呼吸器 自然気胸

手術適応　 １回目 　４日以上リークが続くとき 　再発 ２回目以上 　持続吸引で４日以上リークがつづくとき 　 治療 　タルク 　ミノサイクリン Print Close See www.DynamicMedical.com for the latest version as DynaMed is updated daily Start Calculators PDA Support Weekly Update Help Find: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Browse by Category Search within text Expand All Collapse All Spontaneous pneumothorax in adults Persistent Link to this page: To search within this summary, click Expand All, and then press Ctrl+F/Command+F (or Edit – Find in your browser menu). Top General Information (including ICD-9/-10 Codes) Causes and Risk Factors Complications and Associated Conditions History Physical Diagnosis Prognosis Treatment Prevention and Screening References including Reviews and Guidelines Patient Information Acknowledgements Send Comment to Editor You are viewing a DynaMed summary. Use of DynaMed indicates acceptance of DynaMed Terms of Use. Limitations of DynaMed are contained in the DynaMed Terms of Use. Spontaneous pneumothorax in adults Updated 2009 Aug 20 04:40 PM: case presentation (Am Fam Physician 2009 Aug 1) Birt–Hogg–Dube syndrome presenting as recurrent spontaneous pneumothorax in case report (Ann Intern Med 2009 Feb 17) peer review Related Summaries: Spontaneous pneumothorax in children chronic obstructive pulmonary disease (COPD) Cystic fibrosis (CF) Tension pneumothorax Hemothorax Chest tube insertion General Information (including ICD-9/-10 Codes) Description: accumulation of air or gas in pleural space, not due to trauma(1) ICD-9 Codes: 512 pneumothorax 512.0 spontaneous tension pneumothorax 512.1 iatrogenic pneumothorax 512.8 other spontaneous pneumothorax 011.7 tuberculous pneumothorax 011.70 tuberculous pneumothorax, unspecified examination 011.71 tuberculous pneumothorax, bacteriological or histological examination not done 011.72 tuberculous pneumothorax, bacteriological or histological examination results unknown (at present) 011.73 tuberculous pneumothorax, tubercle bacilli found (in sputum) by microscopy 011.74 tuberculous pneumothorax, tubercle bacilli not found (in sputum) by microscopy, but found by bacterial culture 011.75 tuberculous pneumothorax, tubercle bacilli not found by bacteriological examination, but tuberculosis confirmed histologically 011.76 tuberculous pneumothorax, tubercle bacilli not found by bacteriological or histological examination, but tuberculosis confirmed by other methods (inoculation of animals) ICD-10 Codes: J93 pneumothorax J93.0 spontaneous tension pneumothorax J93.1 other spontaneous pneumothorax J93.8 other pneumothorax J93.9 pneumothorax, unspecified Types: primary spontaneous pneumothorax (PSP)(2) usually occurs in tall, slender males aged 10-30 years rare in persons > 40 years old not associated with clinically apparent lung disease generally benign may be familial (Thorax 1998 Feb;53(2):151 PDF, Am J Med Genet 1991 Aug 1;40(2):155) secondary spontaneous pneumothorax (SSP)(1,2) associated with underlying lung disease potentially life-threatening significant complications Organs Involved: lung(1-3) Who is most affected: primary - typically occurs in tall, thin males aged 10-30 years(2) secondary - typically in patients with underlying lung disease, so peak incidence after age 55 years(1,2) Incidence/Prevalence: overall incidence of pneumothorax in England based on United Kingdom General Practice Research Database 1991-1995 overall incidence of patients consulting in primary care with diagnosis of pneumothorax 24/100,000 annually for men (peak ages 20-24 years and 80-84 years) 9.8/100,000 annually for women (peak ages 30-34 years and 70-74 years) overall incidence of hospital admission for primary diagnosis of pneumothorax 16.7/100,000 annually for men (peak ages 20-24 years and 80-84 years) 5.8/100,000 annually for women (peak ages 20-24 years and 70-74 years) overall mortality due to pneumothorax 1.26/million annually for men (highest > 85 years old) 0.62/million annually for women (highest > 85 years old) Reference - Thorax 2000 Aug;55(8):666 PDF incidence of spontaneous pneumothorax in Olmsted County, Minnesota, USA 1950-1974 age-adjusted annual incidence of primary spontaneous pneumothorax (based on 77 cases) 7.4 per 100,000 in males 1.2 per 100,000 in females age-adjusted annual incidence