Primary Spontaneous Pneumothorax in Adults

Primary spontaneous pneumothorax in adults - UpToDate
04/10/2016, 6:02 AM
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www.uptodate.com 2016 UpToDate
Primary spontaneous pneumothorax in adults

Author: Richard W Light, MD
Section Editor: V Courtney Broaddus, MD
Deputy Editor: Geraldine Finlay, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Sep 26, 2016.
INTRODUCTION A primary spontaneous pneumothorax (PSP) is a pneumothorax that occurs without a
precipitating event in a person who does not have known lung disease. In actuality, most individuals with PSP
have unrecognized lung disease, with the pneumothorax resulting from rupture of a subpleural bleb [1-5].
In this topic review, the incidence, pathogenesis, presentation, and management of PSP are discussed.
Secondary spontaneous pneumothorax, which occurs as a complication of underlying lung disease, is reviewed
in detail elsewhere. (See "Secondary spontaneous pneumothorax in adults".)
INCIDENCE The incidence of primary spontaneous pneumothorax (PSP) in men varies geographically, from
7.4 per 100,000 population per year in the United States to 37 per 100,000 population per year in the United
Kingdom. The incidence is substantially less in women than in men, ranging from 1.2 per 100,000 population per
year in the United States to 15.4 per 100,000 population per year in the United Kingdom [6]. The reason for
these differences is unknown.
Estimates of the incidence of recurrent PSP range from 25 percent to more than 50 percent, with most
recurrences seen within the first year [6]. As an example, a study of 153 patients with PSP found a recurrence
rate of 54 percent [7]. Female gender, tall stature in men, low body weight, and failure to stop smoking have
been associated with an increased risk of recurrence [7,8].
RISK FACTORS Factors that have been proposed or shown to predispose patients to primary spontaneous
pneumothorax (PSP) include smoking, family history, Marfan syndrome, homocystinuria, and thoracic
endometriosis.
Smoking Cigarette smoking is a significant risk factor for primary spontaneous pneumothorax (PSP),
probably due to consequences of airway inflammation. As an example, in an analysis of four studies that
included 505 patients with PSP, 461 of the patients (91 percent) were smokers [6]. Furthermore, the risk of PSP
was directly related to the amount of cigarette smoking. Compared to nonsmokers, the relative risk of PSP in
men was seven times higher in light smokers (1 to 12 cigarettes per day), 21 times higher in moderate smokers
(13 to 22 cigarettes per day), and 102 times higher in heavy smokers (>22 cigarettes per day). For women, the
relative risk was 4, 14, and 68 times higher in light, moderate, and heavy smokers, respectively [9].
Respiratory bronchiolitis, a form of airway inflammation associated with cigarette smoking, may contribute to the
development and recurrence of PSP. In a study of 115 patients with PSP who underwent video-assisted
thoracoscopic surgery (VATS), pneumothorax recurrence rates were higher in patients with extensive rather than
nonextensive respiratory bronchiolitis for both nonoperative and postoperative pneumothorax (p<0.004 and
0.001, respectively) [10].
Family history Reports have been published describing the clustering of PSP in certain families [11-17].
Autosomal dominant, autosomal recessive, polygenic, and X-linked recessive inheritance mechanisms have all
been proposed [12-14]. The autosomal dominant Birt-Hogg-Dub syndrome, which predisposes patients to
benign skin tumors and renal cancer, is associated with an increased incidence of PSP [15,16,18-21]. In one
study of 198 patients with this syndrome, 48 patients (24 percent) had a history of pneumothorax [18]. The
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presence of lung cysts was associated with pneumothorax, as well as lung cyst volume, diameter, and number.
The gene responsible for this familial cancer syndrome (called FLCN) has been mapped to chromosome 17p11.2
[15,16]. FLCN and its associated protein, folliculin, appear to have important tumor suppression function.
However, other mutations of FLCN have been associated with spontaneous pneumothorax and bullous lung
disease in the absence of the oncologic manifestations of Birt-Hogg-Dub syndrome [11,17]. In one Finnish
family with an extensive history of PSP, a novel mutation was associated with autosomal dominant inheritance of
bullous lung lesions in all carriers (100 percent penetrance) [11].
Genetic testing is available for the Birt-Hogg-Dub syndrome [22]. Periodic screening for renal tumors is
recommended in affected patients. (See "Hereditary kidney cancer syndromes", section on 'Birt-Hogg-Dub
syndrome' and "Birt-Hogg-Dub syndrome".)
