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Three-step management of pneumothorax: time for a re-thinkon initial management

Hiroyuki Kaneda *, Takahito Nakano, Yohei Taniguchi, Tomohito Saito, Toshifumi Konobu

and Yukihito SaitoDepartment of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Kansai Medical University Hirakata Hospital, Osaka, Japan

* Corresponding author. Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Kansai Medical University Hirakata Hospital, KansaiMedical University, 2-3-1 Shinmachi, Hirakatashi, Osaka 573-1191, Japan. Tel: +81-72-8040101; fax: +81-72-8042865; e-mail: [email protected](H. Kaneda).

Received 26 July 2012; received in revised form 19 September 2012; accepted 27 September 2012

Abstract Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some publishedguidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management.In published trials, the objective of treatment has not been clari ed and it is not possible to compare the treatment strategies between dif-

ferent trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy forpneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spon-taneous pneumothorax, point out controversial issues and nally propose a three-step strategy for the management of pneumothorax.There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lungshould not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should bethe recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe thatthis management strategy is simple and clinically relevant and not dependent on the classi cation of pneumothorax.

Keywords: Pneumothorax Aspiration Chest tube drainage Observation Initial management

INTRODUCTION

Pneumothorax is a common disease worldwide, but surprisingly,its initial management remains controversial. Pneumothoraxis generally classi ed as spontaneous, which occurs withoutpreceding trauma; traumatic, which occurs as a result of direct orindirect trauma and iatrogenic. In addition, spontaneouspneumothorax is subclassi ed as primary spontaneous, whichoccurs in young patients without obvious underlying lungdisease, or secondary spontaneous, which occurs as a complica-tion of an underlying lung disease. The management of pneumo-thorax varies depending on whether it is primary or secondary[1, 2]. There are some published guidelines for the managementof spontaneous pneumothorax. However, unfortunately, theydiffer in some respects, particularly in initial management. Theconsensus process of the American College of Chest Physiciansguidelines showed simple aspiration to be rarely appropriate inany clinical circumstance [3]. On the other hand, the BritishThoracic Society guideline 2003 recommends simple aspiration asthe rst-line treatment for all cases of primary spontaneouspneumothorax requiring intervention [ 4]. Another issue is that, in

actual clinical practice, there is considerable deviation frompublished guidelines, and this is internationally observed [5 7].

There is a need to outline the optimal management strategyfor pneumothorax. In this report, we systematically review pub-lished randomized controlled trials, point out controversial issuesand nally propose a three-step strategy for the management of pneumothorax on the basis of the review and some otherreported data. We believe that the management strategy forpneumothorax should be simple and clinically relevant and notdependent on the classi cation of pneumothorax.

SYSTEMATIC REVIEW AND META-ANALYSIS FORPRIMARY SPONTANEOUS PNEUMOTHORAX

Some randomized controlled trials and meta-analyses [ 8 10] of pneumothorax treatment have been conducted. Here, we review these previous reports again. We searched the PubMed database(National Library of Medicine) for reports from January 1999through August 2011. We used the following search terms:pneumothorax, combined with observation, aspiration or thora-cocentesis and chest drain, chest tube or tube drainage. Thesearch was limited to randomized controlled trials. The searchand the review nally yielded four randomized controlled trials

This article has been published in Japanese in the Journal of the JapanSociety for Pneumothorax and Cystic Lung Diseases 2011;11:2 8.

