Primary spontaneous pneumothorax: why all

Abstract

The management of PSP continues to be a source of debate. There are few randomised control trials comparing treatment options, and current guidelines based on specialist opinion vary in their recommendations. Initial management options include observation, aspiration, intercostal drainage with and without pleurodesis, and video-assisted thoracoscopic surgery. Primary spontaneous pneumothoraces arise in patients without clinically apparent lung disease, and no obvious precipitating factor. It is a relatively common presentation with a reported incidence of 18 to 28 per 100,000 men per year and 1·2 to 6 per 100,000 women per year. Primary spontaneous pneumothorax usually occurs in young, tall males between the ages of 15 and 34.

The BTS and ACCP have both published guidelines on the treatment of PSP. While they agree on the management of small asymptomatic PSP (observation and outpatient review) and clinically unstable PSP (intercostal drain insertion and admission), they differ on the management of symptomatic small PSP and clinically stable large PSP. The ACCP advise that simple aspiration is rarely appropriate in the treatment of PSP, while the BTS recommend simple aspiration as a first-line treatment. A 2007 Cochrane report, which systematically reviewed all published randomised control trials comparing aspiration to intercostal drain insertion, concluded that there was no difference in the immediate success rate, early failure rate, or one-year success rate between the two interventions. However, aspiration resulted in a lower number of patients requiring admission, and decreased the duration of hospital stay. Current evidence supports the 2003 BTS guidelines, and simple aspiration as first-line treatment in clinically stable pneumothoraces. Until a large randomised control trial is performed, and provides a conclusive evidence base for the most appropriate management of spontaneous pneumothorax, confusion will remain over first-line treatment.