Other PSP also occurs with increased frequency in patients with Marfan syndrome and homocystinuria. In
addition, catamenial pneumothorax may result from thoracic endometriosis, and should be considered in women
presenting with PSP temporally related to menstruation [23-25]. (See "Clinical features, diagnostic approach, and
treatment of adults with thoracic endometriosis".)
Several case reports have described the occurrence of spontaneous pneumothorax among patients with
anorexia nervosa [26-28]. It is thought that the pulmonary parenchymal consequences of malnutrition contribute
to development of pneumothorax in these patients. (See "Anorexia nervosa in adults and adolescents: Medical
complications and their management", section on 'Pulmonary'.)
CLINICAL PRESENTATION
Symptoms and signs Primary spontaneous pneumothorax (PSP) usually develops when the patient is at
rest [29]. Patients are typically in their early 20s, with PSP being rare after age 40. Patients usually complain of
the sudden onset of dyspnea and pleuritic chest pain. The severity of the symptoms is primarily related to the
volume of air in the pleural space, with dyspnea being more prominent if the pneumothorax is large.
Characteristic physical findings when a large pneumothorax is present include decreased chest excursion on the
affected side, diminished breath sounds, and hyperresonant percussion. Subcutaneous emphysema may be
present. Evidence of labored breathing and hemodynamic compromise (eg, tachycardia, hypotension) suggests
a possible tension pneumothorax, which necessitates emergency decompression.
Hypoxemia is common because collapsed and poorly ventilated portions of lung continue to receive significant
perfusion. In contrast, hypercapnia is unusual because underlying lung function is relatively normal and adequate
alveolar ventilation can be maintained by the contralateral lung [1]. Acute respiratory alkalosis may exist if pain,
anxiety, and/or hypoxemia are substantial.
Imaging The presence of a pneumothorax is established by demonstrating a white visceral pleural line on the
chest radiograph. The visceral pleural line defines the interface of the lung and pleural air; it is either straight or
convex towards the chest wall (image 1). In most cases, no pulmonary vessels are visible beyond the visceral
pleural edge. Inspiratory and expiratory films have equal sensitivity in detecting pneumothoraces; thus, a
standard inspiratory chest radiograph is sufficient in most cases [30]. (See "Imaging of pneumothorax".)
The underlying lung parenchyma should be examined for the presence of underlying lung disease that would
suggest a secondary spontaneous pneumothorax. (See "Secondary spontaneous pneumothorax in adults".)
Tension pneumothorax may develop in approximately 1 to 2 percent of PSP [31]. However, the sensitivity and
specificity of the plain chest radiograph for detection of tension are unclear. Contralateral shift of the trachea and
mediastinum is a typical finding in spontaneous pneumothorax and not necessarily suggestive of tension.
Conversely, patients may have clinical evidence of tension (eg, tachycardia, hypotension, dyspnea) in the
absence of "typical" radiographic findings. (See "Imaging of pneumothorax", section on 'Types of
pneumothorax'.)
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CT scanning is generally not necessary unless abnormalities are noted on the plain chest radiograph that require
further evaluation, or an aberrant chest tube placement or a loculated pneumothorax is suspected [32].
Ultrasound can also be used to image patients with suspected pneumothorax, the details of which are discussed
separately. (See "Imaging of pneumothorax", section on 'Ultrasound' and "Thoracic ultrasound: Indications,
advantages, and technique", section on 'Identification of pneumothorax'.)
DIAGNOSIS The diagnosis of primary spontaneous pneumothorax (PSP) is established by detection of a
visceral pleural line on the chest radiograph of a patient without underlying lung disease. (See 'Imaging' above.)
The differential diagnosis includes the causes of spontaneous pneumothorax in patients who have underlying
lung disease that has not yet been diagnosed (eg, catamenial pneumothorax, chronic obstructive lung disease,
interstitial lung disease, lung cancer, lymphangioleiomyomatosis). When managing patients with a persistent air
leak or recurrent spontaneous pneumothorax, a CT scan should be considered as well as a lung biopsy at the
time of thoracoscopy. The diseases associated with secondary spontaneous pneumothorax are discussed in
more detail separately. (See "Secondary spontaneous pneumothorax in adults", section on 'Etiologies'.)
TREATMENT OPTIONS Initial management is directed at removing air from the pleural space, with
subsequent management directed at preventing recurrence. In the discussion that follows, we expand upon
published clinical consensus statements [32-34].