of secondary spontaneous pneumothorax (based on 64 cases) 6.3 per 100,000 in males 2 per 100,000 in females Reference - Am Rev Respir Dis 1979 Dec;120(6):1379 estimated incidence 3.4 per 10,000 hospitalized infants based on 6 identified cases of spontaneous pneumothorax in children aged 28 days to 1 year in retrospective chart review at 1 pediatric hospital in Ohio 1985-1994 Reference - Pediatr Emerg Care 1997 Dec;13(6):401 Causes and Risk Factors Causes: spontaneous rupture of pulmonary or subpleural bleb into pleural space(2) underlying lung disease in secondary spontaneous pneumothorax(1) obstructive lung disease chronic obstructive pulmonary disease acute, severe asthma cystic fibrosis alpha-1 antitrypsin (AAT) deficiency infectious lung disease Pneumocystis carinii pneumonia necrotizing pneumonia tuberculosis interstitial lung disease sarcoidosis idiopathic pulmonary fibrosis histiocytosis X lymphangioleiomyomatosis connective tissue disease rheumatoid arthritis scleroderma Marfan syndrome Ehlers-Danlos syndrome ankylosing spondylitis idiopathic inflammatory myopathy (polymyositis/dermatomyositis) lung cancer or synovial sarcoma esophageal rupture rare associations in case reports loud music (air pressure change) in 5 cases of pneumothorax in 4 patients (Thorax 2004 Aug;59(8):722 PDF in BMJ 2004 Sep 18;329(7467):646) invasive dental procedures with air introduction (J Am Board Fam Pract 2003 Mar-Apr;16(2):165 full-text) Ehlers-Danlos syndrome (Rev Port Pneumol 2006 Jul-Aug;12(4):471) catamenial pneumothorax (recurrent and related to time of menses) associated with diaphragmatic defects (Mayo Clin Proc 2005 May;80(5):677 PDF) acupuncture-induced pneumothorax in case report (South Med J 2006 Nov;99(11):1297) rates of accidental iatrogenic pneumothorax in 7.5 million hospital discharges 2.24% patients admitted for pleurisy 1.14% patients admitted for cancer of kidney and renal pelvic 0.83% patients admitted for conduction disorders and complications of cardiac devices 2.68% for patients who had thoracentesis 1.3% for patients who had nephrectomy 0.06% for patients who had gastrostomy Reference - Med Care 2006 Feb;44(2):182 in AHRQ Research Activities 2006 May;309:16 Pathogenesis: loss of negative intrapleural pressure, collapsed lung(1) pulmonary blebs and bullae found in 94% of 83 patients having pleurodesis for recurrent or complicated spontaneous pneumothorax (Chest 1993 Dec;104(6):1767 PDF) Possible risk factors: smoking associated with increased risk of spontaneous pneumothorax based on case-control study 138 patients admitted to hospital with first spontaneous pneumothorax from 1975-1984 compared to 15,204 persons living in same urban area (County of Stockholm) smoking associated with increased risk of first spontaneous pneumothorax in dose-response relationship (overall relative risk 8.8 in women and 22.3 in men, p < 0.001) Reference - Chest 1987 Dec;92(6):1009 PDF Pneumocystis carinii pneumonia (PCP) associated with spontaneous pneumothorax based on case series 93 episodes of PCP in 298 AIDS patients 12 cases of spontaneous pneumothorax occurred in 10 patients 6 of 12 cases occurred concurrently with PCP 10 of 12 cases involved past history of PCP Reference - Respir Med 1993 Jan;87(1):43 Complications and Associated Conditions Complications: tension pneumothorax(2) hemopneumothorax bronchopleural fistula (Chest 2005 Dec;128(6):3955 full-text, Am J Health Syst Pharm 2008 Feb 15;65(4):322) Associated conditions: spontaneous pneumomediastinum associated with pneumothorax and underlying lung disease (* further peer review in progress) based on case series of 62 patients (mean age 30 years) with preexisting lung disease in 44% pneumothorax present in 32% no mediastinitis or sepsis occurred Reference - Mayo Clin Proc 2009 May;84(5):417 patients with Birt-Hogg-Dube syndrome have significant association with lung cysts and spontaneous pneumothorax (Am J Respir Crit Care Med 2007 May 15;175(10):1044 full-text) Birt–Hogg–Dube syndrome presenting as recurrent spontaneous pneumothorax in case report (Ann Intern Med 2009 Feb 17;150(4):289) History Chief Concern (CC): chest pain(1) dyspnea(1) cough, palpitations, and ptosis (Horner syndrome) are less common symptoms of pneumothorax(3) History of Present Illness (HPI): patients with small pneumothorax (involving < 15% of hemithorax) may have minimal symptoms(2) chest pain characteristics(2) sudden onset sharp usually lateral usually pleuritic chest pain maximum at onset chest pain typically resolves within 24 hours in primary spontaneous pneumothorax symptoms are more severe and do not abate with secondary spontaneous pneumothorax dyspnea can develop gradually(1) most cases may occur at rest based on retrospective study of 219 patients with spontaneous pneumothorax most patients were smokers and had first episode of pneumothorax at least 87% were inactive at onset of symptoms 9% had symptoms during quick movements without exertion 2% had symptoms during moderate exertion, none during heavy exertion Reference - Eur J Respir Dis 1987 Sep;71(3):181 catamenial pneumothorax - rare syndrome of recurrent pneumothorax in menstruating women(3) symptoms occur during menses and abate between cycles concurrent symptoms of endometriosis may also be present consider pneumothorax in ventilated patients with worsening status(3) Past Medical History (PMH): ask about lung disease or history of previous pneumothorax(3) Family History (FH): primary spontaneous pneumothorax may be familial (Thorax 1998 Feb;53(2):151 PDF, Am J Med Genet 1991 Aug 1;40(2):155) Physical General Physical: tachycardia is most common physical finding(2) hypotension, cyanosis and marked tachycardia may suggest tension pneumothorax(2) Neck: contralateral tracheal deviation and jugular venous distention (JVD) may occur with tension pneumothorax Lungs: exam findings in patients with large pneumothorax(2) decreased or absent breath sounds on affected side decreased chest wall motion hyperresonance to percussion decreased fremitus Diagnosis Making the diagnosis: chest x-ray Rule out: tension pneumothorax - requires immediate attention iatrogenic pneumothorax misinterpretation of scapula outline on x-ray bullous emphysema(2) other causes of chest pain Testing to consider: chest x-ray CT scan Blood tests: arterial blood gas measurements found hypoxemia (PaO2 < 80 mm Hg) in 9 of 12 patients with spontaneous pneumothorax in one series (Thorax 1968 Jul;23(4):427 PDF) Imaging studies: chest x-ray chest x-ray may show(3) visceral pleural line outlining edge of lung, with absence of lung markings on outer aspect erect chest x-ray usually sufficient skin folds may look like a line, but lung markings visible on both sides British Thoracic Society guidelines for management of spontaneous pneumothorax plain chest x-ray normally sufficient for diagnosis expiratory chest x-ray not recommended for routine diagnosis (grade B recommendation [inconsistent or limited evidence]) lateral chest x-ray or lateral decubitus chest x-ray recommended if high clinical suspicion and normal posteroanterior chest x-ray (grade B recommendation [inconsistent or limited evidence]) Reference - Thorax 2003 May;58 Suppl 2:ii39 PDF potential indications for CT scan (grade C recommendation [lacking direct evidence]) based on British Thoracic Society guidelines differentiation of pneumothorax from complex bullous lung disease suspicion of aberrant chest tube placement plain chest x-ray obscured by surgical emphysema Reference - Thorax 2003 May;58 Suppl 2:ii39 PDF real time ultrasound can localize known pneumothorax, but has limited sensitivity or specificity for diagnostic use and cannot assess volume, based on series of 27 patients (AJR Am J Roentgenol 1996 Feb;166(2):317 PDF) review of imaging of pneumothorax can be found in BMJ 2005 Jun 25;330(7506):1493 full-text Prognosis Prognosis: risk factors for recurrence include pre-existing lung disease and treatment without pleurodesis (level 2 [mid-level] evidence) based on retrospective cohort study 182 patients with first episode of pneumothorax followed for 6-69 months 138 patients (76%) had follow-up data 86 patients had primary spontaneous pneumothorax 52 patients had secondary spontaneous pneumothorax with pre-existing lung disease (69.6% had chronic obstructive pulmonary disease, 15.5% had tuberculosis) comparing patients with primary vs. secondary spontaneous pneumothorax mean age 23.5 vs. 56 years recurrence rate at 6 months 12.7% vs. 26.2% recurrence rate at 1 year 15.8% vs. 31.2% recurrence rate at 3 years 27% vs. 