20.6
462
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Aspiration
Tube Thoracostomy
Pleurodesis
Surgery
SPECIAL CONSIDERATIONS
Secondary Spontaneous Pneumothorax
Catamenial Pneumothorax
SSP develops as a complication of underlying lung
disease, most commonly chronic obstructive pulmonary
disease (COPD).7 The annual incidence of SSP is approx-
imately 6.3 cases per 100,000 population among men
and 2 cases per 100,000 population among women.4 The
peak incidence occurs between the ages of 60 and 65
years.5
CAUSES
PSP manifests without forewarning signs or symptoms
and is most likely caused by rupture of a subpleural
bleb. This premise is based on cumulative results of
patients undergoing computed tomography (CT), which
demonstrated subpleural blebs in as many as 80%.8,9
Surgical experience confirmed the presence of bullae in
more than 75% of patients who underwent video-assisted
thoracoscopic surgery (VATS) and thoracotomy.10-12
Recent research may indicate a more diffuse pathologic
etiology than simple bleb rupture. Fluorescein-enhanced
pathologic assay of resected lung tissue in PSP patients
reveals significant inflammatory changes and potential
air-leak sites remote from blebs and other visible
abnormalities.13
After the first episode of PSP, recurrence varies,
ranging from 16% to 54%. Most studies indicate an
average of 30%.14,15 Recent research indicates that the
presence of subpleural blebs on high-resolution CT
confers a recurrence risk of up to 68.1%, whereas the
absence of blebs carries a recurrence risk of only 6.1%.16
Most recurrences develop between 6 months and 2 years
after the initial episode.15 Men who are tall and have a
history of smoking are at the greatest risk of recurrence.
Counseling for smoking cessation should be strongly
encouraged.15 After the second episode of PSP, the likeli-
hood of recurrence increases markedly and can reach as
high as 83%.7,14
 27  SPONTANEOUS PNEUMOTHORAX 463

TABLE 27-1 American College of Chest

CLINICAL PRESENTATION Physicians Delphi Consensus
Statement on Spontaneous
PSP typically manifests with sudden pleuritic chest pain
Pneumothoraces
and dyspnea.6,17 Classic findings on physical examination
include diminished breath sounds, hyperresonance, and Clinically stable • Observation 3-6 hr
fremitus; however, patients with small pneumothoraces with small • Follow-up CXR excludes
may have normal findings on physical examination. Most pneumothorax progression: discharge and 1-2 day
patients with PSP are stable, primarily because of their follow-up
• Unreliable or impractical follow-up:
young age and otherwise normal lung function. Patients observation 24 hr
with SSP are more likely to present with respiratory Clinically stable • Admission
distress, a result of respiratory compromise caused by SP with large • Aspiration (or) tube thoracostomy
superimposed on preexisting lung disease.12 Whereas pneumothorax • Heimlich valve (or) water seal
• Highly reliable patients
tension SP is unusual, indicators include tachycardia, cya- • May discharge to home with
nosis, and hypotension. Heimlich valve with < 48 hr
follow-up
Clinically • Admission
IMAGING unstable with
large
• Tube thoracostomy (24-28 Fr)
• Pneumothorax catheter and
pneumothorax Heimlich valve
Chest radiography is the most common diagnostic tool • Acceptable in small subset of
for SP. A thin pleural line can be identified that has been patients
displaced from the chest wall. A small SP may be difficult • If initial placement does not
resolve instability: rapid
to identify on plain radiography; an expiratory view may conversion to suction/water seal
prove more beneficial in determining the presence of SP. device and standard chest tube
Frequently, attempts are made to measure the size of the Management of • >4 days
SP as a percentage of the hemithorax it occupies, although persistent air • Consider VATS and pleurodesis
this method is typically inaccurate.18,19 On occasion, a leak • Recommends against sclerosing
agents through chest tubes
giant bulla can mimic a pneumothorax. Subtle lines • Surgical risk prohibitive, or patient
demarcate a bulla, which tends to be surrounded by refuses surgery
thickened visceral pleura. In addition, a pleural line can • Pleurodesis via chest tube
frequently be seen with lung markings visible beyond the • Talc slurry
• Doxycycline
suspected bulla (double wall sign).20,21 Recurrence • Treatment reserved for second
Controversy exists about the significance of routine prevention spontaneous pneumothorax
chest CT to evaluate for subpleural blebs. Proponents • Operative intervention
contend that identification of large or multiple subpleural • Apical bullae resected, if present
blebs on CT is an indication for early surgical interven- • Abrasive pleurodesis
• Talc slurry: acceptable (alternative
tion to prevent recurrence.11,22,23 Opponents of this prin- sclerosants rarely acceptable in
ciple argue that management should not be influenced by this setting)
these findings alone.24,25 Although CT is seldom required • Parietal pleurectomy: acceptable
for routine diagnosis of SP, when subpleural blebs are (weak consensus)
• Chemical pleurodesis an acceptable
diagnosed on CT, recurrence rates are high and some will alternative
elect early intervention such as bleb resection.16 • Talc slurry
• Doxycycline

MANAGEMENT CXR, Chest x-ray; VATS, video-assisted thoracic surgery.