Initial management Initial treatment options for primary spontaneous pneumothorax (PSP) include
observation, supplemental oxygen, needle aspiration of intrapleural air, chest tube insertion (ie, tube
thoracostomy), and thoracoscopy. The choice of procedure depends on patient characteristics and clinical
circumstances:
Patients who are clinically stable and having their first PSP can be administered supplemental oxygen and
observed if their pneumothorax is small (2 to 3 cm between the lung and chest wall on a chest radiograph)
[35].
Patients who are clinically stable and having their first PSP should undergo needle aspiration if their
pneumothorax is large (>3 cm rim of air on chest radiograph), or if they are symptomatic with chest pain or
dyspnea [32,36,37]. Patients who fail aspiration should have a chest tube inserted (ie, tube thoracostomy)
and thoracoscopy should be considered during the same hospitalization. If the air leak persists and
thoracoscopy is not readily available, chemical pleurodesis through the chest tube should be performed.
Patients who are clinically stable with either a recurrent PSP or a concomitant hemothorax (ie, a
hemopneumothorax), should undergo thoracoscopy after chest tube insertion. If thoracoscopy is not readily
available, chemical pleurodesis through the chest tube may be performed after drainage of the pleural
space.
Clinically unstable patients should undergo chest tube insertion. (See 'Tube thoracostomy' below.)
If chest tube insertion is delayed and the patient is unstable, decompression of the pleural space can be
performed by placing a 14 gauge intravenous catheter into the pleural space. A catheter or needle as long
as 7 cm may be needed, depending on the thickness of the chest wall. The insertion site has traditionally
been in the second or third intercostal space (ICS) at the midclavicular line, but chest wall thickness at that
site may prevent access to the pleural space. Alternatively, an insertion site in the fifth ICS in the anterior
axillary line or anterior to the midaxillary line may be used. (See "Initial evaluation and management of blunt
thoracic trauma in adults", section on 'Initial management'.)
Supplemental oxygen Observation should last six hours, after which reliable patients with ready access to
emergency medical services can be discharged home if a repeat chest radiograph excludes progression of the
pneumothorax. While the patient is hospitalized, supplemental oxygen should be administered to facilitate
resorption of the pleural air.
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The importance of supplemental oxygen should not be underestimated. Air in the pleural space is reabsorbed
when the communication between the alveoli and the pleural space (ie, the air leak) closes. The rate of
resorption can be markedly increased if supplemental oxygen is administered [38]. As an example, a normal rate
of resorption is approximately 1.25 percent of the volume of the hemithorax per 24 hours [6]. However, the rate of
resorption increases six-fold if humidified 100 percent oxygen is administered in an animal model [39].
Aspiration Aspiration is most easily accomplished with a commercially available thoracentesis kit. An 18gauge needle with an 8 to 9 French (Fr) catheter is inserted into the pleural space, the catheter is threaded
deeper into the pleural space, and then the needle is withdrawn. Air is manually withdrawn through the indwelling
catheter until no more can be aspirated. It is assumed that there is a persistent air leak if there is still no
resistance after four liters of air has been aspirated and the lung has not expanded. In that situation,
thoracoscopy should be performed. Alternatively, if thoracoscopy is not readily available, a chest tube should be
inserted.
Two equally acceptable approaches exist once no further air can be aspirated [40]:
A closed stopcock can be attached and the indwelling catheter secured to the chest wall. A chest radiograph
should be obtained four hours later and, if adequate lung expansion has occurred, the catheter can be
removed. Following an additional two hours of observation, another chest radiograph should be performed.
If the lung remains expanded on this chest radiograph, the patient can be discharged [41].
The catheter can be left in place and attached to a Heimlich (ie, one-way) valve. The patient can then be
discharged with follow-up within two days [33,42,43]. (See "Placement and management of thoracostomy
tubes", section on 'Tube selection'.)
One of the advantages of aspiration over tube thoracostomy is that the patient need not be hospitalized, whether
the catheter is removed after the aspiration or left attached to the Heimlich valve.
Based on evidence from several studies, we prefer to manage most hemodynamically-stable patients initially
with aspiration, rather than tube thoracostomy [32,44-49]. As examples:
In a meta-analysis of three randomized, controlled trials (194 patients) that compared aspiration versus tube
thoracostomy, aspiration resulted in shorter hospitalizations and similar clinical outcomes at one week and
one year [44].
