Pneumothorax: Definitive management and prevention of recurrence

INTRODUCTION — Pneumothorax (gas in the pleural space) is considered spontaneous when it presents in the absence of an external factor. Primary spontaneous pneumothorax (PSP) presents in the absence of clinical lung disease while secondary spontaneous pneumothorax (SSP) presents as a complication of underlying lung disease or injury (table 1). The recurrence rate and therefore management strategies of PSP and SSP differ in their timing and threshold to perform a definitive procedure to prevent recurrence.

The definitive management and prevention of recurrent pneumothorax is discussed in this topic review. Our approach expands upon that outlined in published clinical consensus statements and guidelines from The American College of Chest Physicians (2001), British Thoracic Society (2010), European Respiratory Society (2015), the Japanese Association for Chest Surgery (2014), and others [1-6]. The epidemiology and etiology, clinical presentation and diagnosis, and initial management of pneumothorax are discussed separately. (See "Pneumothorax in adults: Epidemiology and etiology" and "Clinical presentation and diagnosis of pneumothorax" and "Treatment of primary spontaneous pneumothorax in adults" and "Treatment of secondary spontaneous pneumothorax in adults".)

INCIDENCE OF RECURRENCE

Primary spontaneous pneumothorax — The estimated recurrence rate after the first primary spontaneous pneumothorax (PSP) is broad, ranging from 0 to 60 percent; however, newer studies suggest average recurrence rates between 10 and 30 percent at one to five year follow-up period, with the highest risk occurring in the first 30 days through the first year [1,2,7-9]. In one of the largest epidemiologic studies of spontaneous pneumothorax, rates of recurrent PSP for males were 4 percent (<7 days), 8 percent (<30 days), 10 percent (<3 months), 13 percent (<1 year), and 20 percent (<5 years) [10]. Rates in females were similarly 5 percent (<7 days), 9 percent (<30 days), 11 percent (<3 months), 15 percent (<1 year), and 22 percent (<5 years). However, these rates may have been underestimated since they were calculated from inpatient admissions and did not include patients treated as outpatients. In contrast, in another systematic review that included 29 randomized trials and observational series, the pooled one-year recurrence rate for patients with PSP was 29 percent [11].

Risk factors reported to be associated with an increased risk of recurrence include [11-18]:

●Female sex

●Tall stature in males

●Low body weight

●Failure to stop smoking or presence of respiratory bronchiolitis

●Large initial pneumothorax size

●Blebs or bullae on chest computed tomography (CT) scan

●Previous events

As an example, one study of 176 patients with PSP reported that the risk of ipsilateral recurrence for patients with blebs and bullae on chest CT was 68 percent compared with 6 percent in patients without blebs and bullae, with the highest risk in those with multiple and bilateral lesions (75 percent) [13]. The risk of contralateral pneumothorax was also higher in patients with blebs and bullae on CT (19 versus 0 percent). (See "Pneumothorax in adults: Epidemiology and etiology", section on 'Primary spontaneous pneumothorax' and "Pneumothorax in adults: Epidemiology and etiology", section on 'Secondary spontaneous pneumothorax'.)

The broad range and high incidence of recurrence in subpopulations of patients with PSP, in particular those found to have blebs or bullae on imaging, has led some experts to propose that the classification of pneumothorax is not necessarily binary (primary versus secondary) but rather a continuum with risk of recurrence ranging from low to high. At minimum, a subpopulation of patients with suspected PSP based on the chest radiograph alone may actually have undiagnosed lung disease and this subpopulation may warrant reclassification as secondary spontaneous pneumothorax (SSP) so that appropriate preventions can be put in place. Future studies should focus on defining cutoffs for recurrence risk to distinguish those with high recurrence in whom pleurodesis is indicated after a first event from those with a low recurrence in whom pleurodesis is not justified until pneumothorax recurs. (See "Pneumothorax in adults: Epidemiology and etiology", section on 'Pathogenesis and risk factors'.)