Algorithms for the management of SP range from estab-
lished management protocols (American College of Chest
Physicians [ACCP] Consensus Statement) to operative
intervention (Table 27-1). Selected therapies depend on a
number of variables: SP size, stability of the patient,
symptom complex, initial SP onset or recurrent episode,
and presence or absence of structural lung disease.19,26 The
principal procedure is evacuation of air from the pleural
space (spontaneous resolution versus instrumentation).
Additional procedures targeted to prevent future SP epi-
sodes may also be considered in cases of SP recurrence.
Observation
Small pneumothoraces are those that are less than 3 cm
in distance between the apical parietal pleura and the
From Baumann MH, Strange C, Heffner JE, et al: Management
of spontaneous pneumothorax: an American College of
Chest Physicians Delphi consensus statement. Chest
119:590–602, 2001.
thoracic cupula, with no lateral component. Asymptom-
atic patients should be managed expectantly26-28 by close
monitoring, physical examination, continuous pulse
oximetry, and repeated chest radiography within 3 to 6
hours. The ACCP recommends against the placement of
chest tubes, or aspiration of small pneumothoraces. Our
practice is to monitor patients in the hospital for a
minimum of 24 hours. Even though some patients with
stable radiographic features may be discharged from the
hospital with follow-up within 12 to 24 hours,16,26 the
potential for catastrophic consequences from a missed
tension pneumothorax is a great risk.29 Small pneumo-
thoraces usually resolve without intervention, but

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464 SECTION 1  THORACIC SURGERY
recurrence is possible. If chest radiography reveals that
the SP is enlarging, immediate intervention is crucial.
Aspiration
Aspiration allows evacuation of pleural air and complete
reexpansion of the lung. This technique can be applied
even for larger pneumothoraces if the patient is stable.
We prefer the Seldinger technique,30,31 which uses a
small, single-lumen central line placed over the superior
rib edge in the second interspace in the midclavicular
line. A three-way stopcock and large syringe are used to
aspirate until resistance is felt, usually signifying full lung
expansion. Chest radiography is then performed to
confirm the findings, and the catheter is removed.27,28,32-36
Commercially prepared kits with one-way valves (Heim-
lich valve)7 allow air to exit but prevent air entry. These
valves can be left in place until full lung expansion is
achieved. For more rapid resolution, however, it is our
preference to perform tube thoracostomy with a small
chest tube. Complications of aspiration, although rare,
may include bleeding and possible lung injury. Reported
success is higher in resolving PSP (66% to 83%) than for
SSP (37%).27,35 SP that does not respond successfully to
aspiration requires tube thoracostomy.
Tube Thoracostomy
Tube thoracostomy is recommended for patients with
large or symptomatic SP and for most patients with SSPs.
Patients with signs of a tension pneumothorax should be
treated without hesitation, even before chest radiography
is performed. Tube placement is through the fifth inter-
costal space in the midaxillary line. In our experience, as
with chest tubes placed through port sites following
VATS, there is no need to tunnel chest tubes placed at
bedside.
A small chest tube can be difficult to direct to the apex
of the chest, so a 28 Fr is preferable. The chest tube is
left in place for 24 to 48 hours. Our practice is to place
the chest tube on water seal once lung expansion has been
confirmed. If an air leak persists and nonoperative man-
agement is preferred, a Heimlich valve can be placed.
The patient can then be discharged for outpatient
management. The efficacy of suction is debated, but
there is no evidence that it speeds the resolution of SP.
If it is used, it should be used judiciously.37 Tube thora-
costomy successfully resolves PSP in approximately 90%
of patients for the first occurrence, 50% for the first
recurrence, and 15% after a second recurrence.38 For
this reason, definitive management of SP recurrences
will require either surgical intervention or chemical
pleurodesis.
Pleurodesis
After tube thoracostomy, chemical pleurodesis may help
prevent SP recurrence. Sclerosing agents are instilled to
create pleural symphysis. The most commonly used
agents are sterile talc slurry and doxycycline solution.
Because adult respiratory distress syndrome may be trig-
gered by high doses of talc, use should be limited to
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5 g.39,40 In theory, talc has the potential to induce malig-
nant transformation after decades of use, but thus far, this
has not been demonstrated in humans.41 Nonetheless,
our agent of preference is doxycycline to sclerose benign
pleural processes. A total of 500 mg of doxycycline com-
bined with lidocaine is infused through the chest tube,
and the patient’s position is shifted from side to side to
distribute the sclerosant. Suction is then placed for 48
hours. Recurrence of SP in patients treated with bedside
pleurodesis is high, ranging from 8% to 40%.40,42,43 In our
institution, this treatment is reserved for patients who are
not considered good operative candidates, most com-
monly patients with SSP.
Surgery
Surgical indications for PSP are recurrence, large or per-
sistent air leaks, and incomplete lung expansion after tube
thoracostomy. Other surgical indications include patients
with a history of bilateral SP and patients in occupations
that would place them at high risk if a pneumothorax
recurred, such as commercial pilots and professional
scuba divers.19,26,37,38 Although some thoracic surgeons
recommend surgery in patients with a first-time PSP if
bullae are detected on CT scan,22 we think that this strat-
egy is highly aggressive, unnecessary, and unproven; thus
we do not incorporate this practice into our treatment
strategies.
VATS is the surgical procedure of choice for SP,
replacing the previous procedure, axillary thoracot-
omy.44,45 The goals of surgery are resection of the offend-
ing bulla, complete lung expansion, and pleurodesis to
prevent recurrence. A standard three-port VATS tech-
nique is used with lung isolation through a double-lumen
endotracheal tube. The entire lung is carefully inspected,
with particular attention to the apex and superior seg-
ments, because these are typical bullae locations. Saline
flooding of the hemithorax during gentle lung inflation
can help locate a ruptured bleb. Some surgeons resect the
apex of the lung even if no bleb is located, although our
practice is to perform lung resection only when a bleb is
identified (Fig. 27-1). Buttressed staple lines are not nec-
essary with otherwise normal lung parenchyma.
Intraoperative pleurodesis should be performed in
addition to blebectomy. Mechanical pleurodesis is our
most common method and is performed with use of a
Bovie scratch pad with aggressive abrasion of the parietal
pleura (Fig. 27-2). It is our practice to infuse doxycycline
as an additional chemical sclerosant, although some sur-
geons choose to infuse talc at the time of surgery with
good results and minimal impairment of pulmonary func-
tion over time.46,47 This is in spite of a recent study out
of Korea suggesting that there is no difference in recur-
rence with mechanical pleurodesis following bleb
resection.48
Another effective method of obtaining pleural sym-
physis is parietal pleurectomy, by either VATS or open
techniques. Results are similar to those of mechanical
abrasion.49,50 Surgeons should make every effort to control
air leak before leaving the operating room. Apical chest
tube placement is crucial to full lung expansion. Postop-
eratively, chest tubes are placed to water seal as soon as