In a randomized trial, 137 patients who had a first episode of PSP were assigned to receive manual
aspiration or tube thoracostomy [45]. The groups had similar rates of immediate (62 versus 68 percent) and
one-week success (89 versus 88 percent); however, aspiration was associated with a shorter hospital stay
(1.8 versus 4 days).
Tube thoracostomy Most patients with PSP can be managed successfully with a small chest tube (22 Fr)
or chest catheter (14 Fr) [48,50]. The chest tube can be connected to a water seal device, with or without
suction and left in position until the pneumothorax resolves. We suggest that suction be applied to the chest tube
if the pneumothorax fails to resolve. (See "Placement and management of thoracostomy tubes".)
Once the air leak has resolved, the lung has expanded, and the pleural air has been removed, the chest tube
can be removed. Twelve hours after the last evidence of an air leak, the chest tube is clamped and, after an
additional 12 hours, a chest radiograph is obtained. Some prefer not to clamp the chest tube because this might
lead to the development of a tension pneumothorax. However, if the tube is removed a tension pneumothorax
can still develop and it is more difficult to treat if there is no chest tube in place. The chest tube can be removed if
the pneumothorax has not reaccumulated.
Thoracoscopy Video-assisted thoracoscopic surgery (VATS) is effective in the treatment of spontaneous
pneumothorax [5,51-53]. With this procedure, pleurodesis is created by pleural abrasion or a partial parietal
pleurectomy; when necessary, an endoscopic stapler can be used to resect bullae, as reported in several
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uncontrolled observational studies [54-57].

Persistent air leak We advocate a more aggressive approach if an air leak persists after three days. For
patients whose lung is at least 90 percent expanded but who have a persistent air leak, the usual choices include
attaching a Heimlich valve to the chest tube, infusing autologous blood into the pleural space, and performing
video-assisted thoracoscopy to oversew the area of leak and perform mechanical pleurodesis. (See 'VATS
pleurodesis' below.)
The simplest approach is to attach a unidirectional flutter valve (ie, a Heimlich valve) to the chest tube, which
usually allows rapid discharge of the patient with subsequent outpatient management.
An alternative technique for patients with a persistent air leak is to perform an autologous blood patch [58,59].
This involves withdrawal of blood from a peripheral arm vein and aseptic infusion of the blood without
anticoagulants into the pleural space through the chest tube. The ideal amount of blood to infuse into the pleural
space is not known. In one series that included both spontaneous and postoperative pneumothoraces, the mean
volume of blood infused was 90 mL and the range was 24 to 200 mL [58]. After infusion of the blood, the tubing
from the chest tube is draped over a hook approximately 60 cm above the patient's chest and then down to a
water seal device on the floor [59]. The chest tube is removed 24 hours after cessation of the air leak. The main
side effect is empyema, which occurred in 9 percent of patients in one series [60]. In one review of 109 patients
with pneumothorax and a persistent air leak, the blood patch technique was effective in 92 percent [61].
Failure of lung reexpansion For patients who have a persistent air leak and whose lung is less than 90
percent expanded, the preferred procedure is VATS. (See 'VATS pleurodesis' below.)
Recurrence prevention The estimated recurrence rate after the first pneumothorax, is 23 to 50 percent over
a one to five year follow up period, with the highest risk occurring in the first 30 days [33,62,63]. Recurrence
rates are higher in patients who have blebs or bullae on high resolution CT scan [64]. We suggest that all
patients with recurrent PSP should undergo an intervention to prevent future recurrences once the acute air leak
has resolved, the lung has expanded, and the pleural air has been removed. In addition, we suggest that patients
experiencing their first PSP should have a preventive intervention if they require VATS or tube thoracostomy as
part of their initial management, or have a vocation in which recurrence of the pneumothorax is dangerous to the
patient or others (eg, airplane pilot or deep sea diver). Options for preventing recurrence include pleurodesis via
VATS, chemical pleurodesis via tube thoracostomy or pigtail catheter at the time of aspiration, and thoracotomy.
The choice between these procedures is best dictated by the expertise of the practitioner at each institution.
VATS pleurodesis Video-assisted thoracoscopic surgery (VATS) is effective not only in the treatment of
spontaneous pneumothorax as described above, but also in the prevention of recurrent pneumothorax [5,5157,65-70]. The rate of recurrent pneumothorax is less than 5 percent after VATS with bleb/bullae resection and
pleurodesis.