The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Interactive CardioVascular and Thoracic Surgery 0 (2012) 1 7 STATE-OF-THE-ARTdoi:10.1093/icvts/ivs445

Interactive CardioVascular and Thoracic Surgery Advance Access published November 1, 2012


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(Table 1), with a combined total of 331 patients [11 14]. Allfour trials compared simple aspiration with tube drainage.Meta-analysis was performed by combining the reported successrate, hospital stay and recurrence rate. Relative risk (RR) was usedas a summary statistic for dichotomous outcomes and weightedmean difference (WMD) for continuous outcomes. All statisticalanalyses were conducted using Comprehensive Meta-analysisSoftware version 2 (Biostat, Englewood, NJ, USA). The software

weighs the data from various publications according to theircohort size. The data can be visualized graphically. Each horizon-tal line represents the 95% con dence interval (95% CI) for eachstudy. The square size represents the cohort size. The diamond atthe bottom of the graph represents the overall odds ratio. Thewidth of the diamond is proportional to the overall 95% CI. Thedata can be analysed using a xed or a random model. Inthe xed model, the effect sizes of each study are conserved. Therandom model uses a more exible approach in which the effectsizes are normalized towards an overall mean effect size. We ana-lysed all data using both models. The outcome for success ratecould not be precisely combined because of differences in theoutcome de nitions. A pooled result for success after 1 week ormore was considered as the success rate. Integrated analysis

revealed that simple aspiration was associated with shorterhospitalization time (WMD, 1.61 days; 95% CI 2.30 to 0.92;Fig. 1). With regard to the success rate, however, simple aspir-ation tended to be less favourable than tube drainage, but thisdifference between the two interventions was not statistically sig-ni cant (RR, 0.91; 95% CI 0.77 1.08; Fig.2). The recurrence ratedid not signi cantly differ between the two interventions (RR,0.89; 95% CI 0.58 1.38; Fig.2). On the basis of our meta-analysis,simple aspiration is recommended for the initial management of pneumothorax because of the shorter hospitalization time, al-though there is no signi cant difference in the success and recur-rence rates. This conclusion is consistent with that of a previously

reported meta-analysis with randomized controlled trials andrecent reviews [2, 8].

BACKGROUND BIAS ABOUT PERSISTENTAIR LEAK AND REANALYSIS WITHEXTRACTED DATA

Kjaergard [15] described the cause of spontaneous pneumo-thorax to be lung perforation and air leak. Many researchershave suggested that one of the principal objectives of pneumo-thorax treatment is to stop the air leak. If the air leak is stopped,the collapsed lung is observed to gradually expand. From January 2006 to December 2008, our institutional databaseshowed 75 cases of chest tube drainage, of which 30 (40%) didnot show air leak until the day after chest tube insertion. Weretrospectively assumed that these cases did not have an air leak even before intervention and that we could observe for graduallung expansion without any intervention.

We think that if there is a bias in the cases in which theair leak stopped before intervention, the treatment cannot be

compared. Of the four papers described above, two reportedimmediate success de ned as persistent lung expansion aftersimple aspiration and lung expansion and chest tube removalwithin 3 days after tube drainage [13, 14]. We presume that thesecases of immediate success include many that did not needany intervention. We calculated the number of patients showing1-week success and excluded those showing immediatesuccess. The objective of this analysis was to examine the per-centage of cases showing a persistent air leak over 3 days thatstopped within 1 week after intervention. Ayed s data showedthat of 25 cases of persistent air leak, in 18 (72%), the air leak stopped within 1 week in the simple aspiration group; further, of

Table 1: Summary of the four studies included in the present meta-analysis

Study Aspiration Tube drainageTotal Immediate success Success Total Immediate success Success

Harvey and Prescott [11] 35 28 38 38Andrivet et al. [12] 33 22 28 26Noppen et al. [13] 27 16 25 33 21 28Ayed et al. [14] 65 40 58 72 49 63

Figure 1: Results of meta-analysis: hospital stay as weighted mean difference.

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23 cases of persistent air leak, in 14 (61%), the air leak stoppedwithin 1 week in the tube drainage group. Noppen s datashowed that, of 11 cases of persistent air leak, in 9 (82%), the airleak stopped within 1 week in the simple aspiration group and,of 12 cases of persistent air leak, in 7 (58%), the air leak stoppedwithin 1 week in the tube drainage group. Therefore, the data

extracted from the above two reports consistently indicated thatsimple aspiration is more effective than tube drainage in stop-ping an air leak. This result is not in agreement with the originalresult of the success obtained from the two papers.

