Aggressive Treatment of SpontaneousPneumothorax

SYDNEY P. HECKER, M.D., ROBERT W. JAMPLIS, M.D..and SIDNEY P. MITCHELL. M.D., Palo Alto

MANAGEMENT OF PATIENTS with spontaneous pneu-mothorax has been actively developed during thepast three decades. Today, aggressive treatment isgenerally accepted for patients with tension pneumo-thorax, bilateral pneumothorax, large hemothoraxor pneumothorax superimposed on impaired pul-monary function.26 In addition, many clinicians haveadopted closed intercostal drainage as the methodof choice in the treatment of idiopathic spontaneouspneumothorax of more than minimal degree.* How-ever, the expectation that conservative treatmentwith bed rest alone is sufficient in most cases is stillpopular.t To assess the merits of each approach,we reviewed the records of all patients with spon-taneous pneumothorax seen at the Palo Alto MedicalClinic between 1950-1959. The results were com-pared with those of other investigators who havedescribed various therapeutic approaches.

MATERIAL AND METHODS

The records of 39 patients who had been treatedfor 48 episodes of spontaneous pneumothorax wereexamined. The ages ranged from 14 to 62 years.Thirty patients (76 per cent) were between 15 and30 years old. There were 35 males (89 per cent)and four females (11 per cent). The right lung wasaffected in 26 instances, the left lung in 20. Bilateralpneumothorax (here counted as two episodes) oc-curred once. These figures correspond closely tothose of many observers.33'35The extent of collapse (Table 1) ranged from

minimal to 100 per cent with tension. In nine in-stances the -degree of collapse was less than 15 percent, which was regarded as minimal. Thirty-eightepisodes involved a pneumothorax of moderate tolarge size. Three episodes were not treated, 20 weretreated conservatively and 25 were treated aggres-sively. In three of the aggressively treated casesprimary thoracotomy was carried out because ofmultiple recurrence.

Aggressive treatment is defined as the use ofclosed intercostal drainage with constant suction

Presented before the Section on Internal Medicine at the 90th An-nual Session of the California Medical Association, Los Angeles, April30 to May 3, 1961.

References 10, 16, 19% 34.tReferences 11, 23, 28, 39.

* In analysis of the results of treatment of 48episodes of spontaneous pneumothorax, aggres-sive treatment by means of closed intercostaldrainage with constant suction was found toachieve the aims of therapy more effectivelythan conservative measures of bed rest with orwithout needle aspiration.

In general, full expansion of the lung wasmore quickly restored, recurrence was of lesserincidence, the period in hospital was shorterand the time away from work was reduced.

whenever more than minimal pneumothorax is pres-ent. Although a variety of tubes can be successfullyused, we employed the S-shaped, stainless steel can-nula described by Clagett. Insertion of this instru-ment is a simple bedside procedure. Commonly, thesecond anterior intercostal space is used. After suit-able skin cleansing and draping, local anesthesia isobtained by the injection of 1 per cent procainesolution (Figure 1). The skin is then nicked with asharp scalpel blade. Strong pressure applied to theS cannula at right angles to the chest wall readilyintroduces it into the pleural space. As it pierces theparietal pleura, the blunt tip of the cannula curvesaway from the lung.

Although a simple waterseal without suction willbe effective in most instances, we routinely employsuction of 15 to 20 cm. (water) to achieve the fastestpossible reexpansion. Management of the patient onconstant suction is outlined in Table 2.

RESULTS OF THERAPY

The results of therapy in the present series aresummarized in Table 3. Three patients received notherapy of any kind. Time required for reexpansionwas 30 days for one and 57 days for a second. Nofollowup is available on the third patient.

TABLE 1.-Data on Degree of Pulmonary Collapse In 48 Episodesof Pneumothorox

Per CentNo. of of Total

Degree of Collapse Episodes Cases

Less than 15 per cent................. 915 to 50 per cent................. 14More than 50 per cent.. ............... 24Not known ... ............ 1

1929502

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Figure 1.-Strong pressure is applied to the S cannula to introduce it into the pleural space.

Fourteen patients treated with bed rest alone hadan average reexpansion time of 23 days, with arange of 7 to 100 days. Eight of these had minimalcollapse, and in the majority of these cases the lungwas reexpanded within two weeks. In six patientswith greater than minimal pneumothorax, reexpan-sion took more than four weeks, and in general, thelarger the initial collapse, the longer the time re-quired for reexpansion. In one instance, a reexpan-sion after a 50 per cent collapse took over threemonths.