Several techniques have been reported to induce pleural symphysis. These include parietal pleurectomy,
intrapleural instillation of talc or a tetracycline derivative, laser abrasion of the parietal pleura, cellulose mesh with
fibrin glue, and pleural abrasion with dry gauze. We prefer mechanical pleurodesis using pleural abrasion with
dry gauze, since it is both simple and effective.
Chemical pleurodesis In patients who are unable or unwilling to undergo VATS, intrapleural injection of a
chemical irritant, most commonly a tetracycline derivative (doxycycline or minocycline), or talc is another
alternative [32]. We prefer to use the tetracycline derivative, doxycycline, for the reasons that follow, although
many experts prefer talc.
Chemical pleurodesis with tetracycline derivatives decreases the recurrence rate of pneumothorax to 20 to 25
percent. In two large trials of 442 patients with PSP, pleurodesis with the intrapleural instillation of a tetracycline
derivative (tetracycline or minocycline) was compared to aspiration and drainage without pleurodesis and
showed comparable reduction in the rates of recurrent PSP by 20 to 25 percent, for minocycline and tetracycline
respectively, over a one to five year follow-up period [71,72]. One study confirmed efficacy in the first seven days,
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when the risk of recurrence is highest [72]. Respiratory failure due to an apparent allergic reaction to doxycycline
intrapleural instillation has been reported [73]. However, chemical pleurodesis with tetracycline (or talc) is
associated with intense chest pain and in some cases chronic pain that may limit the use of this procedure
[71,72]. (See "Chemical pleurodesis".)
Talc slurry administered via medical thoracoscopy can also be used to treat PSP [66,74-76]. Pneumothorax
recurrence rates vary between 2 and 8 percent. However, controversy exists whether talc should be used as the
sclerosant agent in young, otherwise healthy individuals because of safety reasons and for fear of long-term
complications. Intrapleural injection of talc for malignant pleural effusions has been associated with the
development of the acute respiratory distress syndrome (ARDS) in 1 to 2 percent of patients [77]. Additionally, in
one patient, extensive pleural thickening with calcifications developed [78]. On the other hand, several studies
support the safety of talc pleurodesis for prevention of recurrent pneumothorax [66,79,80]. (See "Talc
pleurodesis".)
For patients with recurrent PSP, who have a chest tube in place and are not candidates for VATS pleurodesis, we
prefer doxycycline for pleurodesis because we believe that its effectiveness is comparable to talc and it has not
been associated with the development of ARDS. We suggest using doxycycline (500 mg dissolved in a total
volume of 50 mL of normal saline) administered via the chest tube. Intrapleural doxycycline can be very painful;
as a result, patients should be premedicated with analgesics (eg, opiates) and, possibly, anxiolytics (eg,
midazolam). Some experts also use intrapleural lidocaine 25 mL (250 mg) of a 1 percent solution; however,
intrapleural lidocaine alone is ineffective for pain control.
Thoracotomy The indications for open thoracotomy are the same as those for VATS. Thoracoscopy has
essentially replaced open thoracotomy in the management of spontaneous pneumothorax in many medical
centers for two main reasons: hospitalization is shorter and postoperative pain is less [81,82]. Thoracotomy is
presently recommended only if thoracoscopy is unavailable or has failed. During thoracotomy, apical pleural
blebs are oversewn and the pleura is scarified.
Smoking cessation The strong association between smoking and an initial PSP suggests that smoking
cessation may help prevent recurrent pneumothoraces [7]. In addition, smoking may predict a higher recurrence
rate with talc pleurodesis [76]. (See "Patterns of tobacco use".)
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Basics topic (see "Patient education: Pneumothorax (collapsed lung) (The Basics)")
SUMMARY AND RECOMMENDATIONS
A primary spontaneous pneumothorax (PSP) is a pneumothorax that occurs without a precipitating event in
a person who does not have known lung disease. In actuality, most individuals with PSP have unrecognized
lung disease, with the pneumothorax resulting from rupture of a subpleural bleb. (See 'Introduction' above.).
The incidence is increased in men, smokers, and patients with a family history of PSP. Recurrence is
estimated to occur in 25 to 54 percent of patients. (See 'Incidence' above and 'Risk factors' above.).
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PSP usually occurs when the patient is at rest and manifests as acute dyspnea and pleuritic chest pain. The
peak age is in the early 20s. (See 'Clinical presentation' above.).