Here, it is necessary to address the question why simple aspir-ation is more effective in stopping an air leak than tube drain-age. When air leak is a complication after pulmonary resection,the use of a water seal for tube drainage without expanding thelung too much is more effective than the continuous suction of the drainage [16 18]. Taken together, our clinical experience andthe reports indicate that treating the air leak with simple aspir-ation re-collapses the lung, whereas tube drainage continuouslyexpands the lung. The latter is not desirable to close the perfor-ation of the lung.

COMPARISON OF OBSERVATIONAL ANDINTERVENTIONAL TREATMENT

Considering that expanding the lung has adverse effects on stop-ping the air leak, observation without rapidly expanding the lungwould be the best management. Simpson [ 19] reported that con-servative management of much larger pneumothorax is possibleif there is no underlying lung disease. Few retrospective studiescompared the success and recurrence rates of observational and

interventional treatment (Table 2) [20 28]. These reports involveda relatively small number of patients and all the analyses wereretrospective. A review of these reports reveals that the successrate of observational treatment is very high and seems to be sat-isfactory [20, 21, 26 28]. However, the recurrence rate of obser-vational treatment tends to be higher than that after

intervention [23

26]. This may be because tube drainage withcontinuous suction achieves complete lung re-expansion withcontact between the visceral and parietal pleura, facilitatingclosure of the pleural defect. Inducing adhesion formation overthe pleural defect to help prevent recurrence has been discussed[24, 29 31]. However, no clear conclusion can be reachedbecause of the potential bias in patient backgrounds.

Our institutional database showed that 40% of cases of chesttube drainage did not show an air leak the day after chest tubeinsertion. We think that this percentage includes cases withoutan air leak even before the intervention. As stated above, if thereis a bias in the cases in which the air leak was stopped, it is notpossible to correctly compare the ef cacy of the treatmentoptions. Because of improper evaluation of pneumothorax

during the initial stages, we cannot arrive at any conclusionsafter comparing the results of observational and interventionaltreatment. It is necessary to develop a clear strategy for theinitial management of pneumothorax for implementation inclinical cases and research trials.

RETHINK ABOUT RAPID AIR ELIMINATION

According to Light [1], pneumothorax treatment has two goals:to rid the pleural space of its air and to decrease the

Figure 2: Results of meta-analysis: success rate and recurrence rate.

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likelihood of a recurrence; many other researchers alsodescribed that eliminating intrapleural air is the main principleof pneumothorax treatment [ 32, 33]. Expanding the collapsedlung is not desirable to stop the air leak, and expanding thelung rapidly is necessarily dispensable during initial manage-ment because it does not complete treatment. Some investiga-tors also indicated that the presence of intrapleural air in itself is not an indication for intervention [19, 34]. If there is no airleak, the lung gradually expands without any interventionaltreatment [20, 22]. A review of the data available thus far [19,22, 27, 35] and our experience during clinical practice show that the lung should not be rapidly expanded unless necessary.It is absolutely necessary to expand the lungs, for example, in

cases of tension pneumothorax and cases in which there is acontinuous air leak even if tension pneumothorax is not diag-nosed during consultation, but is suspected to subsequentlyoccur. We think that the indications for interventional treat-ment to expand the lung should be much more re ned, andfewer patients should need intervention. The purpose of tubedrainage and simple aspiration should not be expansion of thelung but recovery of respiratory dysfunction.

Attempts have been made to de ne the management of pneumothorax according to its size [1, 36, 37]. It is widelyaccepted that a small primary spontaneous pneumothorax inpatients without respiratory symptoms can be conservativelymanaged. However, the management of a moderately collapsedlung remains controversial [3, 4]. Here, we would like to propose a

new strategy that is based on the presence of symptoms of acuterespiratory dysfunction and an air leak. Therefore, the size of thepneumothorax at a certain point of time is not very important,but the change in the rate of collapse is important, because thedevelopment of lung collapse reveals the existence of the air leak.

