[Initial treatment of primary spontaneous pneumothorax by a team which does not include a thoracic surgeon]

Primary Spontaneous Pneumothorax (PSP) refers to air in the pleural cavity occurring in the absence of overt underlining pulmonary disease. Smoking is an important predisposing factor for PSP. Once PSP is diagnosed the size of the PSP should be assessed according to a chest radiogram. PSP smaller than 20% with minimal symptoms should be observed on an outpatient basis. Symptomatic patients or those with a larger PSP should be hospitalized and treated initially by an intrapleural catheter or a small chest tube inserted by the Seldiger technique without active suction. If full lung expansion and air leak cessation is not achieved within 24 hours active suction should be applied. Following this treatment up to 90% of large or symptomatic PSP cases can be managed successfully. In cases of failure of the lung to expand or persistent air leak within 3 days, recurrent PSP, or first presentation of bilateral PSP the patient should be referred to a surgical team. The preferred surgical option is VATS while open thoracotomy [either limited muscle sparing or full thoracotomy] should be used in special cases. Following this scheme some PSP cases in early stage can successfully be treated in hospitals which do not have a thoracic surgeon.