Treatment of spontaneous pneumothorax

Spontaneous pneumothorax (SP) continues to be a frequent management problem. The lack of universally accepted management guidelines and a myriad of treatment options contribute to the current heterogeneous approach to SP. Forthcoming guidelines may improve management. Meantime, simple observation in stable patients with a primary spontaneous pneumothorax (PSP) is reasonable, and encouraging smoking cessation is paramount. More aggressive management of a patient with a secondary spontaneous pneumothorax (SSP) is advisable and should include at least chest tube drainage with chest tube size selection key. Careful assessment of recurrence risk and early corrective intervention for patients with a persistent air leak will improve care of both PSP and SSP patients. If chest tube-directed pleurodesis is chosen for recurrence prevention, talc is the most successful agent available. However, no more than 5 g of talc should be utilized, given the potential increased risk for acute respiratory failure at higher doses, and patients should be advised of alternatives such as doxycycline. No overwhelming clinical outcome advantages for a thoracoscopic over a limited thoracotomy approach to SP management has been reported in any randomized controlled trial. Institutional experience with and the availability of thoracoscopy or limited thoracotomy should dictate the operative approach to SP recurrence prevention and air leak correction until further study clarifies the choice.