How should complete lung collapse secondary to primary spontaneous pneumothorax be managed? 

Management of primary spontaneous pneumothorax (PSP) depends on the symptoms and size of lung collapse. The British Thoracic Society recommends needle aspiration (NA) for all PSP requiring intervention, followed by intercostal drain (ICD) if NA fails. We compared the role of NA versus ICD as the first step in PSP with 'complete lung collapse'.This was a retrospective observational study of 877 consecutive pneumothorax episodes at University Hospitals of North Midlands, Stoke on Trent, UK. Chest X-ray (CXR) at presentation was reviewed to identify PSP with complete lung collapse. The primary outcome measure was successful lung re-inflation after initial intervention.Two-hundred and sixty-six PSP patients were identified; 69 had complete lung collapse on CXR of which 35 had NA and 34 had ICD. The ICD group had a significantly better immediate success compared with the NA group (62% versus 11%, odds ratio (OR) = 12.5, p<0.0001; after adjustment for potential confounders, OR increased to 26.4, p=0.0001) although long-term outcomes were comparable.There should be clear consensus on definition and management of complete lung collapse. PSP with complete lung collapse could be managed as a separate subgroup where ICD placement is considered to be the first intervention.