POLSKI

PRZEGLD CHIRURGICZNY
2013, 85, 1, 1219

10.2478/pjs-2013-0003

Treatment of recurrent primary spontaneous

pneumothorax own experience
Grayna Tomczyk1, Konrad Paweczyk1,2, Marek Marciniak1,2,
AdamRzechonek1,2, Jerzy Koodziej1,2
Department of Thoracic Surgery, Lower Silesian Centre of Lung Diseases in Wrocaw1
Ordynator: dr n. med. M. Marciniak
Department of Thoracic Surgery, Medical University in Wrocaw2
Kierownik: dr n. med. M. Marciniak
Primary spontaneous pneumothorax could be aserious therapeutic problem in case of recurrence. Lack
of therapeutic standards sometimes leads to delay in definitive surgical treatment and could cause
respiratory complications.
The aim of the study was the evaluation of treatment results in patients with recurrence of primary spontaneous pneumothorax and looking for optimal therapeutic method after first recurrence
(surgical treatment vs. pleural drainage).
Material and methods. Between 01.01.2009 and 31.07.2010 fifty four patients with recurrent primary spontaneous pneumothorax was hospitalized in Wrocaw Thoracic Surgery Centre (24.3% of all
patients with pneumothorax). The recurrence was treated surgically in 24 cases, in 30 pleural drainage
was performed: simple drainage (n=14) or drainage with chemical pleurodesis (n=16). Mean age of
patients treated without surgery was higher than surgically treated (p=0,012).
Results. In surgery group no recurrence was found, in drainage group 11 recurrences occurred
(p=0.0009). In group of 11 patients with second recurrence, pleurodesis was performed four times (36%)
vs. 12 times (63%) in 19 patients without arecurrence of the disease. 70% of non-surgically treated
patients vs. 50% of surgically treated were afraid of recurrence (p=0.01). Among 11 patients in drainage group, nine underwent surgery at the second episode of recurrence.
Conclusions. The optimal treatment method in case of first recurrence of primary spontaneous pneumothorax is surgical treatment. When it is not possible chemical pleurodesis should be performed
during pleural drainage. Most of the patients after second recurrence are treated surgically anyway.
The surgical treatment significantly reduces patients fears for future recurrence of the disease.
Younger patients are most often surgically treated.
Key words: spontaneous pneumothorax, recurrent pneumothorax, videothoracoscopy

A spontaneous pneumothorax is a common

disease entity not only in the departments of
thoracic surgery, but also in the general surgery departments. Treatment of pneumothorax diagnosed for the first time depends on its
size, symptoms, location of an emphysematous
space or a profile of a department to which a
patient gets. Most of surgeons choose a pleural
drainage during the first disease episode. A
spontaneous pneumothorax could be a serious
therapeutic and care problem in the case of
recurrence. A diagnosed recurrence of disease

requires a specialist treatment in a thoracic

surgery department.
The thoracic surgery has been significantly
developed in recent years. The progress of
technology has enabled the introduction of
specialist surgical procedures, especially videothoracoscopic procedures, and hence less
invasive surgical treatment of patients suffering from pneumothorax.
Despite progress in the methods of treatment of spontaneous pneumothorax, standards for the treatment of this disease in the

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Treatment of recurrent primary spontaneous pneumothorax own experience