Early management
We suggest supplemental oxygen and observation if the patient is clinically stable and the pneumothorax is
small (ie, the distance between the lung and the chest wall is 3 cm on a chest radiograph), rather than
aspiration, chest tube insertion, or video-assisted thoracoscopy (VATS) (Grade 2C). Observation should last
six hours, after which the patient can be discharged home, if a repeat chest radiograph excludes
progression of the pneumothorax and the patient has access to emergency medical services. (See 'Initial
management' above and 'Supplemental oxygen' above.)
We recommend pleural aspiration as initial therapy if the patient is clinically stable and the pneumothorax is
large, rather than supplemental oxygen with observation, chest tube insertion, or VATS (Grade 1A). This
recommendation is based on the observation that the success of pleural aspiration is sufficiently high to
warrant its trial before progressing to options that, although more likely to succeed, are also more likely to
have adverse effects. A chest tube should be inserted if aspiration fails and VATS should be considered
during the same hospitalization based upon the high success rate of VATS, both short- and long-term.
Chemical pleurodesis should be performed through the chest tube if VATS is not readily available. (See
'Initial management' above and 'Aspiration' above.)
We suggest that patients who are clinically stable with a recurrent PSP undergo chest tube insertion
followed by VATS (Grade 2B). This is based upon both the short-term success rate of VATS and our belief
that all patients with recurrent PSP should undergo a preventive intervention, which can be accomplished at
the same time by VATS. Chemical pleurodesis should be performed through the chest tube if VATS is not
readily available. (See 'Initial management' above.)
Clinically unstable patients should undergo chest tube insertion. If the chest tube insertion is delayed,
decompression performed by advancing a standard 14 gauge intravenous catheter into the pleural space at
the junction of the midclavicular line and the second or third intercostal space can be performed as a bridge.
The chest tube can be connected to a water seal device, with or without suction. We suggest that suction be
applied to the chest tube if the pneumothorax fails to resolve (Grade 2C). (See 'Initial management' above
and 'Tube thoracostomy' above.)
Patients who require mechanical ventilation or who may have a large air leak should be managed with a 24
to 28 French (Fr) chest tube, rather than a smaller chest tube. All other patients who require chest tube
insertion can be managed with a 16 to 22 Fr chest tube or a 14 Fr chest catheter, instead of a larger chest
tube. (See 'Tube thoracostomy' above.)
For patients being managed with a chest tube whose lung is at least 90 percent expanded but who have an
air leak that persists longer than three days, we suggest that the chest tube be attached to a Heimlich valve
and the patient discharged home, rather than ongoing management with a chest tube (Grade 2C). An
alternative approach is to perform an autologous blood patch. (See 'Persistent air leak' above.)
For patients being managed with a chest tube who have a persistent air leak and whose lung is less than 90
percent expanded, we suggest VATS, rather than ongoing management with a chest tube (Grade 2B). (See
'Failure of lung reexpansion' above.)
Preventing recurrence
We suggest a preventive intervention for patients experiencing their first PSP if they are undergoing VATS or
tube thoracostomy as part of their initial management, or have a vocation in which recurrence of the
pneumothorax is dangerous to the patient or others (eg, airplane pilot or deep sea diver) (Grade 2B).
Otherwise, we prefer to forego preventive interventions until a patient experiences recurrent PSP. (See
'Recurrence prevention' above.)
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Once it has been determined that a preventive procedure is required, we recommend VATS with
pleurodesis, rather than tube thoracostomy with chemical pleurodesis (Grade 1B). This procedure reduces
the recurrence rate to less than 5 percent. (See 'VATS pleurodesis' above.)
For patients who are not operative candidates or who refuse VATS, we recommend tube thoracostomy with
chemical pleurodesis, rather than tube thoracostomy drainage alone, once it has been determined that a
preventive intervention is indicated (Grade 1A). This procedure reduces the recurrence rate to less than 25
percent. (See 'Chemical pleurodesis' above.)
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Topic 6706 Version 31.0
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GRAPHICS
Chest radiograph of a pneumothorax after stab wound
This plain chest radiograph shows a left apicolateral pneumothorax with

typical convex white visceral pleural line (yellow arrows).
Courtesy of Paul Stark, MD.
Graphic 56589 Version 5.0
Normal chest radiograph
Posteroanterior view of a normal chest radiograph.

Courtesy of Carol M Black, MD.
Graphic 65576 Version 1.0
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Contributor Disclosures
Richard W Light, MD Consultant/Advisory Boards: Care Fusion [Pleural eusions (Tunneled pleural
catheter)]. V Courtney Broaddus, MD Nothing to disclose Geraldine Finlay, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy
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