Secondary spontaneous pneumothorax — Data to support high recurrence rates in this population are largely derived from patients with chronic obstructive pulmonary disease (COPD). For example, one study reported a 50 percent likelihood of recurrent SSP over three years among patients with a pneumothorax due to COPD who did not have an intervention to prevent recurrence [19].

Similar high recurrence rates have been described in other populations of patients with acute and chronic lung disease including female patients with lymphangioleiomyomatosis and individuals with nontuberculous mycobacteria and Birt-Hogg-Dubé syndrome [20].

One of the largest epidemiologic studies of spontaneous pneumothorax suggested that the rates of recurrent SSP may be lower than originally thought [10]; rates of recurrence for males were 7 percent (<7 days), 14 percent (<30 days), 20 percent (<3 months), 27 percent (<1 year), and 33 percent (<5 years). Rates in females were similarly 6 percent (<7 days), 13 percent (<30 days), 19 percent (<3 months), 25 percent (<1 year), and 31 percent (<5 years). However, these rates may have been underestimated since they were calculated from inpatient admissions over a 46-year period and adjustments for interventions was not clear. (See "Sporadic lymphangioleiomyomatosis: Clinical presentation and diagnostic evaluation", section on 'Pulmonary' and "Birt-Hogg-Dubé syndrome", section on 'Pulmonary manifestations'.)

Risk factors for recurrence may be similar to those in patients with PSP (eg, smoking) [14] (see 'Primary spontaneous pneumothorax' above) but are less well studied since most patients with SSP proceed with a definitive measure to prevent recurrence after their initial event.

INDICATIONS — Once patients have undergone initial management for pneumothorax, clinicians should assess the risk of recurrence to evaluate whether definitive management (usually pleurodesis) is indicated. Several indications for the prevention of recurrence exist (algorithm 1).

Primary spontaneous pneumothorax at high risk of recurrence — Since the risk of recurrence is considered low in patients with primary spontaneous pneumothorax (PSP; ie, pneumothorax without underlying lung disorder), most patients with a first episode of PSP do not typically undergo definitive treatment until it recurs. However, a small percentage of patients need a definitive intervention even with a first episode. These include patients with a prolonged (persistent) air leak (PAL; typically defined as air leak >5 days), patients with a high risk occupation or hobby (eg, airline pilot, deep sea diver), patients with contralateral, bilateral, or life-threatening PSP, and patients with a first contralateral pneumothorax, a high burden of cysts, desire to avoid recurrence, or undergoing thoracoscopy for another indication (eg, hemothorax, lung biopsy). Further details are provided separately. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Indications for definitive procedure after first event' and "Pneumothorax and air travel" and "Complications of SCUBA diving".)

First episode of secondary spontaneous pneumothorax — Since the recurrence rate is considered high (eg, >50 percent), most patients with a first episode of secondary spontaneous pneumothorax (SSP; ie, spontaneous pneumothorax due to underlying lung disorder) should undergo a definitive intervention to prevent recurrence. Individual exceptions may be applied to patients with very small loculated pneumothoraces (eg, patients with cystic fibrosis [6]) or patients who decline definitive treatment. Further details are provided separately. (See "Treatment of secondary spontaneous pneumothorax in adults", section on 'Preventing recurrence and follow-up'.)

Prolonged air leak — Any pneumothorax that presents with a PAL beyond five days should be assessed for a definitive procedure based upon the rationale that the underlying defect is large and unlikely to heal rapidly on its own. In such cases a definitive procedure is both a therapeutic (to seal the leak) and a preventative measure. PALs are more commonly encountered in patients with SSP than PSP.

Recurrent pneumothorax — Any patient with recurrent pneumothorax (even in the contralateral lung) should undergo a definitive procedure since the likelihood of future events, particularly life-threatening ones, is high. (See 'Incidence of recurrence' above.)

