Pneumothorax—Time for New Guidelines?

Rob Hallifax, DPhil, MRCP, BMCh; Julius P. Janssen, MD, PhD


Semin Respir Crit Care Med. 2019;40(3):314-322. 

In This Article

Abstract and Introduction


Pneumothorax is a common pathology, but optimal management strategies are not yet defined. There are significant differences in international guidelines and therefore variation in clinical practice.

There is increasing interest in pneumothorax research, particularly primary spontaneous pneumothorax (PSP), with evidence of lung abnormalities in this group without clinically apparent lung disease and recently completed clinical trials aiming to optimize management. The most robust evidence base is that of the equivalence of needle aspiration and chest tube insertion for initial management of PSP; although, patients with secondary spontaneous pneumothorax may also benefit. A convincing case for surgical intervention or thoracoscopy and talc poudrage to prevent recurrence at first episode in PSP has yet to be made. Clinicians should be vigilant for PSP being the first manifestation of a systemic disease, and should have a low threshold for onward referral.

Time to change guidelines? First, chest tube drainage and hospitalization without recurrence prevention should no longer be standard treatment, as this has no advantage over the less invasive manual aspiration, which moreover can be performed on an outpatient basis in an important number of patients. The results of recent trials in conservative and ambulatory management are eagerly awaited. Second, shared decision-making should become more important with the well-informed patient, who may want to avoid a 1 in 3 recurrence rate and therefore will have the possibility to choose treatment including recurrence prevention even after the first episode of PSP. Third, surgical research should urgently make clear if the current practice of resection of emphysema-like changes is routinely necessary, alongside pleurodesis. Future studies should utilize risk stratification by clinical and radiological parameters (e.g., high-resolution computed tomography scanning and digital air leak monitoring) to predict short- and long-term outcomes, and hence personalize management.


Pneumothorax is a common pathology, defined as air present in the pleural space. A pneumothorax developing secondary to injury is categorized as being traumatic, and may be secondary to a blunt or penetrating trauma to the chest wall, or iatrogenic if occurring as a complication of an invasive medical procedure. However, pneumothorax can occur spontaneously without any preceding trauma or injury. The first "spontaneous" type is further subdivided into primary spontaneous pneumothorax (PSP) that occurs in apparently normal lungs. Spontaneous pneumothoraces developing in patients with known lung disease are termed secondary spontaneous pneumothoraces (SSPs). In the 2010 British Thoracic Society (BTS) guidelines on pneumothorax, patients who are older than 50 or with significant smoking history are defined as SSP because of the high likelihood of having pathological lung changes even in the presence of a normal chest radiograph (CXR).[1] The reason for this categorization was the considerable difference in outcomes of each type and consequently the management strategy. However, due to the fact that the majority of patients with so-called PSP appear to have an abnormal lung parenchyma on chest computed tomography (CT) scan, it is questionable if true PSP exists, and as already has been stated by the task force on pneumothorax of the European Respiratory Society, the definitions of primary and secondary pneumothorax become increasingly blurred.[2]

The aim of this review article is to summarize the latest understanding of the etiology and epidemiology of pneumothorax. With an increasing international interest in providing evidence-based management of pneumothorax, the authors will review the evidence behind the current guidelines and consider whether it is time for them to be revised.