49.5% treatment with chest tube drainage alone vs. chemical pleurodesis associated with increased recurrence risk (p < 0.05) 70 patients treated with chest tube drainage alone 68 patients treated with chemical pleurodesis (intrapleural tetracycline or gentamicin) comparing chest tube drainage alone vs. pleurodesis recurrence rate at 6 months 26% vs. 13% recurrence rate at 1 year 33% vs. 16% recurrence rate at 3 years 50% vs. 27% height/weight ratio > 3 cm/kg associated with increased risk of recurrence (p = 0.0074) Reference - Respirology 2005 Jun;10(3):378 risk factors for recurrence include tall stature, female gender, and failure to stop smoking (level 2 [mid-level] evidence) based on retrospective cohort study 153 patients > 15 years old with 275 episodes of primary spontaneous pneumothorax were followed for 4 years recurrence rate 54.2% (83 of 153 patients) recurrence rate 71% in women vs. 46% in men (p < 0.01) recurrence rate 70% with continued smoking vs. 40% with smoking cessation (p < 0.05) among male patients, mean height 69.3 inches in patients with recurrence vs. 67.9 inches in patients without recurrence (p = 0.008) Reference - Thorax 1997 Sep;52(9):805 PDF Treatment Treatment overview: observation alone (with supplemental oxygen) may be adequate for small primary spontaneous pneumothorax aspiration or chest tube drainage may be used to facilitate re-expansion of lung limited evidence comparing simple aspiration vs. chest tube for re-expansion of lung simple aspiration for primary spontaneous pneumothorax might be as effective as tube thoracostomy and may avoid need for hospitalization (level 2 [mid-level] evidence) thoracic drainage may be associated with higher initial success rate than needle aspiration, but no difference in recurrence rate at 3 months (level 2 [mid-level] evidence) chest drain removal painful but insufficient evidence to guide analgesic management prophylactic antibiotics appear unnecessary for closed tube thoracostomy for primary spontaneous pneumothorax (grade B recommendation [inconsistent or limited evidence]) pleurodesis with sclerosing agent via chest tube or thoracoscopy used to reduce recurrence rate thoracoscopic talc pleurodesis reduces recurrence rate compared to chest tube drainage (level 1 [likely reliable] evidence) talc pleurodesis reported to be associated with respiratory failure (level 3 [lacking direct] evidence) mixed talc associated with worsened gas exchange and more systemic inflammation than graded talc (level 3 [lacking direct] evidence) minocycline pleurodesis following video-assisted thoracoscopic surgery is painful but may reduce recurrence risk (level 2 [mid-level] evidence) surgery may be indicated for persistent air leak, recurrent or bilateral pneumothorax, or high-risk profession video-assisted thoracoscopic surgery (VATS) compared to open surgery had inconsistent results in terms of recurrence risk in 2 systematic reviews Medications: prophylactic antibiotics appear unnecessary for closed tube thoracostomy for primary spontaneous pneumothorax (grade B recommendation [inconsistent or limited evidence]) based on observational study with no infections 119 patients had tube thoracostomy for primary spontaneous pneumothorax and were followed without prophylactic antibiotics 8 patients with surgery for prolonged air leak were excluded 28 patients (25%) had some induration around chest tube entry site which resolved spontaneously 12 (11%) had elevated white blood cell count and 8 (7%) had fever < 48 hours, both of which resolved spontaneously no bacterial cultures resulted in significant growth Reference - J Cardiothorac Surg 2006 Nov 13;1:43 full-text pleurodesis with sclerosing agent via chest tube or thoracoscopy therapeutic role(1) goal is to achieve symphysis between visceral and parietal pleura and prevent recurrence of pneumothorax may be most useful for recurrent or secondary spontaneous pneumothorax, due to increased risk for recurrence pleurodesis via chest tube to prevent recurrence considered appropriate in patients refusing surgery or when surgery is contraindicated commonly used sclerosing agents include talc slurry, doxycycline, bleomycin sulfate(3) talc preparations can be administered by talc poudrage via thoracoscopy or via chest tube (talc slurry)(1) inexpensive, efficient, and can be performed at bedside(1) thoracoscopic talc pleurodesis reduces recurrence rate compared to chest tube drainage (level 1 [likely reliable] evidence) based on randomized trial 108 patients ≤ 50 years old with primary spontaneous pneumothorax were randomized to thoracoscopic talc pleurodesis (talcage) vs. chest tube drainage mean follow-up 60.5 months in talcage patients and 54 months in pleural drainage patients comparing talcage vs. chest tube drainage second procedure required after prolonged drainage > 7 days in 2% vs. 21% (p < 0.01, NNT 6) recurrence rate 5% vs. 34% (p < 0.01, NNT 4) recurrence rate 8.2% vs. 34% in intention-to-treat analysis assuming 2 dropouts in talcage group had recurrences (p < 0.05, NNT 4) no complications or adverse effects reported in either treatment group talcage associated with increased pain and low-grade fever for 1-2 days Reference - Eur Respir J 2002 Oct;20(4):1003 full-text, commentary can be found in Eur Respir J 2003 Apr;21(4):732 full-text DynaMed commentary - type of talc used not specified but study took place in Europe so graded talc probably used talc pleurodesis reported to be associated with respiratory failure (level 3 [lacking direct] evidence) based on 2 retrospective cohort studies not specific to spontaneous pneumothorax 78 patients treated with 89 talc pleurodesis procedures from 1993-1997 were evaluated respiratory complications or death occurred in 33% adult respiratory distress syndrome developed in 9% no differences in outcomes between patient groups, application methods or talc doses Reference - Am J Surg 1999 May;177(5):437 58 patients who had 75 procedures of talc slurry via tube thoracostomy from 1991-1992 were evaluated 52 patients (90%) had malignant pleural effusions mean follow-up 171 days (range 2-450 days) pleurodesis successful in 38 of 47 procedures (81%), defined as absence of pleural fluid reaccumulation adverse effects in 73 procedures included fever in 46 (63%) empyema in 4 (5%) atrial arrhythmia in 3 (4%) hypotension in 3 (4%) hypoxemic respiratory failure in 3 (4%) no deaths attributed to procedure occurred Reference - Chest 1994 Aug;106(2):342 PDF, commentary can be found in Chest 1995 Jul;108(1):289 PDF graded talc is European standard, while mixed talc used in United States and United Kingdom(1) graded talc - most particles < 10 micrometers removed mixed talc - mean particle size < 15 micrometers mixed talc associated with worsened gas exchange and more systemic inflammation than graded talc (level 3 [lacking direct] evidence) based on randomized trial without clinical outcomes (extrapolated from related patient population other than spontaneous pneumothorax) 48 patients with malignant pleural effusion randomized to mixed talc vs. graded talc for pleurodesis fever occurred in 41% mixed talc vs. 4% graded talc patients (p < 0.001, NNH 2) Reference - Am J Respir Crit Care Med 2004 Aug 15;170(4):377 full-text minocycline pleurodesis following video-assisted thoracoscopic surgery is painful but may reduce recurrence risk (level 2 [mid-level] evidence) based on randomized trial with unclear randomization 202 patients < 50 years old with primary spontaneous pneumothorax treated with video-assisted thoracoscopic surgery were randomized to additional minocycline pleurodesis vs. observation indications for video-assisted thoracoscopic surgery were ipsilateral or contralateral recurrence, continuous air leaks for > 3 days, hemopneumothorax, or high-risk profession randomization was assigned by even and odd chart numbers so unclear if allocation concealment or adequate randomization occurred, but no significant baseline differences reported after full lung expansion, minocycline group received 2% lidocaine 20 mL then minocycline 300 or 400 mg (7 mg/kg) in saline 20 mL via thoracostomy tube comparing minocycline pleurodesis vs. observation meperidine requested in 83% vs. 66% (p = 0.006, NNH 6) recurrent ipsilateral pneumothorax at 12-47 months (median follow-up 28-30 months) in 1.9% vs. 8.1% (p = 0.044, NNT 16) Reference - Am J Respir Crit Care Med 2006 Mar 1;173(5):548 full-text, commentary can be found in Am J Respir Crit Care Med 2006 Jul 1;174(1):103 full-text silver nitrate(1) sclerosing agent