case of recurrence have not been developed

yet. The decision whether to drain a patient
once again or perform pleurodesis during the
drainage or whether a patient should undergo a surgical treatment (and if so, which
method is to be chosen: via videothoracoscopic approach or by classical thoracotomy)
continues to be based on experience of a thoracic surgery centre. Lack of therapeutic
standards sometimes leads to delay in a definitive treatment (surgical procedure) and in
the course of time it could cause complications, such as an armoured lung, pleural fibrosis or empyema.
The aim of this study was the evaluation of
treatment results in patients with recurrence
of primary spontaneous pneumothorax and
looking for optimal therapeutic method after
the first recurrence (surgical treatment vs.
pleural drainage). The expertise on treatment
of this disease entity contained in the medical
literature was also presented by comparing it
with the Wrocaw experience. The collected
and evaluated material can also be helpful in
determining the standard procedure in patients with the recurrent spontaneous pneumothorax.
MATERIAL AND METHODS
In the period between 1 January 2009 and
31 July 2010 there were a total of 235 hospitalisations due to diagnosing pneumothorax
in 222 patients in the Wrocaw Thoracic Surgery Centre, including the Department of
Thoracic Surgery and the Thoracic Surgery
Department of Lower Silesian Centre of Lung
Diseases. Nine patients were hospitalized
twice, two-three times.
The patients admitted to the Wrocaw Thoracic Surgery Centre with a pneumothorax
diagnosis are routinely subjected to a pleural
drainage. On a day following drainage, a chest
X-ray is performed at a patients bed (a patient
is connected to an active drainage system). On
the second alternatively third day, in the case
of lack of air leak, a chest X-ray is performed
with a closed drain. If a lung is expanded, the
drain is removed. In the absence of lung expansion, a patient is reconnected to the drainage
kit, and another X-ray with a closed drain is
performed after 2-3 days. If a lung cannot be
expanded, a patient is qualified for a chemical

13

pleurodesis procedure, a surgery or continues

to be a temporary drain carrier. A procedure
depends on a general patients state, concomitant diseases as well as whether there is air
leak or not. Elder patients, suffering from
concomitant diseases, are usually treated less
invasively (extended drainage, pleurodesis,
temporary drain carrier state). Doxycyclinum
at a dose of 300-500 mg intrapleurally is most
often used for a chemical pleurodesis. Rarely,
most often in the case of contraindications or
no consent to a surgical procedure, a talcum
at a dose of 5 g is used, administered intrapleurally in a form of suspension. It is usually
avoided to maintain a drain in the pleural cavity over 7 days, due to the possibility of an
ascending infection and a pleural empyema
development.
The patients admitted to the Wrocaw Thoracic Surgery Centre with a recurrent pneumothorax diagnosis are re-drained. Particularly, in the case of a small pneumothorax (less
than 15% of pleura volume) located at the top
of the pleural cavity, the patients are monitored. There are no standard rules of procedure
at the second pneumothorax episode, some
surgeons choose a surgical procedure first off,
and some use a chemical pleurodesis of a pleural cavity. A procedure depends mainly on a
recurrence intervals,presence of air leak and
patients age. A decision on a surgical treatment is usually made if disease recurs quickly,
air leakcontinues or a young age of a patient
(school) or their occupational activity does not
allow for a prolonged stay in a hospital. Drainage treatment or drainage with pleurodesis is
continued to be carried out in patients suffering from internal malfunctions, the elderly
patients or in the absence of consent to a surgery.
Between 1 January 2009 and 31 July 2010
a pneumothorax after a chest injury was diagnosed in 15 (6.75%) patients in the Wroclaw
Thoracic Surgery Centre. Iatrogenic pneumothorax was diagnosed in 35 (15.76%) patients (in 5 patients it followed a cardiac
pacemaker implantation, in 26 fluid puncture, and in 4 a previous surgery thoracotomy). A spontaneous primary first pneumothorax was diagnosed in 73 (32.88%) patients, a spontaneous secondary pneumothorax
in 43 (19.76%) patients (in 19 cases due to a
pulmonary carcinoma, 11 advanced chronic
obstructive lung disease, 6 a bullous emphy-

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G. Tomczyk et al.

