Part 2 · The Pleura

Pneumothorax

Classification, surgical indications, VATS blebectomy, and achieving complete pleural symphysis.

PleuraSurgical relevance
Definition

Pneumothorax is the presence of air in the pleural cavity. Classified as spontaneous (primary or secondary) or traumatic (iatrogenic or non-iatrogenic).

Classification

Classification and causes of pneumothorax
TypeSpecific causes
Primary spontaneous (PSP)
Rupture of apical subpleural bleb in young adults; associations: Marfan's syndrome, homocystinuria, Birt-Hogg-Dubé syndrome
Secondary spontaneous (SSP)
Airway diseaseCOPD (most common), asthma, cystic fibrosis
InfectionPTB, Pneumocystis jirovecii (PCP)
ILDLAM, lymphangioleiomyomatosis, eosinophilic granuloma
NeoplasiaCarcinoma lung, sarcoma (cavitating)
CatamenialCyclical PTX coinciding with menstruation; endometrial implants on diaphragm or pleura
Traumatic — iatrogenic
Lung biopsy · thoracentesis · central line placement · mechanical ventilation (barotrauma)
Traumatic — non-iatrogenic
Penetrating or blunt chest trauma · diving · descent from altitude
Chest X-ray showing right-sided spontaneous pneumothorax with visible pleural line and lung collapse
Fig. 1. PA chest radiograph showing a right-sided spontaneous pneumothorax — the pleural line is clearly visible, with the collapsed lung margin separated from the chest wall by a lucent air space. Via Wikimedia Commons. Public domain.

Primary spontaneous pneumothorax (PSP)

Classic description: tall, thin male, 20–30 years, smoker, positive family history. Ruptured blebs are visible on CT in ~15% of cases, typically at the apex and along fissures. Thoracoscopy at the time of surgery reveals blebs even in imaging-negative cases. Recurrence rates: ~50% after first episode, increasing with each subsequent episode. Simultaneous bilateral PSP occurs in ~10%.

Management

Initial management

  • Small, asymptomatic PSP (<2 cm rim): observation, high-flow oxygen to accelerate pleural air absorption, discharge with 2-week follow-up
  • Large or symptomatic: needle aspiration (first-line for PSP) or intercostal chest drain — small-bore drain (8–14 Fr) equivalent to large-bore for uncomplicated PTX
  • SSP: lower threshold for ICD — underlying lung disease means less physiological reserve; these patients deteriorate faster
  • Tension pneumothorax: immediate needle decompression (2nd ICS, midclavicular line) before ICD — clinical diagnosis, do not wait for X-ray
Current management guidelines

For stepwise management algorithms, size thresholds, and ambulatory device use, refer to the BTS Pleural Disease Guidelines (current edition).

Surgical indications

  • Second ipsilateral episode
  • First contralateral episode
  • Bilateral simultaneous pneumothorax
  • Persistent air leak >5–7 days
  • Massive air leak preventing lung re-expansion
  • Complications: haemopneumothorax, empyema
  • High-risk occupation (pilots, divers) — offer surgery after first episode
  • Catamenial pneumothorax — VATS with diaphragmatic excision and pleurodesis
  • Remote location without access to emergency care

Operative principles

Two goals of pneumothorax surgery

(1) Remove the causative bleb/bulla — blebectomy or bullectomy with stapler. (2) Achieve complete pleural symphysis to prevent recurrence — pleurodesis, pleural abrasion, or pleurectomy. Both must be achieved at the same operation.

VATS (preferred)

Three-port technique. Inspect entire pleural cavity. Staple the apex bleb. Mechanical pleurodesis or talc poudrage. 98% success rate. Low morbidity.

Axillary thoracotomy

3rd interspace. Useful when VATS is unavailable or previous failed VATS. Excellent access to apex for blebectomy and pleural abrasion.

Median sternotomy

Bilateral simultaneous pneumothorax only. Approach to both apices at one sitting.

Pleurodesis agents

Talc (graded medical talc, magnesium trisilicate hydroxide — asbestos-free, 15–25 microns, 2–4 grams) is the most effective chemical sclerosant. Administration: slurry via chest tube, insufflation (poudrage), or aerosolised spray via thoracoscope. Complications: chemical pleuritis, fever, rarely pneumonitis and ARDS. Other agents: povidone-iodine, bleomycin, tetracycline — lower efficacy than talc.

Haemopneumothorax

Bleeding into the pleural space complicates 5% of spontaneous pneumothoraces, due to tearing of pleural adhesions as the lung collapses. Haemopneumothorax >500 mL or haemodynamic instability requires VATS evacuation and definitive management — do not manage with ICD alone as clotted blood organises rapidly.

Further reading

All clinical content should be verified against current guidelines before clinical application. This resource is intended for revision and educational purposes only.

Standard textbooks

  • Shields TW, LoCicero J, Reed CE, Feins RH. General Thoracic Surgery. 7th ed. Lippincott Williams & Wilkins.
  • Sellke FW, del Nido PJ, Swanson SJ. Sabiston & Spencer Surgery of the Chest. 9th ed. Elsevier.
  • Pearson FG, et al. Thoracic Surgery. 3rd ed. Churchill Livingstone.

Current guidelines & resources