For six patients treated with bed rest and thora-centesis, reexpansion took from 8 to 56 days, withthe average 25 days. In two of these cases collapsewas minimal and reexpansion was complete in 10and 14 days. The other four patients, all of whomhad more than 50 per cent collapse, required overfour weeks to recover.

For 22 patients with more than minimal collapsetreated with closed intercostal drainage and constantsuction, the average reexpansion time was threedays and the average hospital stay was six days. Ina majority of these patients the lung was fully re-expanded in less than one day, but in three casesthe response to therapy was slow. In one instance,although prompt reexpansion occurred, the lungcollapsed again when the tube was clamped. Thissequence was repeated several times, and 16 dayselapsed before the leak sealed and the lung remainedexpanded. In another case, reexpansion occurredpromptly, but on the third day a break in the tubeleading to the waterseal permitted recurrence whichrequired an additional three days to overcome.Complete failure to produce reexpansion by means

of intercostal drainage occurred in one patient, whohad chronic pneumothorax. In this case, however,underlying pulmonary fibrosis and emphysemasubsequently prevented reexpansion despite decorti-cation twice, segmental resection twice, and thoraco-

TABLE 2.-Regimen for Management of Spontaneous Pneumothoraxwith Closed Intercostal Suction

1. Strict bed rest.2. Constant suction at 15 cm. (water) for 48 hours.3. X-ray films (with portable equipment) of inspiration-

expiration daily.4. If the lung expands promptly and remains expanded, the

tube is clamped after 48 hours.5. If the lung is still expanded after the tube has been

clamped for 24 hours, remove the "S" cannula, scrapingthe parietal pleura during withdrawal to promote forma-tion of adhesions.

6. Patient dismissed from the hospital and returns to work.

TABLE 3.-Results of Therapy

AverageNumber Reexpansion Range

Treatment of Cases Time (Days) (Days)

No treatment .................... 3 43 30 to 57

Bed rest:Less than 15 per cent

collapse ................ 8.....8More than 15 per cent

collapse ......................6Thoracentesis:

Less than 15 per centcollapse ......................2

More than 50 per centcollapse ...4............4

Closed intercostal drainage withsuction-all more than 15 percent collapse .....................

12 7 to 14

>28 12 to 100

11 8to 14

>35 30 to 56

3 ito 16

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plasty. Most of these patients were back at work orschool within seven days. In 17 instances (80 percent) in which no complication occurred, the aver-age time of return to work was eight days.

Analysis of these data indicates that when col-lapse is minimal (less than 15 per cent) and treat-ment is a conservative regimen of bed rest with orwithout needle aspiration, reexpansion of the lungtakes an average of two weeks. When the initialcollapse is greater than 15 per cent, the averagetime for reexpansion with conservative therapy ismore than four weeks, again regardless of the useof intermittent aspiration. Closed intercostal drain-age with constant suction, on the other hand, reducesreexpansion time to an average of three days andalso significantly reduces the period of disability.

DISCUSSION

The aims of therapy in spontaneous pneumothoraxare to relieve symptoms, prevent complications, min-imize disability, minimize economic loss and preventrecurrence. Success in fulfilling these objectives de-pends largely on the method of treatment (Table 4).Conservative TreatmentThe causes of spontaneous pneumothorax were

not well understood until relatively recent times,and therapy has evolved with the changing conceptsof the disease. As early as 1826, Devilliers de-scribed an episode of pneumothorax resulting fromthe rupture of an emphysematous bleb. However,the possibility that such ruptures represented theusual pathogenesis of spontaneous pneumothoraxwas given little attention. In 1856, MacDowell de-scribed a patient with pneumothorax complicatingpulmonary tuberculosis. This observation led to thetheory that underlying tuberculosis was a commoncause of spontaneous pneumothorax. Accordingly,prolonged bed rest was generally prescribed, pri-marily to treat the infection. This rationale per-sisted for more than half a century, but was shakenin 1932 when Kjaergaard20 reported that in 50patients with spontaneous pneumothorax observedover a period of several years, the incidence oftuberculosis was no higher than in the general pop-ulation. Gradually, as an increasing number of re-ports appeared confirming the observations ofKjaergaard, it was recognized that the majority ofcases of spontaneous pneumothorax were caused bya ruptured bleb.6'34'40 The introduction of thora-coscopy and the more frequent use of thoracotomyhave strengthened this theory. In 1946, Macklin andMacklin24 described production of pneumothorax bythe establishment of pulmonary interstitial emphy-sema followed by pneumomediastinum followed byrupture of air through the mediastinal pleura. Thismechanism probably accounts for fewer than 5 per