sema, 5 tuberculosis, 1 mucoviscidosis, 1

histiocytosis).
A recurrence of (primary) spontaneous
pneumothorax was found in 54 (24.32%) patients and this group of patients was subjected
to further tests and observations.
The patients with an iatrogenic, posttraumatic pneumothorax as well as the patients with the first pneumothorax episode
were excluded from the study. The patients
with a secondary pneumothorax were not
qualified for the study due to either often
observed poor general condition of patients
because of the severity of the underlying disease (pulmonary carcinoma, chronic obstructive pulmonary disease, tuberculosis, mucoviscidosis, histiocytosis) disqualifying a patient from a radical surgical treatment of a
emphysema. Repeatedly, the patients with a
secondary pneumothorax due to a significant
damage to the lung parenchyma and air leak
(ca. 30% acc. to the material of the Wrocaw
Thoracic Surgery Centre) remain drain carriers just after the first episode of pneumothorax.
After the completed treatment of pneumothorax in the surgical department, the patients undergo the first radiological control in
the thoracic surgery clinic of the Centre after
14 days, and then a regular follow-up in approximately six-month periods. The health
state of patients was assessed during the follow-up visits and with use of a short questionnaire sent to the patients. Follow-up period
ranged 6-23 months.
We compared results of recurrent pneumothorax patients treated with a conservative
method (pleural drainage or drainage with
pleurodesis) and with an invasive method
(VATS or thoracotomy). STATISTICA application was used for statistical analysis. The relationships were tested by Students t test or
chi-square test, and p-value <0.05 was considered statistically significant.
RESULTS
The recurrences of a primary spontaneous
pneumothorax were found in 54 patients (12
women and 42 men), which constituted 24.3%
of the total patients with pneumothorax hospitalised between 01.01.2009 and 31.07.2010.
Excluding patients with iatrogenic, post-

traumatic, spontaneous secondary pneumothorax, 73 patients with a primary spontaneous

pneumothorax were admitted to our centre for
the first time. Among these patients, a pneumothorax recurrence treated again in our
centre was diagnosed in 31 patients (which is
42.5% of recurrences in the Wrocaw Thoracic
Surgery Centre material). Remaining 23 patients were admitted to the WOT with a recurrent spontaneous primary pneumothorax after
the first episode treated with a drainage in
other centres.
The relation of male to female was 3.5:1.
Mean age of the patients was 48.6 years (17-81
years), including 27 patients at the age over
50 years.
Tobacco smoking was found in 40 patients
(74%). There was no pneumothorax in any
patients family.
24 patients, mean age 42.5 years (19-69
years),underwent a surgery after a pneumothorax recurrence. Among patients treated
surgically 13 patients were treated via videothoracoscopic approach, and 11 patients with
a conventional thoracotomy. In 30 patients at
the mean age of 53.6 years (17-81 years), the
second recurrence of pneumothorax was
treated with drainage. A pleurodesis was performed in 16 patients in this group with the
use of doxycyclinum (n=12) and talcum (n=4).
It was found that the mean age of patients
treated non-surgically (a drainage or a drainage with pleurodesis) is significantly higher in
comparison to the patients treated surgically
(VATS or thoracotomy) (p=0.012). The tab. 1
presents the characteristics of patients treated
surgically and non-surgically (with a pleural
drainage).
In the analysed material all patients admitted with the second pneumothorax recurrence,
were treated with a pleural drainage before a
decision on a surgery. There was no further
recurrence in any patient with recurrent pneumothorax who was treated surgically. In a
non-surgical group of patients, a recurrent
pneumothorax was observed in 37% (n=11). A
significant difference was found between a
subsequent recurrent pneumothorax and a
treatment method while testing a difference
with the chi-square test (p=0.0009). Among
patients with the first recurrence of pneumothorax treated non-surgically, drainage
alone or drainage with pleurodesis was used.
In a group of 11 patients with the second recur-

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Treatment of recurrent primary spontaneous pneumothorax own experience

15

Table 1. Characteristics of patients treated surgically and non-surgically (with drainage)

Mean age (years)

Side

right (n)
left (n)
Mean stay in ahospital during the first episode of
pneumothorax (days)
Mean duration of drainage during the first episode of
pneumothorax (days)
Mean duration of drainage during the recurrent
pneumothorax (days)
Mean interval between the first episode and recurrence
of pneumothorax
Recurrent pneumothorax after treatment
yes (n)
no (n)
Pneumothorax on the other side
yes (n)
no (n)
Fear of recurrent pneumothorax
yes (n)
no (n)

rence of pneumothorax, pleurodesis was performed in 36% vs. 63% without a recurrence
of the pneumothorax. While analysing the
questionnaire results it was found that 70% of
non-surgically treated patients (n=21) were
afraid of pneumothorax recurrence. 50% of
patients (n=12) in a group of operated patients
feel such a fear. This difference is statistically
significant (p=0.01). Among eleven patients
with the first recurrence of pneumothorax
treated with drainage only (nosurgery), nine
underwent surgery at the second episode of
recurrence (6 via videothoracoscopic approach
and 3 thoracotomy). Among two other patients, one did not give their consent to the
proposed surgical procedure and the second
was disqualified due to the concomitant diseases. These patients were treated with a
pleural drainage again.
DISCUSSION
The primary spontaneous pneumothorax is
a common clinical problem with an increasing
incidence trend (1). A risk of disease recurrence
is high and it ranges, according to various
sources, from 20 to 60% (2, 3). The recurrence
frequency amounted to 42.5% in the material
of the Wrocaw Thoracic Surgery Centre
(WOT). Therefore, a high percentage of a recurrent spontaneous pneumothorax creates a