INDICATIONS FOR INTERVENTIONALTREATMENT

Pneumothorax is generally considered to be a benign diseasewith good prognosis, although sudden death has been reported

[24, 38]. Continuous air leak can progress into tension pneumo-thorax with the risk of sudden death. There are several casereports of diagnostic dif culty or missed diagnoses of tensionpneumothorax [ 39 41]. The incidence is reportedly 1 5% of spontaneous pneumothorax [ 22, 24, 42 44]. Tension pneumo-thorax must be treated by immediately evacuating the air.Therefore, the diagnosis of tension pneumothorax is undoubted-ly an indication for immediate intervention (Table 3). Althoughneedle decompression is useful for the emergent release of pleural tension, cases of tension pneumothorax that are consid-ered to have a persistent air leak should be eventually treatedwith tube drainage rather than repeating aspiration.

Another certain indication of intervention is bilateral pneumo-

thorax that rarely occurs, but also causes potentially life-threatening acute respiratory dysfunction. The incidence of bilat-eral pneumothorax is reported to be 0.5 1.9% [20, 45]. In thesecases, tube drainage for expanding at least one side of the lungis necessary to save the patient s life. Patients with severe under-lying lung disease tend to develop severe acute respiratory dys-function even with a relatively small pneumothorax. Interventionis also necessary in such cases.

A continuous air leak in the absence of tension pneumothoraxcan be detected with careful examination, such as the patient ssymptoms and repeated chest radiographs. We think that the airleak in itself is also an indication for intervention, because lungcollapse with continuous air leak nally develops tensionpneumothorax. On the basis of the discussion in the second

section, we suggest that repeating simple aspiration is more ef-fective for stopping the air leak than tube drainage, althoughprospective randomized trials with patients having the samebackground of air leak are necessary to reach a clear conclusion.For preventing the development of tension pneumothorax, tubedrainage is more effective.

The initial treatment of a case of totally collapsed lungwithout severe respiratory dysfunction that is suspected not tobe tension pneumothorax is controversial. A recent retrospectivestudy [46] compared complete and partial atelectasis in patientswith primary spontaneous pneumothorax and found that 29.4%of the patients with complete atelectasis and that 10% of those

Table 2: Success and recurrence rates of observational and interventional treatment

Author and year Observational treatment Aspiration Tube drainage P -value

Success rateHyde [20] 86 Beumer [21] 91 Kelly [28] 90 50 83 66 97

Kellyet al. [27] 79 (5) 50 (60) 73 (73) 0.014 (


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with partial atelectasis showed persistent air leak after tubedrainage. Thus, when compared with partial atelectasis, com-plete atelectasis is estimated to more frequently have a persist-ent air leak, even before tube drainage. If complete atelectasisaccompanies a continuous air leak, the patients easily developtension pneumothorax. Besides, a completely collapsed lung ismore likely to subsequently lead to serious complications, suchas infection of the lung and pleura and restrictive lung impair-ment. Therefore, we think that a completely collapsed lung is in

itself an indication for tube drainage.

THREE-STEP MANAGEMENTOF PNEUMOTHORAX

We propose that the management of pneumothorax should bedivided into three steps depending on the main objective of treat-ment (Table 4). The objective of the rst step is resolving acuterespiratory dysfunction. In this rst step, we are required to con-sider whether intervention is necessary to treat acute respiratorydysfunction and other potentially lethal complications. This comes

under the initial management of the disease, which is mostlyperformed in the emergency department of a hospital. The mostimportant task in this step is to determine whether there is an airleak, in addition to the patient s symptoms and the size of thepneumothorax in the chest radiograph. If the existence of an airleak is con rmed by the patient s symptoms or physical examin-ation, such as severe chest pain, observation of lung collapse on achest radiograph and high intrathoracic pressure, any interventionis necessary. Simple aspiration might be permissible for an air leak