Concomitant indication for thoracoscopy — Patients with hemothorax or need for lung biopsy may be considered for pleurodesis at the time of surgery. (See "Overview of minimally invasive thoracic surgery".)

Other populations — The risk of recurrence should be individualized in other patient populations (eg, trauma, iatrogenic). Among these causes, iatrogenic and traumatic pneumothorax are the most common, and a definitive procedure is not typically necessary unless a prolonged air leak develops. In contrast, patients with a structural abnormality that is irreversible, such as Marfan syndrome, may potentially benefit from definitive treatment to prevent recurrence. (See "Treatment of secondary spontaneous pneumothorax in adults", section on 'Other pneumothorax types' and "Treatment of secondary spontaneous pneumothorax in adults", section on 'Pneumothorax and pregnancy'.)

Factors for decision-making — Factors that should be taken into consideration that need discussion with the patient include:

●The assessed likelihood of recurrence and the risk at recurrence

●Patient values and preferences

●Ability to tolerate a surgical procedure (eg, surgery or conscious sedation)

●Access to healthcare facility in the event of a recurrence

The potential for lung transplantation is much higher in patients with SSP than PSP. Although pleurodesis can increase the morbidity associated with subsequent lung transplantation (eg, bleeding, requirement for transfusion, length of surgery), it should not affect the decision to proceed with the definitive intervention itself when indicated, but it may affect the type of definitive procedure chosen. (See 'Pleurodesis' below.)

DEFINITIVE MEASURES — Options for preventing recurrence include surgical and nonsurgical approaches:

●In most cases, we prefer video-assisted thoracic surgery (VATS) pleurodesis based upon its high efficacy when compared with nonsurgical approaches. The chosen method of pleurodesis (eg, chemical, abrasion, pleurectomy) and the inclusion of a procedure to treat blebs (eg, stapling, ligation) is usually at the discretion of the surgeon, although we acknowledge that significant variability exists among institutions and countries. Medical thoracoscopy can allow talc poudrage but is unsuitable for treating underlying lung blebs and should only be considered if VATS is contraindicated. (See 'Surgical candidates (VATS)' below and "Medical thoracoscopy (pleuroscopy): Diagnostic and therapeutic applications".)

●For those unable or unwilling to undergo VATS, chemical pleurodesis via chest tube is preferred. (See 'Nonsurgical candidates (chemical pleurodesis)' below.)

The choice of chemical sclerosing agent is highly variable among experts.

Surgical candidates (VATS) — In those with primary or secondary spontaneous pneumothorax with an indication for a definitive procedure, we suggest VATS based upon the high efficacy and lower adverse effect profile when compared with open thoracotomy [16,21-34].

Although pleurodesis via open thoracotomy has higher success rates, VATS has largely supplanted open thoracotomy for the management of spontaneous pneumothorax in most centers [35,36]. Thoracotomy is recommended only if VATS is unavailable or has failed or in patients who desire the lowest level of recurrence risk (eg, high risk occupation) [5]. This recommendation is based upon meta-analyses comparing open thoracotomy with VATS that have consistently shown lower recurrence rates with open procedures (approximately 1 percent with open versus 5 percent with VATS) but with greater blood loss, more postoperative pain, and longer hospital stays [5,37,38].

The two most common procedures that are performed during surgical thoracoscopy are pleurodesis and blebectomy/bullectomy. Many surgeons choose to perform both at the time of surgery since some data suggest that the recurrence rate is lower when both procedures are performed simultaneously. However, some surgeons perform pleurodesis without blebectomy/bullectomy or vice versa based upon data that suggest combining both procedures worsens the adverse effects. We prefer combining blebectomy/bullectomy with pleurodesis since it makes biologic sense that recurrence is lower when both procedures are used.

Limited data report no difference in pneumothorax recurrence, length of hospital stay, need for further treatment, duration of air leak, complications, or mortality following bullectomy or surgical pleurodesis [5].

