Surgical management of spontaneous pneumothorax

Chest tubes: indications, placement, management, and complications

Use of tube thoracostomy in intensive care units for evacuation of air or fluid from the pleural space has become commonplace. In addition to recognition of pathological states necessitating chest tube insertion, intensivists are frequently involved in placement, maintenance, troubleshooting, and discontinuation of chest tubes. Numerous advances have permitted safe use of tube thoracostomy for treatment of spontaneous or iatrogenic pneumothoracies and hydrothoracies following cardiothoracic surgery or trauma, or for drainage of pus, bile, or chylous effusions. We review current indications for chest tube placement, insertion techniques, and available equipment, including drainage systems. Guidelines for maintenance and discontinuation are also discussed. As with any surgical procedure, complications may arise. Appropriate training and competence in usage may reduce the incidence of complications.

[Treatment of spontaneous pneumothorax]

Experience with 300 episodes of spontaneous pneumothorax in 209 patients is reported. The treatment results of two time periods 1980-1983 (A) and 1985-1987 (B) are compared. During the second period the diagnostic work-up was much more extensive and included pleurography, CT-scan and thoracoscopy. This resulted in a more differentiated therapy and a reduction in the recurrence rate from 41% to 22%. Among the different modes of treatment chest-tube drainage alone had the worst results with a 44% rate of early and late recurrence. Better results were obtained with pleurodesis using fibrin adhesive either through a pleural catheter (24%) or thoracoscopically (13%). Operative treatment had the lowest recurrence rate (4%). In the primary treatment of spontaneous pneumothorax chest-tube drainage had a recurrence rate of 33% and catheter-pleurodesis with fibrin adhesive of 18% while no relapse could be observed in the group treated by thoracoscopy or operation. In the treatment of recurrent pneumothorax chest-tube drainage alone is unsuitable because of a failure rate of 64%. Catheter pleurodesis also had a high rate of recurrence (30%). The best results were again obtained by thoracoscopic (19%) and operative treatment (4%). On the basis of the described experience an individualized approach to the treatment of spontaneous pneumothorax is recommended.