high number of side effects, not routinely used treatment of catamenial pneumothorax (menstrual-related) may include oral contraceptives(3) Surgery: possible indications for surgical intervention(3) primary spontaneous pneumothorax air leak persists > 4 days recurrence secondary spontaneous pneumothorax bilateral spontaneous pneumothorax second ipsilateral pneumothorax first contralateral pneumothorax persistent air leak (> 4 days) despite continuous tube drainage high-risk professions such as pilots and deep-sea divers surgical interventions may include(1) resection of blebs and bullae (usually by stapling, perhaps electrocoagulation or laser for smaller bullous lesions) pleural abrasion - mechanical abrasion of parietal pleural with dry gauze or electrosurgical tip cleaner chemical pleurodesis (tetracycline) to visceral pleura partial or complete parietal pleurectomy resection of lung lesions surgical access may occur via(1) thoracotomy axillary thoracotomy anterior thoracotomy muscle-sparing lateral thoracotomy posterior, lateral or axillary mini-thoracotomy sternotomy for bilateral procedure video-assisted thoracoscopic surgery (VATS) video-assisted thoracoscopic surgery (VATS) compared to open surgery had inconsistent results in terms of recurrence risk in 2 systematic reviews video-assisted thoracoscopic surgery associated with shorter hospital stay, less pain, less pain medication use and fewer recurrences than open thoracotomy (level 2 [mid-level] evidence) based on systematic review with conclusions not supported by high-quality trials systematic review of 12 randomized trials with 670 patients 4 trials reported allocation concealment, of which 3 reported intention-to-treat analysis these 3 high-quality trials generally did not report these outcomes or did not support significant differences Reference - BMJ 2004 Oct 30;329(7473):1008 full-text video-assisted thoracoscopic surgery associated with higher recurrence risk compared to open surgery for pneumothorax (level 2 [mid-level] evidence) based on systematic review with non-randomized studies systematic review of 4 randomized and 25 non-randomized studies comparing video-assisted thoracoscopic vs. open surgery for pneumothorax comparing video-assisted thoracoscopic vs. open surgery in studies using same method of pleurodesis non-significantly increased risk of recurrence in 3 randomized trials (relative risk 4, 95% CI 0.86-18.19) significantly increased risk of recurrence in 16 non-randomized studies (relative risk 4.9, 95% CI 2.67-8.92) significantly increased risk of recurrence in overall meta-analysis (relative risk 4.7, 95% CI 2.7-8.29) comparing video-assisted thoracoscopic vs. open surgery in all studies non-significantly increased risk of recurrence in 4 randomized trials (relative risk 4, 95% CI 0.24-9.7) significantly increased risk of recurrence in 25 non-randomized studies (relative risk 4, 95% CI 2.54-6.29) significantly increased risk of recurrence in overall meta-analysis (relative risk 4, 95% CI 2.58-6.16) after excluding 1 outlier study (with 54% recurrence rate), overall recurrence rates were 5.4% with video-assisted surgery vs. 1.1% with open surgery (NNH 23) Reference - Lancet 2007 Jul 28;370(9584):329, editorial can be found in Lancet 2007 Jul 28;370(9584):294 Consultation and referral: consider referral to thoracic surgeon if persistent air leak (> 4 days)(3) Other management: observation may be adequate if first primary spontaneous pneumothorax, or for limited recurrent pneumothorax in stable patients(1) observation may be adequate if pneumothorax is small, defined as < 3 cm between lung apex and dome of thoracic cavity(3) or defined as < 15% of hemithorax(2) supplemental oxygen should be given to accelerate reabsorption of air by pleura(2,3) methods to remove air in pleural space for re-expansion of lung simple aspiration(1) intercostal chest tube drainage (tube thoracostomy)(2) attached to Heimlich valve or water-seal device no evidence that application of suction improves outcomes limited evidence comparing simple aspiration vs. chest tube for re-expansion of lung simple aspiration for primary spontaneous pneumothorax might be as effective as tube thoracostomy and may avoid need for hospitalization (level 2 [mid-level] evidence) based