TABLE 4.-Therapeutic Methods In Spontaneous Puoumothorox

CONSERVATIVE:Bed rest alone.Ambulatory, but off work until lung fully reexpanded.Thoracentesis and repeated needle aspiration of air.

AGGRESSIVE:Effective:

Intercostal tube with water-seal drainage with or with-out constant suction.

Ineffective:Thoracoscopy and pleurodesis by instillation of irritat-

ing substances.SURGICAL:

Reserved for complications:Thoracotomy, with definitive procedure dependentupon the underlying disease.

TABLE 5.-Average Reexpansion Time Reported by VariousInvestigators In Patients Treated with

Bed Rest Alone

Series Date Weeks

Kjaergaard20 ............ 19326to 10Ornstein & Lercher3l .1942 1 to 4Niehaus29 .................... 1947 5Daughtry & ChesneylO............... 1948 4Hyde & Hyde17............... 1948 7Rapport et al.32 .. 19535Dubose12 .......... 1953 2Briggs et al.5. .......... 1953 2Myers28.19545%>4...........50%>Shefts et al.36.......... 1954 3Kircher & Swartzel19.............. 1954 4

cent of the cases of spontaneous pneumothorax.Myers28 reported a negative tuberculin test reactionin 74 of 115 patients with spontaneous pneumo-thorax. Gradually, the belief that tuberculosis wasan underlying factor faded.With the question of tuberculosis disposed of,

dissatisfaction with the rationale of bed rest alonebegan to develop. There is little evidence that in-activity shortens reexpansion time. Several weeksusually elapse before the patient is "cured" (Table5). With a program of modified bed rest, as em-ployed by Myers,28 half of the patients observedhad reexpansion in a four-week period. Since thepatient generally does not return to work whilepneumothorax is present, economic considerationsalone were enough to make a more rapidly effectivetreatment desirable.The objective of treatment then shifted to active

removal of the pleural air to hasten recovery. Airremoval by "paracentesis thoracis" was first de-scribed by Hewson in 1767.15 At first, aspirationwas used solely to relieve tension pneumothorax.More recently repeated aspiration of pleural air hasbeen used in efforts to shorten the course of theillness even when tension is absent. It has proveddisappointing (Table 6). The procedure fails be-cause the pleural surfaces are not brought together

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TABLE 6.-Spontaneous Pneumothorax-Average ReexpansionTlme with Bed Rest Alone Compared with

Repeated Needle Aspiration

Average ReexpansionTime (Days)

Bed Rest Bed Rest andReported By Date Alone Needle Aspiration

Briggs5-....---------- 1953 34 22Dubose12 .1953 15 12Shefts36 .................. 1954 21 21Marrangoni26 .. . 1955 29 47

and maintained in contact. Efforts to accomplish thiswith a needle entail risk of laceration of the expand-ing lung. Thus, since the leak is not sealed, air maypromptly reenter the pleural space, and little i3gained.Aggressive TreatmentThe underwater seal was described by Noble

in 1873.30 He attached a rubber tubing to an inter-costal cannula and placed the other end under water.In recent years, the intercostal tube with watersealdrainage has become the method of therapy pre-ferred by most investigators.'10'16'1934 It allows safe,rapid withdrawal of all the pleural air. This bringsthe visceral and parietal pleura into contact andtends to seal the leak. Straight catheters, Foleycatheters, stainless steel cannulas and plastic tubeshave all been successfully employed to evacuate theair.When the intrapleural pressure increases during

expiration, air is forced from the chest through thetubing and into the water trap, thus evacuating theair from the pleural space. Several hard coughs mayexpel all the pleural air and completely expand thelung. When air is no longer passing through thetorn edge- of the bleb, fibrin deposition and healingcan begin. Table 7 shows the expansion time re-ported by various investigators who used thismethod.

