Indications for definitive therapy in adult patients with nontraumatic pneumothorax

PSP: primary spontaneous pneumothorax; SSP: secondary spontaneous pneumothorax; VATS: video-assisted thoracoscopic surgery.

* The risk of recurrence in patients with SSP is much higher than with PSP (approximately 30 to 50% in the first year), thereby justifying a definitive procedure following chest tube thoracostomy.

¶ The risk of recurrence is considered low (10 to 15% at one year) in patients with PSP, such that most patients with a first episode of PSP do not typically undergo definitive treatment until it recurs. However, a small percentage of patients who are considered at a higher than usual risk of recurrence may need a preventive intervention. Risk factors for recurrence include contralateral, bilateral, or life-threatening PSP; high-risk profession or hobbies; prolonged air leak after thoracostomy; and a high burden of cysts. Patients who desire to avoid recurrence or are undergoing thoracoscopy for another reason may also be offered definitive therapy.

Δ Pneumothorax may be the presenting feature in some patients with an unknown primary lung disorder, such as catamenial pneumothorax and lymphangioleiomyomatosis. Lung biopsy may be indicated in such situations during which a definitive procedure for pneumothorax can be performed. Refer to UTD topic for details.

◊ Choosing among these options is typically at the discretion of the surgeon and practice varies widely among institutions and countries. Surgeons may also combine pleurodesis with a blebectomy/bullectomy. Rarely, some surgeons perform bullectomy alone. Recurrence rates after surgical pleurodesis are less than 5 to 10% during the first year.