Treatment method
p
surgical treatment
nonsurgical treatment
n=24
n=30
42,5
53,6
0,012
12
18
0,23
12
12
7,31,81
6,92,03
0,38
(5-10)
(4-14)
5,31,40
5,51,58
0,52
(3-9)
(3-10)
6,451,82
6,93,51
0,57
(3-10)
(3-20)
665
398
0,05
(3-2920)
(4-1825)
0
11
0,0009
24
19
0
3
0,11
24
27
12
21
0,01
12
9

serious clinical problem for surgeons who deal

with treatment of this disease entity.
The results presented above, based on the
analysis of the WOT material, give an evidence
of several previously found facts related to the
epidemiology of a primary spontaneous pneumothorax. A majority of male sex with 3.5:1
ratio was proven, which is similar to the published data (4). In comparison to 70s and 80s
studies, where this ratio was 6:1-8:1, an increase in the incidence of pneumothorax in the
female population is currently indicated, which
may be associated with the observed popularisation of smoking among women.
We observe in the analysed material that a
recurrent pneumothorax occurs at a high percentage in patients who are over 50 year old
(50% of patients). It is known on the basis of
literature that a primary pneumothorax concerns more often younger people (1). However,
it should be noted that the above study concerns persons with a recurrent spontaneous
pneumothorax, and not patients treated for
the first time. A high percentage of persons
over 50 years in the analysed population may
be caused by two reasons. First, a pneumothorax may recur in many persons even after
several years from the first pneumothorax
episode, and secondly there may be a tendency to more frequent pneumothorax recurrences among older people. It may not be excluded that in some of people over 50 years

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G. Tomczyk et al.

(most of tobacco smokers) a tobacco-dependent

lung diseases occur, which were not previously diagnosed (COPD, emphysema). This is
another factor contributing to recurrences
among older people.
While analysing the results of the spontaneous pneumothorax treatment with a conservative or a surgical procedure, the average age
of patients in both groups was also evaluated.
The mean age of patients non-surgically
treated (a drainage or a drainage with pleurodesis) is significantly higher in comparison to
patients treated surgically (VATS or thoracotomy) (p=0.012). The older patients not infrequently suffer from concomitant diseases,
among which the most frequently observed
are: arterial hypertension, diabetes, ischaemic
heart disease. Lack of the above loads causes
younger patients to be more eagerly and
quickly qualified for a surgery. Patients with
additional loads, before deciding on a highly
invasive method of treatment, which is chest
opening, must undergo additional specialist
consultations (e.g. cardiologic ones). Severity
of concomitant diseases may lead to disqualification from a surgery. In such a case pleural
cavity drainage is usually continued. Where it
is impossible to remove a drain (continuing air
leak, persistent air space) a patient is discharged from the hospital as a temporary drain
carrier.
It also results from the our clinical observations that the older patients are less likely to
give their consent to a surgery and they choose
subsequent pleural cavity drainage when a
pneumothorax recurs. The younger people are
more eager to choose a surgical treatment,
which is due to a learning or occupational activity in this age group.
Tobacco smoking is a recognised risk factor
of a spontaneous pneumothorax. In the analysed population tobacco smoking was found in
74% patients with a recurrent disease. Data
from the literature suggests that smoking increases the risk of pneumothorax 9-fold in men
and 22-fold in women (2, 5).
Analysis of incidence indicates that pneumothorax occurs more often on the right side,
according to other authors it is of the same
frequency on either side. It may also be found
simultaneously on both sides which concerns
2-7% cases (6). In the analysed population of
the Wrocaw Thoracic Surgery Centre it was
demonstrated that a pneumothorax is found

