Editing Pneumothorax (section)

== Management ==

* Options: bed rest and observation; aspiration; small-bore catheter; tube thoracostomy; VATS; open thoracotomy.
* Simple, small, uncomplicated, clinically stable, asymptomatic PTX: more conservative treatment, perhaps even just bed rest and observation, with oxygen (oxygen favours healing by increasing the gradient for nitrogen absorption from the pleural space). Should hospitalise for at least 24 hours.
** Needle aspiration may be appropriate in this population (don't repeat if it doesn't work)
** Especially applies to small PTX from biopsy needle
** Progression in size requires drainage with small-bore chest tube such as Rocket 14Fr
* Symptomatic: tube thoracostomy with UWSD is mandatory
** Tailor the size of the tube to the risk of substantial air leak
** Direct tube towards apex
** Reasonable to leave off suction initially (risk of re-expansion oedema), check re-expansion, then apply -10 to -20 cm H2O if needed. Use minimum suction to re-inflate lung.
** Remove chest tube when air leak has stopped for at least 48-72 hours
* Persistent air leak - defined as >48 hours
** Much more common with SSP as opposed to PSP (40% at 7 days compared to 5% at 7 days)
** ACCP guidelines suggest surgical intervention at 4 days for PSP and 5 days for SSP, since a longer waiting time does not seem to substantially modify outcome
* Indications for surgery in primary spontaneous pneumothorax
** Rationale
*** Prevent recurrence (30% without intervention, 2-3% with intervention)
** First episode
*** Prolonged air leak (4 days)
*** Non-re-expansion of the lung
*** Bilateral pneumothorax
*** Haemothorax
*** Tension pneumothorax
*** Complete pneumothorax
*** Occupational hazard
*** Absence of medical facilities in isolated areas
*** Associated single large bulla
** Second episode
*** Ipsilateral recurrence
*** Contralateral recurrence
* Lifestyle modifications if not had surgery
** No scuba diving, piloting planes

=== Surgery - resect the cause and obliterate the pleural space ===

* Mostly need recurrent primary spontaneous PTX before considering VATS
* If blebs or bullae >1cm are seen, wedge resection is necessary
* Controversial as to whether VATS or limited thoracotomy are better. In bilateral disease, VATS is also reasonable.
* Mechanical abrasion of the parietal pleura
* Pleural space should be obliterated with apical parietal pleurectomy, pleural abrasion or chemical irritation
** Apical parietal pleurectomy - surgical fixation of the lung to the endothoracic fascia - good long-term results
** Pleural abrasion preferred for patients likely to need further thoracic surgery as it preserves the extra-pleural plane of dissection. Recurrence rate 2.3%
** Chemical pleurodesis - mostly talc (powder of hydrous magnesium silicate. Commercially available talc is free of asbestos. 
* Pleurodesis with talc is good in older patients or patients with malignancy, but surgery would be preferred in most patients.

=== Talc pleurodesis: maximum of 5g introduced as a slurry through chest tube ===

* Common reactions:
** Low-grade fever
** Local pain
** Local infection - very hard/impossible to cure
** Respiratory distress