Pleurodesis — We prefer mechanical pleurodesis using pleural abrasion with dry gauze as the initial procedure, since it is both simple and effective. Talc is associated with high success rates, and should be included in those considered at highest risk of recurrence or those with recalcitrant pneumothorax in whom avoidance of recurrence is critical. In patients considered at high risk of recurrence, some surgeons also choose to combine an apical pleurectomy (ie, partial pleurectomy to the region of lung most affected by blebs) with abrasion to the visceral pleura over the rest of the lung. (See 'Talc' below.)

●Techniques – Several surgical techniques have been reported to induce pleural symphysis (ie, pleurodesis) with significant variation in practice among surgeons, institutions, and countries. These include:

•Parietal or full pleurectomy (usually unilateral, occasionally bilateral) [14,39-41]

•Intrapleural insufflation of talc or a tetracycline derivative (ie, chemical pleurodesis) [42]

•Pleural abrasion to visceral and parietal pleura with dry gauze [43]

•Laser abrasion of the parietal pleura [44,45]

•Cellulose mesh with fibrin glue [46,47]

•Combinations of the above (eg, abrasion with partial pleurectomy and chemical pleurodesis)

●Choosing a technique – Choosing among these options is often at the discretion of the surgeon but also dependent upon factors including the following:

•Presenting manifestations of the patient (eg, severe, life-threatening symptoms versus asymptomatic)

•Preferences and values of the patient

•Potential future need for lung transplantation

•Number of previous recurrences of pneumothorax

•Severity of underlying lung disease or burden of cysts

•Risk associated with VATS

•Previous pleurodesis

There is also considerable variability among countries, with mesh and fibrin glue being popular in Japan while mechanical abrasion or chemical pleurodesis is popular in the United States; similarly, talc is often the preferred sclerosant used in Europe, while a tetracycline derivative is preferred by some United States institutions.

Performing lung transplants in patients who have undergone pleurodesis is technically challenging and associated with increased blood loss due to dissection of the scarred pleural membrane. Although previous pleurodesis is not a contraindication for lung transplantation, we prefer a targeted/partial approach to pleurodesis in transplant candidates using VATS-directed closure of the site of air leak and/or blebectomy and consideration of mechanical abrasion of the apical pleural surface to achieve apical pleurodesis. This approach in theory provides enough pleurodesis to prevent large pneumothoraces while avoiding the formation of dense thick pleural symphysis, typical of chemical pleurodesis, which can be difficult to dissect. When feasible, we avoid full pleurodesis with chemicals, unless the frequency and degree of recurrence indicates the need for more aggressive measures (eg, bilateral life-threatening recurrence, recalcitrant pneumothorax) [48]. (See "Lung transplantation: General guidelines for recipient selection", section on 'Previous cardiothoracic surgery'.)

Bleb/bulla closure — Although ill-defined, blebs are considered “blisters” that are visible to the naked eye on the surface of the pleura (typically 1 to 2 cm in size) while bullae are typically intraparenchymal and >1 cm in size, often large. Consistent with the practice of many surgeons, we suggest VATS apical blebectomy/bullectomy simultaneously with pleurodesis based upon retrospective data that report recurrence rates <5 percent using this combined approach [26,38,49-51]. However, data are conflicting and some surgeons perform pleurodesis alone based upon data that report lower recurrence rates in patients with VATS-directed insufflation of talc compared with bullectomy alone (0.3 versus 3.8 percent) [16,52], while others perform blebectomy/bullectomy alone based upon data that report recurrence rates <9 percent with bullectomy alone [53].

The rationale for blebectomy/bullectomy is that patients with secondary spontaneous pneumothorax (SSP) and, less often, patients with primary spontaneous pneumothorax (PSP), have underlying subpleural blebs or bullae (cysts ≥1 cm) that are considered the most likely cause of spontaneous pneumothorax.