FIGURE 27-1  ■  Video-assisted technique of apical bleb resection.
(Reprinted with permission of the Cleveland Clinic Center for
Medical Art Photography. © 2008.)
FIGURE 27-2  ■  Video-assisted mechanical pleurodesis with use
of an electrocautery scratch pad. (Reprinted with permission of
the Cleveland Clinic Center for Medical Art Photography. © 2008.)
a chest x-ray demonstrates full expansion, and no air leak
is present. VATS successfully resolves SP and prevents
recurrence in more than 90% of patients.51 Whereas
some studies show that recurrence of SP is slightly higher
with VATS compared with thoracotomy, this small incre-
ment does not justify the discomfort and lost work days
in this generally young population.52 Thoracotomy is
reserved for VATS failures and complex giant bleb resec-
tions not amenable to VATS.
SPECIAL CONSIDERATIONS
Secondary Spontaneous Pneumothorax
Clinical presentation of SSP is similar to that of PSP;
however, dyspnea and respiratory compromise are often
more profound, given the presence of underlying lung
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27  SPONTANEOUS PNEUMOTHORAX 465
disease, even with small pneumothoraces. In this setting,
intervention should be performed quickly with tube tho-
racostomy. Major causes of SSP are COPD with bleb
rupture followed by Pneumocystis infection in patients with
HIV infection, asthma, cystic fibrosis, necrotizing pneu-
monia, or tuberculosis. Less common causes are idio-
pathic pulmonary fibrosis, Langerhans cell histiocytosis,
lung cancer, lymphangioleiomyomatosis, sarcoidosis, and
catamenial pneumothorax.12 SP in patients with COPD
portends poor long-term prognosis.53 Management strat-
egies must be tailored to the individual patient. Operative
risk in a markedly compromised patient must be weighed
against the potential morbidity and prolonged hospital
course that can accompany nonoperative intervention.
We have found Heimlich valves particularly valuable in
managing patients with prolonged air leak because they
allow easy ambulation and outpatient management.
Catamenial Pneumothorax
Catamenial pneumothorax is a rare form of SP usually
occurring within 72 hours of menstruation. The typical
patient is between 30 and 40 years of age, although age
may range substantially. Theories are unproven but
suggest that catamenial pneumothorax is caused by con-
genital diaphragmatic fenestrations that allow passage of
air through the peritoneum to the pleura or pathologic
intrathoracic endometrial implants that cause perforation
of the visceral pleura.54,55 Right-sided catamenial pneu-
mothorax is more common, but the reasons for this are
unclear. When catamenial pneumothorax recurs despite
intervention, treatment can be challenging. Hormonal
manipulation with gonadotropin-releasing hormone ago-
nists has been recommended; however, side effects can
be unpleasant, and it should be combined with surgery
for optimal results.55 Our approach is to inspect the dia-
phragm for fenestrations thoracoscopically. If they are
identified, fenestrations should be closed. This should be
combined with mechanical pleurodesis or pleurectomy.
Hormonal manipulation for one or two menstrual cycles
can be considered while awaiting complete pleural
symphysis.55
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