Simple sequential treatment for primary spontaneous pneumothorax: one step closer

Abstract

Primary spontaneous pneumothorax (PSP) remains a significant clinical problem in emergency departments and respiratory medicine units. The management of minimally symptomatic patients presenting with their first small PSP on a chest radiograph is straightforward; a period of simple observation with follow-up chest radiography will usually suffice. Attempts to prevent recurrence at this stage are generally not recommended, as 50–70% of these patients will not have a recurrence 1–3. However, despite literature replete with discussions on the assessment and management of PSP, no standard approach to symptomatic or “large” PSPs has been universally adopted. Two significant guidelines for management of pneumothoraces have addressed this problem, one of which was evidence-based and the other consensus-based 4, 5. Objectives for managing these patients should be straightforward. Ideally, a diagnosis and treatment algorithm should be adopted that would predict those who need intervention. It should facilitate the treatment and discharge of a significant proportion of these patients in the emergency department without the need for hospital admission. It should also allow for continuing management of patients who require in-patient pleural drainage without further invasive procedures, until it becomes apparent that they have a persistent air leak necessitating surgical intervention. Finally, these young and otherwise fit patients should be managed in a setting that allows them to remain mobile during their pleural drainage. Predicting which patients require treatment for their PSPs seems relatively straightforward. Breathless patients or those with persistent significant chest pain should not be left without intervention, regardless of the size of the pneumothorax on the chest radiograph 4, 6. What is less apparent is when to intervene in clinically stable patients with large pneumothoraces. The definition of what constitutes a large pneumothorax varies, with the American College of Chest Physicians (ACCP) defining it as ≥3 cm …