Blebs/bullae are typically apical in location. While some defects (with or without air leaks) are visible to the naked eye (or on imaging), others are not apparent. Thus, many surgeons choose to resect the apex of the lung based upon the observation that even in the absence of obvious blebs/bullae, patients with pneumothorax have subclinical blebs noted on pathologic analysis of resected tissue. In support, many high grade blebs have been detected by fluorescein-enhanced autofluorescence thoracoscopy (FEAT) in areas that appear normal during white light thoracoscopy [54]. When blebs or bullae are so numerous that resection of all blebs is not feasible, the surgeon may choose to resect only those that are large and leave smaller ones intact before proceeding with pleurodesis.

The optimal surgical technique to treat underlying blebs/bullae is uncertain and, in most cases, the decision is typically left to the discretion and experience of the surgeon. In our experience, most surgeons resect blebs/bullae using a stapling technique since data support low recurrence rates with stapling [50], and both pneumostasis and hemostasis can be achieved with this method. Other techniques include suturing, staple reinforcement at the suture line, ligation, or coagulation of visible lesions. (See "Bullectomy for giant bullae".)

Lung volume reduction — For patients with emphysema who meet inclusion and exclusion criteria for lung volume reduction surgery (LVRS), it may be appropriate to perform LVRS at the time of surgical pleurodesis. (See "Lung volume reduction surgery in COPD", section on 'Patient selection'.)

Nonsurgical candidates (chemical pleurodesis) — In patients who are unable or unwilling to undergo VATS or medical thoracoscopy, we suggest intrapleural injection of a chemical irritant, either graded talc or a tetracycline derivative (doxycycline or minocycline), if available [5]. Other sclerosants have been used (eg, iodopovidone). Many experts, including contributors of this topic, prefer talc due to its consistent high efficacy, especially in malignant pleural effusion. However, there is evidence that graded talc, which is now available in the United States, rarely, causes lung injury due to the larger size of its particles compared with ungraded talc, which may ultimately minimize the most worrisome adverse effect of talc (ie, lung injury) [55]. Regardless of the sclerosant chosen, chemical pleurodesis via tube thoracostomy is not as effective as VATS pleurodesis or pleurodesis with medical thoracoscopy since rates of recurrence are about 25 percent [19,56].

Tetracycline derivatives — Chemical pleurodesis with tetracycline derivatives decreases the recurrence rate of pneumothorax to rates as low as 13 percent (range 13 to 25 percent). In two large trials of 442 patients with PSP, pleurodesis with the intrapleural instillation of a tetracycline derivative (tetracycline or minocycline) was compared with aspiration and drainage without pleurodesis [19,57]. Over a one to five year follow-up period, the rates of recurrent PSP fell from 41 to 25 percent (tetracycline) in one study [19] and from 33 to 13 percent (minocycline) in another study [57]. In those that failed, thoracoscopic evaluation by VATS revealed loose intrapleural adhesions only, suggesting that an intense inflammatory response was not initiated in some patients at the outset.

Other than postpleurodesis pain, tetracycline derivatives are well-tolerated. Respiratory failure due to an apparent allergic reaction to intrapleural instillation of doxycycline has been reported [58]. Additional technical details regarding tetracycline derivative administration are provided separately. (See "Chemical pleurodesis for the prevention of recurrent pleural effusion".)

Talc — Talc is a cheap sclerosant that induces an intense inflammatory response. Talc pleurodesis is the most commonly preferred sclerosant in Europe but is also used frequently in the United States. Talc is consistently, among studies and in all populations, an effective sclerosant. In patients with PSP, recurrence rates vary between 2 and 8 percent after medical thoracoscopy, a rate that reflects that seen in other populations.

Several studies support the safety and efficacy of talc pleurodesis for the prevention of recurrent pneumothorax, when graded talc is chosen [30,59-61]. However, most data are derived from patients with malignant pleural effusion rather than pneumothorax and delivery is thoracoscopic rather than via a chest tube thoracotomy.