although insertion of a chest tube is ultimately necessary for con-tinuous drainage of the air. If no air leak is found and the lunghas not collapsed completely, it is essential to maintain the stop-page of the air leak, which constitutes the second step. In thisstep, the objective of treatment is resolving the air leak.Observational treatment to avoid rapid lung expansion can helpin sustention of closing the perforation. It must be noted thatinterventions are never performed for treating the air leak,because such interventions potentially lead to the recurrence of the leak by increasing the size of the perforation. In cases whereinterventional treatment is given at the rst step and a persistentair leak is found, the patient needs af rmative treatment, such as

Table 4: Three-step management of pneumothorax

Step Treatment objective Recommended treatment

Step 1a Acute respiratory dysfunctionTo recover from respiratory functionTo avoid respiratory dysfunction

Tube drainage (or simple aspiration)Tube drainage (or simple aspiration)

Step 2 Air leak To maintain stoppage of air leak To stop air leak To stop air leak after drainage

Observational treatmentRepeating aspiration (vs tube drainage)Water seal management in tube drainage, surgery (bullectomy,bulla ligation, etc.), pleurodesis, bronchial intervention, others

Step 3 RecurrenceTo prevent recurrence Pleurodesis b ,

surgery (bullectomy, pleurectomy, etc.), others

a Step 1 is defined as initial management.b Efficacy of tube drainage in preventing recurrence is controversial.

Table 3: Recommended initial management depending on clinical condition

Pneumothorax type Treatment purpose Recommended treatment

Tension pneumothorax To recover from acute respiratory dysfunction Any intervention a

First: aspiration (diagnosis)Second: tube drainage

Bilateral pneumothorax To recover from acute respi ratory dysfunction Drainage of at least one side of the lung

With severe lung disease To recover from acute respiratory dysfunction Any interventiona

Suspected air leak To avoid acute respiratory dysfunction Any interventiona

Completely collapsed lung To avoid acute respiratory dysfunction Any interventiona

Symptomatic To avoid acute respiratory dysfunctionSymptomatic relief

Any interventiona

(aspiration > drainage)Supposed absence of air leak To maintain stoppage of air leak Observational treatment

a Tube drainage or repeating aspiration.



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pleurodesis or surgery, to stop the air leak. This procedure is apart of the next aspect of the second step, i.e. targeting the airleak. If an air leak is absent and repeated pneumothorax isobserved, aggressive treatment is necessary to prevent therecurrence, which comes under the third step.

Traditional pneumothorax management depended on theclassi cation of pneumothorax into primary, spontaneous or sec-ondary; however, classifying pneumothorax is sometimes clinic-

ally dif

cult before computed tomography is performed. Ourproposed three-step management strategy can be applied notonly to primary spontaneous pneumothorax but also secondaryand traumatic pneumothorax. Secondary spontaneous pneumo-thorax would require more interventions than primary spontan-eous pneumothorax in Step 1.

CONCLUSION

We believe that there are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak,which is the obvious cause of the disease; frequently occurringrecurrence. These three characteristics correspond to the three

steps of our proposed management in pneumothorax. Thecentral idea is that the lung should not be expanded rapidly,unless necessary. The objective of treatment has not been clari- ed in published trials, and therefore, it is not possible tocompare the treatment strategies between different trailsbecause of inappropriate evaluation of the air leak. The primaryobjective of both simple aspiration and chest drainage should bethe recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. After con- rming the air leak, interventions such as simple aspiration orchest drainage and observational treatment may be used for themanagement of the air leak.

ACKNOWLEDGEMENTS

We thank Tomoko Fuji for her data management and Yoko Odafor her assistance in this study.

Con ict of interest: none declared.

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