on limited randomized trial evidence in randomized trial with wide confidence intervals 137 patients with first primary spontaneous pneumothorax (symptomatic or size > 20% hemithorax) were randomized to simple aspiration vs. tube thoracostomy simple aspiration group had 16 gauge plastic catheter inserted and connected to water-seal vacuum with negative pressure 10-15 cm H2O until cessation of air flow or maximum 30 minutes; second aspiration done if post-procedure chest x-ray showed persistent pneumothorax; tube thoracostomy done if second attempt unsuccessful or continuous air leak tube thoracostomy group had 20 French plastic tube inserted and connected to underwater seal suction with negative pressure 20 cm H2O for 24 hours after cessation of air flow and lung expansion confirmed on x-ray; video-assisted thoracoscopic surgery done if unsuccessful immediate success defined as complete or nearly complete lung expansion following aspiration complete lung expansion and chest tube removal (without air leak) within 3 days of tube insertion comparing simple aspiration vs. tube thoracostomy immediate success rate 62% vs. 68% (not significant, 95% CI for absolute difference -22.5% to +9.4%) success rate at 1 week 89% vs. 88% (not significant, 95% CI for absolute difference -9% to +12.4%) hospitalization rate 26% vs. 100% (p < 0.0001, NNT 2) inability to work for mean 3.6 vs. 6.04 days (p < 0.0001) recurrence rate at 3 months 15% vs. 8% (not significant, 95% CI for absolute difference -3.7% to +17.8%) recurrence rate at 1 year 25% vs. 24% (not significant, 95% CI for absolute difference -13.3% to +15.3%) recurrence rate at 2 years 31% vs. 25% (not significant, 95% CI for absolute difference -9.2% to +20.8%) Reference - Eur Respir J 2006 Mar;27(3):477 full-text in Cochrane review with limited evidence systematic review of randomized trials comparing simple aspiration with intercostal tube drainage in adults with primary spontaneous pneumothorax only 1 trial with 60 patients met inclusion criteria no significant differences in immediate success rate, early failure rate, duration of hospitalization, rates of procedures for lung pleurodesis, or 1-year success rate simple aspiration associated with fewer patients hospitalized all outcomes limited by wide confidence intervals Reference - systematic review last updated 2006 Nov 12 (Cochrane Library 2007 Issue 1:CD004479) in systematic review with heterogeneity systematic review of 3 randomized trials comparing simple aspiration vs. chest-tube insertion in 194 patients with primary spontaneous pneumothorax simple aspiration associated with shorter hospitalization (weighted mean difference -1.3 days, p < 0.05) no significant differences in success rates at ≥ 1 week or recurrence at 1 year, but limited by heterogeneity due to differences in outcome definitions simple aspiration associated with shorter hospitalization by 1.3 days (95% CI 0.39-2.2 days) Reference - Respir Med 2004 Jul;98(7):579 thoracic drainage may be associated with higher initial success rate than needle aspiration, but no difference in recurrence rate at 3 months (level 2 [mid-level] evidence) based on randomized trial with differences in procedures and definitions between randomized groups 61 patients > 18 years old with first episode or first recurrence of spontaneous pneumothorax were randomized to thoracic drainage vs. simple needle aspiration 53 patients (87%) had primary spontaneous pneumothorax thoracic drainage group had immediate chest tube insertion with negative pressure 20-25 cm H2O for 24 hours after cessation of air flow then tube clamped for 24 hours then tube removed if no recurrent pneumothorax on chest x-ray needle aspiration group had needle aspiration with negative pressure 10-15 cm H2O until cessation of air flow or maximum 30 minutes, then catheter removed needle aspiration done immediately if poor clinical tolerance or after 3 days of bed rest if clinically tolerating pneumothorax second needle aspiration could be repeated after 24 hours, then chest tube insertion if unsuccessful treatment failure defined as thoracic drainage - persistent bubbling at end of 10-day aspiration period or short-term recurrence of pneumothorax requiring second chest tube insertion needle aspiration - incomplete