However, intrapleural injection of talc has been associated with more adverse effects than tetracycline (tachycardia, fever, pain, respiratory failure). For example, the development of the acute respiratory failure/acute respiratory distress syndrome (ARDS) has been reported in 0 to 3.8 percent of patients and, although some cases are transient, other rare cases may be fatal [62-66]. Small retrospective studies have suggested that small particle size, old age, and interstitial abnormalities may increase the risk of ARDS, although not all data were derived in patients with pneumothorax [67,68]. Another case of extensive pleural thickening with calcifications has also been reported [69]. Further details regarding talc pleurodesis are provided separately. (See "Chemical pleurodesis for the prevention of recurrent pleural effusion".)

There exists concerns that talc already creates an intense pleural reaction thus combination with other methods of pleurodesis (eg, abrasion) is unnecessary. In addition, concerns exist in using talc in those with significant intraparenchymal disease burden, who may not have significant reserve to tolerate an episode of ARDS or respiratory failure. There are insufficient data to support or disprove these concerns at present.

Others — One study reported similar efficacy between iodopovidone and talc when delivered thoracoscopically [70].

Limited data suggest that autologous blood patches may help to stop air leak and shortens length of stay [5]. (See "Alveolopleural fistula and prolonged air leak in adults", section on 'Autologous blood patch pleurodesis'.)

Bronchoscopic measures, such as endobronchial valve placement, may also be useful in patients not suited for surgery. Further details are provided separately. (See "Alveolopleural fistula and prolonged air leak in adults" and "Alveolopleural fistula and prolonged air leak in adults", section on 'Bronchoscopic interventions'.)

Timing — When a definitive procedure is indicated, it is usually performed during the same hospitalization (three to five days), since the risk of recurrence is greatest in the first month, although this is not always feasible.

POSTPLEURODESIS PAIN — Despite the intrapleural administration of anesthetic (eg, lidocaine) preprocedurally, moderate to severe pain is a common complication after pleurodesis that may last for two weeks, sometimes longer [59,71,72]. It generally dissipates slowly (weeks to months). Although the pain can arise from ongoing pleural inflammation, chronic post-thoracoscopy intercostal neuralgia is common with prevalence reported as high as 40 percent, and half of these cases are neuropathic in character. (See "Overview of cancer pain syndromes", section on 'Postsurgical pain syndromes'.)

Importantly, the severity of the pain is often underestimated by physicians. Accordingly, postoperative pain should be addressed in institutional protocols. Frequently, narcotic medication is needed in the short-term. Nonsteroidal agents were avoided in the immediate postoperative period since it was thought that nonsteroidal anti-inflammatory drugs (NSAIDs) might interfere with the inflammation that is required to ensure effective pleural membrane symphysis. However, a study comparing opioids with NSAIDs for pain reported no difference in the efficacy of pleurodesis in patients with malignant pleural effusion [73]. (See "Chemical pleurodesis for the prevention of recurrent pleural effusion".)

FOLLOW-UP — Following a definitive procedure, the chest tube remains in place and patients are assessed daily for pain and for closure of the air leak. Frequent radiographs or ultrasonograms are performed to check for lung expansion. (See "Thoracostomy tubes and catheters: Management and removal", section on 'Management of thoracostomy tubes'.)

Sealed air leak — Once the air leak has been sealed, the chest tube can be removed, and the patient can be discharged and followed up in an outpatient clinic, similar to that described elsewhere. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Follow-up thoracostomy management (one to five days)' and "Treatment of primary spontaneous pneumothorax in adults", section on 'Outpatient follow-up and management'.)

Prolonged air leak or refractory pneumothorax — If an air leak persists or pneumothorax recurs despite pleurodesis, management may be complex due to loculations from the previous attempt at pleurodesis. In such cases, a multidisciplinary approach is advised where discussion of several options should be undertaken, including catheter-directed pleurodesis, thoracoscopic revision, placement of endobronchial valves, or conservative management. A rare patient is left with residual chronic pneumothorax.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pneumothorax".)

