| EDITORIAL

PNEUMOTHORAX

Spontaneous pneumothorax: stop chest

tube as first-line therapy
Jean-Marie Tschopp1 and Charles-Hugo Marquette2

Affiliations: 1Centre Valaisan de Pneumologie, Montana, Switzerland. 2Université Côte d’Azur, CHU de Nice,
FHU Oncoage, Service de Pneumologie, Nice, France.

Correspondence: Jean-Marie Tschopp, 20 rue du Poiet, 3963 Montana, Switzerland.

E-mail: [email protected]

@ERSpublications
In this issue of the ERJ, a randomised study shows that simple aspiration can be very successful in
both PSP and SSP http://ow.ly/8h7u309Wmji

Cite this article as: Tschopp J-M, Marquette C-H. Spontaneous pneumothorax: stop chest tube as first-line
therapy. Eur Respir J 2017; 49: 1700306 [https://doi.org/10.1183/13993003.00306-2017].

Spontaneous pneumothorax is traditionally divided between primary spontaneous pneumothorax (PSP)

and secondary spontaneous pneumothorax (SSP) when there is some underlying lung disease. For decades
management of spontaneous pneumothorax has remained highly debatable despite different published
guidelines [1–3], many of which contradict each other. Our task force, comprising a multidisciplinary
panel of pulmonologists, thoracic surgeons and epidemiologists, recently published a consensus statement
[4] on PSP to highlight new findings on the clinical approach, pathophysiology and management strategies
of this disease. Pneumothorax remains an under-researched area. The epidemiology of PSP is still poorly
documented regarding risk factors or rates of recurrence of PSP. Although smoking remains the principal
and well-established risk factor [5], advice for quitting smoking [6] should be routinely given. This disease
affects young patients in good health. They are therefore an ideal target population for receiving preventive
advice. The pathophysiology of PSP is better understood because of many recent findings. The old concept
[7] of PSP because of a localised rupture of a bleb or a bulla is obsolete and has been questioned by many
recent studies. We now have robust evidence that the occurrence of PSP is mainly the result of a diffuse
histopathological change of the lung parenchyma under the visceral pleura known as emphysema-like
changes [8, 9]. There is also a diffuse decrease in the lung density measured by computed tomography
(CT) [10] and diffuse increased porosity [11] at the periphery of both lungs. These recent findings explain
why a localised surgical approach is less effective than a diffuse pleurodesis, whatever the method of
pleurodesis used [12, 13, 14]. Most patients with PSP have no or minimal symptoms, and the entire panel
of this European task force [4] agreed that the clinical evaluation of patients with PSP should be more
symptom driven and not based only on the measurement of the size of pneumothorax on plain chest
radiography or CT, which have little clinical value [15, 16]. Tension pneumothorax is very rare [17]. Most
patients with spontaneous pneumothorax commonly experience minimal or no symptoms.
In recent years, there has been a change in the management strategy of spontaneous pneumothorax
leading to more use of a conservative approach [1, 3] based on the idea that air in the pleural cavity is well
supported. This is not surprising. Chest physicians historically were familiar with inducing artificial
pneumothorax in cases of tuberculosis and using the same apparatus for aspirating pneumothorax on an
ambulatory basis. With the advent of the chest tube, the use of chest tube drainage (CTD) became
widespread although such an approach required hospitalisation and was mainly practised by surgeons [18]
and not by pulmonologists. 50 years ago, STRADLING and POOLE [19] had already recommended a
conservative and outpatient treatment of pneumothorax. Later on, many randomised studies [20–25]

Received: Feb 12 2017 | Accepted: Feb 16 2017

Conflict of interest: None declared.
Copyright ©ERS 2017

https://doi.org/10.1183/13993003.00306-2017 Eur Respir J 2017; 49: 1700306

 PNEUMOTHORAX | J.-M. TSCHOPP AND C.-H. MARQUETTE

proved that simple needle aspiration significantly reduced hospital stay without a higher recurrence rate of
pneumothorax, explaining the choice of needle aspiration as a first-line therapy recommended by some
guidelines [1, 3]. However, all these well-controlled studies dealt with PSP, apart from the study by
ANDRIVET et al. [23], which included eight SSP cases in their data.
In this issue of the European Respiratory Journal, THELLE et al. [26] have published a randomised study
comparing needle aspiration and CTD in 127 patients with spontaneous pneumothorax. This study is
interesting for many reasons. It was carried out by a multidisciplinary team that included pulmonologists,
thoracic surgeons and public health scientists. It was performed in different hospitals and included a
substantial number of SSP (48 SSP out of 127 cases). This study covered two pulmonary departments and
one surgical department and was carried out by junior physicians and thus reflects normal clinical life in
clinical practice. To our knowledge, it is the first randomised study with such an important number of
patients with SSP. Hospital stay and the immediate success rate were significantly and respectively shorter
and higher in the needle aspiration group than the CTD group. Interestingly, these two parameters
remained significantly better when separately analysing the results in PSP and SSP. There were no
complications after needle aspiration but 15 patients undergoing CTD presented some complications. These
results are new and important for the clinician. They confirm the real benefit of simple needle aspiration in
both PSP and SSP. They will contribute to modifying the guidelines recommendations in cases of SSP.
If confirmed by other studies, the first line of treatment in a first episode of spontaneous pneumothorax has
definitely to be observation, or needle aspiration if some treatment has to be offered to the patient. Unless there
really is some respiratory distress, one should definitely avoid chest tube insertion, which is not only painful for
the patient, as shown by AYED et al. [24], but exposes him/her to a risk of potential complications. Contrary to
PSP, patients with SSP are more at risk of complications from chest drainage because of their underlying lung
disease and one ought to avoid exposing them to unnecessary immobilisation. One might argue that a lower
rate of complications would have been recorded if the procedure were done by more experienced physicians
and not by junior doctors on call. The rate of complications found in this study is the same as in other similar
studies. This study describes the usual process for looking after patients with spontaneous pneumothorax; the
reality is that in most hospitals, cases of pneumothorax are usually looked after by young doctors. It also shows
that these young doctors had been well taught how to perform needle aspiration. That is not always the case in
hospital practice [27]. Such a study will help stimulate more prospective and controlled studies on spontaneous
pneumothorax, such as the current Australasian multidisciplinary study [28]. Too many publications on
pneumothorax deal with retrospective studies carried out in the same department with biased recruitment of
patients. We need to better define the best way of ambulatory management for a first episode of pneumothorax
and make treatment of pneumothorax as cost-effective as possible. The use of an ambulatory Heimlich valve
might be a new and promising approach, as recently shown [29, 30].
Spontaneous pneumothorax remains an area for further research. In the meantime, the study by THELLE
et al. [26] is an important one to improve the management of both primary and secondary pneumothorax
more conservatively. Every clinician also ought to routinely provide more advice about smoking cessation
to reduce the chance of recurrence in patients with a first episode of pneumothorax.

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