on the right side in 55.6% of patients, and on

the left in 44.4% of patients, which is consistent with the previous literature observations.
While analysing the results of a recurrent
pneumothorax treatment the factors that affect the decisions on how to treat the disease
were evaluated. Choice of treatment method,
which was also demonstrated in this study,
results in long-term treatment outcomes. A
surgeon, who decides on further therapeutic
methods, pays attention to drainage duration.
Usually the drain extension (over 7-10 days)
is an indication for a surgical treatment. This
is due to a risk of ascending infection and the
lack of healing features of a damaged lung
parenchyma. The statistical analysis showed
no significant differences in the duration of the
first pneumothorax drainage in both groups
(p=0.52). There were no significant differences
for the same average length of stay in the
hospital during the first episode of pneumothorax in patients treated with a surgery and
patients treated without a surgery (p=0.38)
At the time of a pneumothorax recurrence
it is routinely secured in the Wrocaw Thoracic Surgery Centre with a pleural drainage.
Time needed for making a decision on a possible surgical treatment is gained in this way.
A patient can be prepared for this treatment
according to the schedule, and has also possibility and time to consider it and to give their
consent to a surgical intervention. The second
pleural cavity drainage is one of the important
factors on the basis of which a decision is
taken as to a patients future. During this
period some surgeons choose to perform pleural cavity pleurodesis, and if this procedure is
effective, the surgery is deferred until the next
recurrence of pneumothorax. Other doctors opt
for surgery knowing that the risk of a subsequent recurrence is very high. The literature
data show that a pleural drainagetreatment
is successful in about 75-100% of patients in
the first episode of pneumothorax, it is less
likely to be effective after the first recurrence
(52%), and even less after the second and subsequent one (7). While supplementing the
treatment of pneumothorax with a chemical
pleurodesis one should be aware that some
agents (talcum) can induce a massive fibrosis
in the pleural cavity after a longer time (8).
According to the experience of our centre, a
talcum pleurodesis is not performed in young-

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Treatment of recurrent primary spontaneous pneumothorax own experience

er patients, and it is reserved for older people

only in the case of contraindications to a surgery or presence of fluid which accompanies a
pneumothorax (e.g. caused by cancer).
In the studied material among patients with
the first recurrence of pneumothorax treated
with a drainage (n=30), 16 patients underwent
chemical pleurodesis (doxycycline at a dose of
300-500 mg was used in 12 patients, talcum
5g in 4 patients). Remaining 14 patients were
treated with a pleural drainage only, without
pleurodesis.
One of the analysed factors which could
potentially influence the treatment method
selection (and therefore the outcomes) is an
interval between the first episode and a recurrence of pneumothorax. In the material of the
Wrocaw Thoracic Surgery Centre the mean
interval between the first episode and a recurrent pneumothorax was 516 days, and 665 and
398 days for the patients treated surgically
and with drainage, respectively.
The pneumothorax recurred sooner in the
patients treated non-surgically, which is significant in the statistical analysis (p=0.05).
Therefore, a sooner pneumothorax recurrence
resulted in decision on another drainage attempt.
Among the patients treated surgically
(n=24), both with an open thoracotomy and via
videothoracoscopic approach, no pneumothorax recurrence was found. Effectiveness of
surgical treatment during a follow-up period
was 100%.It is confirmed by the literature data
where the results of a classic thoracotomy
treatment (along with a parietal pleurectomy)
are assessed to be 97-99% (9, 10, 11). Similar
results are obtained by using a videothoracoscopic approach less invasive and better
tolerated by a patient.
Treatment of pneumothorax with a surgery
enables to effectively remove a disease cause
(resection of subpleural alveoli) as well as
prevent recurrences (performance of a pleurectomy). The complications are observed in
0-7% of patients treated surgically, and the
most common are: pleural bleeding, pyothorax,
extended air leak and Horners syndrome (12).
In the case of video-assisted thoracoscopy, the
percentage of complications is lower and the
hospitalisation duration shorter. Within the
analysed period from January 2009 to 31 July
2010, a surgical treatment of non-complicated
pneumothorax in the Wrocaw Thoracic Surgery