PATIENT INFORMATION — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")

PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Lymphangioleiomyomatosis (LAM)".)

SUMMARY AND RECOMMENDATIONS

●Incidence – Primary spontaneous pneumothorax (PSP) presents in the absence of clinical lung disease, while secondary spontaneous pneumothorax (SSP) presents as a complication of underlying lung disease (table 1). Recurrence rates vary but, in general, the risk of recurrence is higher with SSP (>30 to 50 percent) than with PSP (10 to 30 percent). (See 'Introduction' above and 'Incidence of recurrence' above.)

●Indications – Once patients have undergone initial management, clinicians should assess the risk of recurrence to evaluate whether definitive management is indicated. Indications include patients with PSP assessed to be at high risk of recurrence, patients with high risk professions or hobbies (eg, airplane pilot or deep sea diver), patients with a prolonged (persistent) air leak (typically >5 days), patients with SSP or recurrent pneumothorax, or patients with a concomitant indication for thoracoscopy (eg, hemothorax or lung biopsy) (algorithm 1). (See 'Indications' above.)

●Type of approach – For most patients in whom a definitive procedure is indicated, we recommend surgical approaches rather than nonsurgical approaches (Grade 1B). This preference is based upon the high efficacy of surgery in this population who are at a high risk of recurrence.

•Among the available surgical approaches, we suggest video-assisted thoracic surgery (VATS) rather than open thoracotomy due to the shorter length of hospital stay and lower morbidity (pain and blood loss) associated with VATS (Grade 2C). (See 'Surgical candidates (VATS)' above.)

•The method of pleurodesis (chemical sclerosant, abrasion, pleurectomy, mesh, fibrin glue, combinations) and the inclusion of a procedure to treat blebs/bullae (eg, apical resection, stapling, ligation, suturing, coagulation) is usually at the discretion of the surgeon and dependent upon presenting features of the patient, patient preferences, future need for lung transplantation, number of previous recurrences, severity of underlying disease, and surgical risk. We prefer VATS pleurodesis with dry gauze abrasion, stapling of blebs/bullae or talc insufflation, which are associated with the highest success rates, especially in those considered at highest risk of recurrence or those with recalcitrant pneumothorax in whom avoidance of recurrence is critical. (See 'Pleurodesis' above and 'Bleb/bulla closure' above.)

•For patients in whom a definitive procedure is indicated who are poor candidates for or are unwilling to undergo VATS, we suggest chemical pleurodesis via tube thoracostomy rather than tube thoracostomy drainage alone (Grade 2C). This procedure reduces the recurrence rate to <25 percent when a tetracycline compound is used as the sclerosant. Success may be higher when graded talc is used as the sclerosant; choosing the sclerosant is individualized and should weigh the risk of adverse effects against the efficacy. (See 'Nonsurgical candidates (chemical pleurodesis)' above.)

●Postpleurodesis pain – Despite the intrapleural administration of anesthetic preprocedurally, moderate to severe thoracic pain (especially intercostal neuralgia) is a common complication after VATS pleurodesis that may last for two weeks or longer. (See 'Postpleurodesis pain' above.)

●Follow-up – Our approach is the following (see 'Follow-up' above and "Treatment of primary spontaneous pneumothorax in adults", section on 'Follow-up thoracostomy management (one to five days)' and "Treatment of primary spontaneous pneumothorax in adults", section on 'Outpatient follow-up and management'):

•Sealed – Once the air leak has been sealed, the chest tube can be removed, and the patient can be discharged and followed up in outpatient clinic.

•Prolonged air leak – However, if an air leak persists or pneumothorax recurs despite pleurodesis, a multidisciplinary approach is advised where discussion of several options should be undertaken including catheter-directed pleurodesis, thoracoscopic revision, or conservative management. Rarely, some patients are left with residual chronic pneumothorax.