The treatment of primary and secondary pneumothorax is very different

The accumulation of air in the pleural cavity is called pneumothorax. The disease has a high incidence rate, affecting human health worldwide and bringing a serious economic burden to society. If not treated correctly and promptly, pneumothorax can be fatal. So how to treat it?

Treatment goals:

The goal of early treatment of patients with pneumothorax is mainly to exclude tension pneumothorax and relieve symptoms of dyspnea. Since patients with secondary pneumothorax have more severe symptoms and are more likely to develop cardiopulmonary insufficiency, while patients with primary pneumothorax often lack clinical symptoms and are relatively less likely to develop tension pneumothorax, the treatment methods for primary pneumothorax and secondary pneumothorax are different.

Treatment:

There are significant differences in the treatment recommendations for pneumothorax among the guidelines. Treatments for pneumothorax include conservative observation, pleural puncture and aspiration, closed chest drainage, and surgical operations. The appropriate treatment method can be selected based on the patient's symptoms, whether the hemodynamics is stable, the size of the pneumothorax, the cause of the pneumothorax, whether it is the first onset or recurrence, and the effectiveness of the initial treatment.

1. Primary spontaneous pneumothorax

If the pleural rupture is closed, the air in the pleural cavity will gradually decrease because the pulmonary capillaries can absorb the air on their own. Studies have shown that patients receiving conservative treatment can absorb 2.2% of the intrathoracic gas volume (pneumothorax area shown on chest X-ray) on their own every day. Since oxygen inhalation can speed up its absorption by 4 times, high-concentration oxygen is often given to patients receiving conservative treatment.

Since the therapeutic effect of large-caliber surgical cannula puncture and drainage is similar to that of thin-tube puncture and drainage, and thin-tube puncture can reduce patient discomfort, both guidelines do not recommend the use of large-caliber surgical cannula drainage for patients with primary pneumothorax. Instead, they recommend the Seldinger puncture method for thin-tube drainage (the Seldinger puncture method uses a puncture needle to penetrate and then insert a guide wire, then withdraw the puncture needle and insert the drainage tube along the guide wire into the chest cavity to achieve the drainage purpose).

A prospective randomized trial involving 56 patients with massive primary pneumothorax showed that there was no significant difference in treatment success rate and recurrence rate between pleural puncture and closed chest drainage, but pleural puncture and aspiration could significantly reduce the number of days of hospitalization. Therefore, pleural puncture and aspiration can be used to treat patients with massive primary pneumothorax.

An earlier Cochrane systematic review, although only a single-center randomized controlled study was included, also suggested that thoracentesis and closed chest drainage were similar in early effects and one year after treatment, but the hospitalization rate of patients in the former was lower.

2. Secondary spontaneous pneumothorax

Due to the many complications, obvious symptoms and impact on cardiopulmonary function, secondary pneumothorax often requires more active treatment. Therefore, both the ACCP and BTS guidelines recommend hospitalization for all patients with secondary pneumothorax. Patients with secondary pneumothorax can receive oxygen therapy, but caution should be exercised in patients who are prone to CO2 retention.

Although almost all patients eventually require closed chest drainage, the BTS guidelines recommend a trial of thoracentesis for patients with small secondary pneumothorax (1-2 cm) with no obvious symptoms, while the ACCP does not recommend it.

Compared with primary pneumothorax, the pleural cavity rupture of secondary pneumothorax is often difficult to close on its own, so the average length of hospital stay will be prolonged. Some studies have also shown that the average length of hospital stay for patients with secondary pneumothorax is more than 10 days longer than that for patients with primary pneumothorax.

If the pleural rupture of a pneumothorax patient does not close for 48 hours, a thoracic surgeon must be consulted and given an individualized treatment plan. The decision on whether to take further surgical treatment should be made based on the risk of recurrence and the risk of surgical complications. Some patients who are not suitable for surgical treatment require longer periods of conservative treatment or less invasive treatment.