Closed intercostal drainage usually reexpands thelung within three days. Kircher and Swartzel,'9 how-ever, reported an average requirement of 14 days ina group of three patients. Sochocky37 also had lessthan average success with the intercostal tube ineight patients, reexpansion taking from 12 to 20days. 'In an additional 12 patients, however, hereported full expansion within 24 hours when suc-tion was applied to the intercostal tube and a pleuralsclerosive agent was employed.

While there have been differences of opinion onthe indications for closed intercostal drainage (Table8) the safety and effectiveness of this approach hasled us to employ it as the method of choice in allpatients with more than a minimal collapse. We seeno reason to reserve it for a second or third episodeor for cases in which the degree of collapse islarger than 50 per cent. To use "conservative"

TABLE 7.-Spontaneons Pneumothorax-Average ReexpansionTime In Patients Treated with Closed

Intercostal Drainage

Reported By Date Time (Days)

Daughtry and ChesneylO 1948 3Hughes, Kraeft &Lowry1 . 1951 "minutes"

Kreutzer et al.32........... 1952 14Rapport et al.32........... 1952 2Dubose et al.12 ........... 1953 3.4Briggs, Walters &Byron5 ........... 1953 3

Shefts et al.36........... .1954 2Kircher and Swartzel19.. 1954 14Marrangoni, Storey &Geib26 ............ 1955 100% "immediate"

Sochocky37 ...... . 1958 12 to 20 without suction1 day with 15 to 30 mm.

suction

TABLE 8.-Indications for Closed Intercostal Drainage InSpontaneous Pneumothorax, as Reported by Various

Investigators

Investigator Date Indications

Brock6.------------- 1948 Reserve for chronic orrecurrent episodes.

Daughtry & Chesneyl . 1948 Collapse sufficient to al-low safe introductionof a trocar.

Hughes, Kraeft & Lowry16. 1951 Collapse sufficient to al-low safe introductionof a trocar.

Rapport et al.32........... 1952 >251% collapse.Kreutzer et al.22........... 1952 >50 collapse.Dubose et al.12 1953 >25%o collapse.Briggs, Walters & Byron5_.. 1953 >50%o collapse.Kircher and Swartzel19... 1954 >20% collapse.Briggs and Byron4. 1955 Minimal collapse.Rubel et al.34 .. .. . 1956 >20% collapse.Sochocky37 .. ... . 1960 Minimal collapse.

TABLE 9.-Comparlson of Conservative and Aggressive Treatmentof Spontaneous Pneumothorax

Results withConservative Aggressive

Aim Treatment Treatment

Symptom relief .-------- Variable ImmediateComplications ......... Common RareReturn to work.-------- Weeks to months DaysCost.---------------------$500 to $1,000 $200 to $300

therapy in these cases is, in the words of Campbelland Varco,7 "scarcely conservative of the patients'comfort, convenience, finances or predisposition toserious complication." The advantages of aggressivetreatment are summarized in Table 9.

Prevention of Recurrence

There is some evidence that closed intercostaldrainage is superior to simple bed rest in prevent-ing recurrence. Lindskog and Halasz23 reported re-currence in 16 of 26 patients treated with bed restalone, in three of eight treated with needle aspira-tion and in only four of 29 patients treated withclosed intercostal drainage.

VOL. 96. NO. 2 * FEBRUARY 1962 83

In early efforts to prevent recurrence thoracos-copy was employed and attempts were made topromote pleural adhesions by instillation of irri-tating substances. Numerous agents, including silvernitrate, blood, glucose, talc and, more recently,Kaolin,@ have been employed.* Although thismethod is sometimes successful, the morbidity interms of fever and severe chest pain is very high,and recurrence despite chemical pleurodesis is notinfrequent.14 Failures occur because the blebs mostlikely to rupture are usually apical, whereas insuf-flated substances tend to fall to the diaphragm orenter between the fissures at some distance from thesite at which adhesions are desired. In addition, theadhesions are frequently filmy. Occasionally, pul-monary entrapment may ensue and cause impairedfunction, but this is often transient. With occasionalexceptions,18 these approaches to prevention of re-currence have generally been discarded in favor ofthoracotomy, which permits carrying out a definitiveprocedure.SurgeryThoracotomy is generally reserved for the com-

plications of pneumothorax. The indications are asfollows:1. Recurrence:

Three or more recurrent spontaneous pneumo-thoraxes (this is the most common indication).

