Current management of spontaneous pneumothorax

Spontaneous pneumothorax is divided into primary, when there is no underlying lung disease, and secondary, mainly caused by chronic obstructive pulmonary disease. A variety of different non-invasive and invasive treatment options exist. Due to the lack of large randomised controlled trials no level A evidence is present. A first episode of a primary spontaneous pneumothorax is treated by observation if it is < 20% or by simple aspiration if it is > 20%, but recurrences are frequent. For recurrent or persisting pneumothorax a more invasive approach is indicated whereby video-assisted thoracic surgery provides a treatment of lung (resection of blebs or bullae) and pleura (pleurectomy or abrasion). In patients with a secondary spontaneous pneumothorax related to chronic obstructive pulmonary disease, there is an associated increased mortality and a more aggressive approach is warranted consisting of initial thoracic drainage followed by recurrence prevention by thoracoscopy or thoracotomy in patients with a low or moderate operative risk. Talc instillation by the thoracic drain is preferred for patients with a high operative risk.