lung re-expansion (< 80% total surface) or recurrence of complete pneumothorax within first 24 hours after last procedure comparing thoracic drainage vs. needle aspiration success rates 93% vs. 67% (p = 0.01, NNT 4) mean hospital stay 7 vs. 7 days (not significant), but needle aspiration delayed by 72 hours in 26 patients recurrence rate at 3 months 29% vs. 21% (not significant) Reference - Chest 1995 Aug;108(2):335 PDF, commentary can be found in Chest 1996 Jul;110(1):303 PDF needle aspiration may reduce hospitalization compared to tube thoracostomy for spontaneous pneumothorax in emergency department (level 2 [mid-level] evidence) (* further peer review in progress) based on systematic review of trials with methodologic limitations systematic review of 3 randomized trials comparing needle aspiration to tube thoracostomy for spontaneous pneumothorax in 270 adult patients in emergency department methodologic limitations include unclear allocation concealment small sample size no significant differences in immediate failure, 1-week failure, risk of complications or 1-year recurrence rate needle aspiration associated with lower hospitalization rate in 2 trials and shorter hospitalization in all 3 trials Reference - Ann Emerg Med 2008 Jan;51(1):107 chest drain removal painful but insufficient evidence to guide analgesic management (see Chest tube insertion for details and procedural information) Follow-up: follow-up chest x-ray showing stable or smaller pneumothorax in 24 hours suggests adequate treatment(3) deep-sea diving contraindicated in patients with previous spontaneous pneumothorax until definitive bilateral surgical pleurectomy has been performed(3) Prevention and Screening Prevention: smoking cessation(1) References including Reviews and Guidelines General references used: 1. Tschopp JM, Rami-Porta R, Noppen M, Astoul P. Management of spontaneous pneumothorax: state of the art. Eur Respir J. 2006 Sep;28(3):637-50. full-text 2. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000 Mar 23;342(12):868-74., commentary can be found in N Engl J Med 2000 Jul 27;343(4):300, summary can be found in Am Fam Physician 2000 Sep 15;62(6):1398 3. Dincer HE, Randolph JL. The intricacies of pneumothorax: Management depends on accurate classification. Postgrad Med 2005 Dec;118(6):online Reviews: case presentation can be found in Am Fam Physician 2009 Aug 1;80(3):287 review of pleural cavity disease can be found in BMJ 2000 May 13;320(7245):1318 full-text review of pneumothorax in sports can be found in Phys Sportsmed 2000 Aug;28(8):23 review of imaging of pneumothorax can be found in BMJ 2005 Jun 25;330(7506):1493 full-text Guidelines: British Thoracic Society guidelines for management of spontaneous pneumothorax can be found in Thorax 2003 May;58 Suppl 2:ii39 full-text, commentary can be found in Thorax 2004 Apr;59(4):355 full-text American College of Chest Physicians consensus statement on management of spontaneous pneumothorax can be found in Chest 2001 Feb;119(2):590 full-text, commentary can be found in Chest 2001 Sep;120(3):1041 full-text, Chest 2002 Feb;121(2):669 full-text Patient Information Patient information: handout on spontaneous pneumothorax from American Lung Association handout on pneumothorax from EBSCO Publishing Health Library PDF or in Spanish PDF Acknowledgements DynaMed topics are created and maintained by the DynaMed Editorial Team. Over 500 journals and evidence-based sources (DynaMed Content Sources) are monitored directly or indirectly using a 7-step evidence-based method for systematic literature surveillance. DynaMed topics are updated daily as newly discovered best available evidence is identified. Special acknowledgements: Sarvotham Kini, MD FACEP FACS (Associate Professor; Director of Education - Division of Emergency Medicine; Program Director - Emergency Medicine Residency, Medical University of South Carolina, Charleston, South Carolina, USA) has provided peer review since 2008 Aug 6. Competing interests: Each participating member of the DynaMed Editorial Team has declared no competing interests (financial or otherwise) related to this topic. Dr. Kini has declared no competing interests (financial or otherwise) related to this topic. 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