2. Continued leak:Repeated failure of the lung to remain expandedwhen suction is discontinued.

3. Pleural complications:(a) Massive hydrothorax(b) Hemothorax(c) Empyema(d) Captive lung.Of these, recurrence is the commonest and is

reported in approximately 10 to 30 per cent ofcases.8"1729'31 Three or more recurrences are con-sidered an indication for surgical treatment. Failureto reexpand the lung or to maintain expansion whensuction is discontinued requires thoracotomy toclose or resect the site of the persistent leak. Thiswas necessary in one of the patients in the presentseries. Pleural complications including massive hy-drothorax, hemothorax, empyema, and peel forma-tion with captive lung are all indications foroperation.3'25'27The underlying lesion determines the surgical

procedure. If the leak is small and the bleb single,simple closure may be performed. Resection of awedge, a segment, or a lobe may be necessary de-pending on the extent of the disease. Decorticationis required for captive lung.

Prevention of recurrence can be attempted in anumber of ways. Efforts to promote formation ofadhesions are usually confined to abrasion of thepleural surfaces with a dry gauze sponge. This hasbeen shown to produce dense adhesions.2 Parietalpleurectomy has been recommended as an effectivemethod of preventing recurrence without greatlyimpairing pulmonary function.13'38 This procedure,however, is occasionally followed by bleeding, andis not clearly superior to the simpler technique ofabrasion. A radical approach has been describedin an investigation by Baronofsky,1 who did bilateralthoracotomy in 26 patients with pneumothorax,usually at one operation. In 25 of them blebs wereseen in both lungs, and often bilateral resection wasdone. It is probably safe to assume that such anapproach will never be widely used, since the rela-tively small incidence of contralateral recurrencedoes not warrant a surgical attack of this magnitude.

Palo Alto Medical Clinic, 300 Homer Ave., Palo Alto (Hecker).

References 9, 13, 14, 18, 21.

REFERENCES

1. Baronofsky, I. D.: Bilateral therapy for unilateralspontaneous pneumothorax, J. Thoracic Surg., 34:310-322,1957.

8. Beardsley, J. M., and Pahigian, V. M.: Scrubbing thepleura in the treatment of chronic and recurrent sponta-neous pneumothorax, Surg., 30:967-76, 1951.

3. Brewer, L. A.: The surgical management of chronic"spontaneous" pneumothorax, J. Thor. Surg., 19:167-198,1950.

4. Briggs, J. N., and Byron, F. X.: Spontaneous pneumo-thorax with emphasis on treatment, Am. J. Surg., 89:356-9,1955.

5. Briggs, J. N., Walters, R. W., and Byron, F. X.: Spon-taneous pneumothorax, Dis. Chest, 24:564.570, 1953.

6. Brock, R. C.: Recurrent and spontaneous pneumotho-rax, Thorax, 3:88-111, 1948.

7. Campbell, G. S., and Varco, R. L.: Management ofspontaneous pneumothorax, J. Lancet, 77:44345, Nov. 1957.

8. Cohen, S., and Kinsman, J. M.: Nontraumatic sponta-neous pneumothorax among military personnel, N.E.J.M.,235:461, 1946.

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10. Daughtry, D. C., and Chesney, J. G.: Treatment ofspontaneous pneumothorax, Trans. Natl. Tuberc. Assoc.48th Ann. Meeting, 66-82, 1948.

11. Draper, A. J.: Spontaneous mediastinal emphysemaand pneumothorax, Am. J. Med., 5:59-68, 1948.

12. Dubose, H. M., Price, H. J., and Guilfoil, P. H.:Spontaneous pneumothorax; medical and surgical manage-ment, N.E.J.M., 248:752, 1953.

13. Gaensler, E. A.: Parietal pleurectomy for recurrentspontaneous pneumothorax, SGO, 102:293-308, 1956.

14. Grossman, L. A.: Recurrent bilateral spontaneouspneumothorax treated with artificial hemothorax, Ann. Int.Med., 39:1303-7, 1953.

15. Hewson, W.: The operation of the paracentesis thora-cis proposed for air in the chest, Med. Observ. and Inquiries,June 15, 1767.