17

Centre was performed with both an open thoracotomy and via videothoracoscopic approach.
Since January 2010 the recurrent non-complicated pneumothorax has been treated via videothoracoscopic approach as a rule, and the
percentage of conversion to thoracotomy is low
(2-5%) and most commonly caused by intraoperative adhesions in the pleural cavity or a intraoperative haemorrhage (12). According to
the opinion of the Wrocaw Thoracic Surgery
Centres physicians, video-assisted thoracoscopy provides as good evaluation and access to
an operated area as a classic thoracotomy enabling also a very good visualisation of the
pathological changes (multiple image magnification), smaller operative trauma as well as a
shorter stay in the hospital in comparison to a
classic thoracotomy. While analysing the studied patients population it should be noted that
despite the significance of individual choice of
treatment for each patient (including clinical
symptoms, presence of air leak, pneumothorax
size) a surgical treatment at first disease recurrence is the most effective.
The results show that the performance of
drainageonly in the recurrence of pneumothorax is an ineffective treatment, and in the case
of disqualification or lack of patients consent
to a surgery, the drainage should be supplemented with a chemical pleurodesis of a pleural cavity. Since most of pleurodesis procedures
were, according to the analysed material, performed withdoxycyclinum (75%) it seems to be
a sufficiently effective remedy to prevent pneumothorax recurrences.
In the group of 30 patients where a pneumothorax recurrence was treated with drainage, subsequent pneumothorax recurrence in
11 patients was found. Among these persons,
9 patients underwent a surgery. Pleural cavity drainage was used in two patients again.
No subsequent pneumothorax recurrences
were noted in the observed period in the group
of 11 patients who were described above. According to our observations, the patients with
the first pneumothorax recurrence treated
with another drainage, are treated surgically
at the disease recurrence anyway. This is consistent with the literature data (13) according
to which application of a drain alone into a
pleural cavity does not effectively prevent recurrence of pneumothorax.
By observing the population of patients who
are treated for pneumothorax, regardless of

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G. Tomczyk et al.

the method of treatment, it is noted that many

of them, even at discharge from the hospital,
feel the fear of recurrence. Therefore, the subject of the study was also to assess the patient
fears of a disease recurrence. While analysing
the findings of the questionnaires, it was found
that the patients who were treated surgically
have a better awareness of the effectiveness of
this form of therapy, and this is another factor
in favour that the patients with the first recurrence of pneumothorax should be treated
surgically.
In assessing the literature data a similar
percentage of persons who fear of pneumothorax recurrence (49.5%) was found in the article
by the Japanese authors (14). It is one of few
studies which assesses the quality of life of
patients with a recurrent pneumothorax. The
most common complaints of patients after a
surgical pneumothorax treatment include
pain, dysaesthesia in a scar region, limitation
of exercise. Also according to the literature,
approximately one third of the patients modify their lifestyle because of the fear of pneumothorax recurrence (including avoiding exercise, coughing, or travel by plane) (15).
Some authors indicatealso a possibility of
treating the first episode of spontaneous pneumothorax via videothoracoscopic approach
stating that this treatment is not only safe,
effective, and gives an excellent cosmetic result, but it also allows to resolve definitely the
fears of patients of a recurrent pneumothorax

(16). However, it seems that in the case of the

first incident of pneumothorax, a pleural drainage is a better procedure, since approximately
a half of patients (57.5% in the analysed material) may avoid a surgery.
CONCLUSIONS
1. The optimal treatment method in the case
of the first recurrence of primary spontaneous pneumothorax is a surgical treatment
(by thoracotomy or via videothoracoscopic
approach).
2. If a surgical treatment after the first recurrence of pneumothorax is not possible a
pleural cavity drainage should be supplemented by a chemical pleurodesis.
3. Most of the patients after the second pneumothorax recurrence (when the first recurrence was treated with a drainage) is
treated surgically.
4. The surgical treatment of a spontaneous
pneumothorax significantly reduces patients fears of future recurrence of the
disease which may, in turn, influence a
patients quality of life after the treatment.
5. Younger patients are more often surgically
treated.
6. The patients hospitalised because a primary spontaneous pneumothorax should be
advised not to smoke.

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Received: 8.01.2013r.
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