PSP & SSP SSP associated with lung disease e.g. TB, COAD & symptoms more severe than PSP Size of pneumothorax not determine the severity of symptoms Tension pneumothorax cardiorespiratoy distress i.e. cyanosis, sweating, severe tachypnoea, tachycardia and hypotension Pneumothorax – erect inspiratory PA cxr displacement of pleural line CT scan for small pneumothorax
PSP Male, young, tall & thin
PSP referral to chest physician in 24hr, ref to thoracic surgeon if persistent air leak in 5-7 days chest tube SSP early referral, d/w thoracic surgeon if persistent air leak in 48 hrs Surgical empysema?
The size of the pneumothorax determines the rate of resolution and is a relative indication for active intervention. Best measured by Digital radiography (Picture-Archiving Communication Systems, PACS)
Chemical plerodesis – sclerosing agent e.g. tetracycline open or VATS approach
AIM: resect any visible bullae or blebs on the visceral pleura and also to obliterate emphysema-like changes9 or pleural porosities under the surface of the visceral pleura.8 The second objective is to create a symphysis between the two opposing pleural surfaces as an additional means of preventing recurrence 1. Open thoracotomy and pleurectomy remain the procedure with the lowest recurrence rate (approximately 1%) for difficult or recurrent pneumothoraces. (A) 2. Video-assisted thoracoscopic surgery (VATS) with pleurectomy and pleural abrasion is better tolerated but has a higher recurrence rate of approximately 5%. (A) 3. Surgical chemical pleurodesis is best achieved by using 5 g sterile graded talc, with which the complications of adult respiratory distress syndrome and empyema are rare.
By: Dr. Ismah
Reference: Management of spontaneous pneumothorax,
British Thoracic Society pleural disease guideline 2010
• Not routinely used because may cause re expansion
• Indicated when persistent air leak with or without incomplete
re-expansion of the lung after 48 hrs
• High-volume low-pressure systems such as Vernon-Thompson
pumps or wall suction with low pressure adaptors
• Communication between the bronchial tree and pleural space.
• Persistent air leak or a failure to re-inflate the lung despite
chest tube drainage for 24 h.
• Chest drains inserted into the lung parenchyma
- Large bore chest drains (multiple if necessary) and the use of
- Refractory cases surgical repair of the air leak by
thoracoplasty, lung resection/stapling, pleural
Indications for surgical advice:
• Persistent air leak (despite 5 to 7 days of chest tube drainage)
or failure of lung re-expansion.
• Synchronous bilateral spontaneous pneumothorax.
• Professions at risk (eg, pilots, divers).
• Second ipsilateral pneumothorax.
• First contralateral pneumothorax.
• Spontaneous haemothorax
Advice & f/up
• Avoid air travel until 1 weeks post fully resolution
• Avoid diving unless has undergone bilateral surgical
pleurectomy and has normal lung function and chest CT scan
• Observation/ NA F/up in 2-4 weeks