16. Hughes, F. A., Kraeft, N. H., and Lowry, C. C.:Treatment of idiopathic spontaneous pneumothorax,J.A.M.A., 146:244-7, 1951.

17. Hyde, B., and Hyde, L.: Benign idiopathic spontane-ous pneumothorax: A review of 63 cases, Am. J. Med. Sci.,215-427-33, 1948.

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18. Joynt, G. H., and Laird, R. C.: Treatment of sponta-neous pneumothorax with Kaolin, Dis. Chest, 34:514-20,Nov. 1958.

19. Kircher, L. T., and Swartzel, R. L.: Spontaneous pneu-mothorax and its treatment, J.A.M.A., 155:24-29, 1954.

20. Kjaergaard, H.: Spontaneous pneumothorax in theapparently healthy, Acta Med. Scandinav. Supp., 43:1, 1932.

21. Knowles, J. H., Gorlin, R., and Storey, C.: Effects ofpleural talc poudrage on pulmonary function, J. Thor.Surg., 34:250-6, 1957.

22. Kreutzer, F. L., Brizzolara, L. S., and Roger, W. L:Treatment of spontaneous pneumothorax by means of con-tinuous intra-pleural suction, Dis. Chest, 21:663-76, 1952.

23. Lindskog, G. E., and Halasz, N. A.: Spontaneouspneumothorax: A consideration of pathogenesis and man-agement with review of 72 hospitalized cases, Arch. Surg.,75:693-98, 1957.

24. Macklin, M. T., and Macklin, C. C.: Malignant inter-stitial emphysema of lungs and mediastinum, Medicine,23:281-358, Dec. 1944.

25. MacQuigg, R. E.: Spontaneous pneumothorax: Thecase for early thoracotomy, Am. Surgeon, 21:478-87, 1955.

26. Marrangoni, A. G., Storey, C. F., and Geib, P. O.:The management of spontaneous pneumothorax, Am. Rev.Tuberc. and Pulm. Dis., 72:257-67, 1955.

27. Meade, R. H., and Blades, B.: The surgical treatmentof recurrent and chronic spontaneous pneumothorax of non-tuberculous origin, Am. Rev. Tuberc., 60:683-9, 1949.

28. Myers, J. A.: Simple spontaneous pneumothorax, Dis.Chest, 26:420-441, 1954.

29. Niehaus, R. F.: Simple spontaneous pneumothorax inapparently healthy individuals: Report of 24 cases, Am. J.Roentg., 57:12, 1947.

30. Noble: Some particulars of treatment in a case ofpneumothorax, Brit. Med. J., Oct. 11, 1873.

31. Ornstein, G. G., and Lercher, L.: Quart. Bull. SeaviewHospital, 7:149, 1942.

32. Rapport, R. L., Thurlow, A. A., and Klassen, K. P.:Etiology and management of spontaneous pneumothorax,Arch. Surg., 67:266-75, 1953.

33. Rottenberv. L. A., and Golden, R.: Spontaneous pneu-mothorax: A study of 105 cases, Radiology, 53:157.167, 1949.

34. Rubel, W. F., Harter, J. S., Bryant, J. R., and Davis,W. B.: The management of spontaneous pneumothorax, Am.Surg., 22:211X6, 1956.

35. Schneider, L, and Reissman, I. I.: Idiopathic sponta-neous pneumothorax: History of 100 unselected cases, Radi-ology, 44:485-88, 1945.

36. Shefts, L. M., Kilpatric, C., Swindell, T., and Gab-bard, J. G.: Management of spontaneous pneumothorax,Dis. Chest, 26:273-285, 1954.

37. Sochocky, S.: Simple spontaneous pneumothorax,Brit. J. Clin. Practice, 14:12-17, Jan. 1960.

38. Thomas, P. A., and Gebauer, P. W.: Pleurectomy forrecurrent spontaneous pneumothorax, J. Thor. Surg., 35:111-7, 1958.

39. Tysinger, D. S., Jr., and Meneely, G. R.: Spontaneouspneumothorax-clinical diagnosis and management, Am. J.Surg., 89:360-3, 1955.

40. Woods, F. M.: Cystic diseases of the lung, J. Int.Coll. Surg., 19:568-575, 1953.

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