Spontaneous pneumothorax is a condition where air accumulates in the pleural space, the area between the lung and the chest wall. This air leak causes the lung to partially or completely collapse, leading to symptoms like sudden chest pain and shortness of breath. While some cases may resolve with observation or simple interventions like oxygen therapy or needle aspiration, surgery is a definitive treatment option for specific situations. It aims to prevent future episodes of lung collapse.
When is Surgery Necessary?
Surgery for spontaneous pneumothorax is considered when non-surgical treatments are insufficient or when certain risk factors are present. One common indication is a persistent air leak, defined as lasting longer than five to seven days despite conservative management with a chest tube. Another reason for surgery is recurrent pneumothorax on the same or opposite side. Patients experiencing a second or subsequent episode are often advised to undergo surgery to reduce further recurrences.
Bilateral pneumothorax, where both lungs are affected, warrants surgical consideration. Individuals in certain high-risk occupations, such as pilots or divers, are candidates for surgery even after a first episode, due to dangers in their professional environments. Underlying medical conditions, such as Birt-Hogg-Dubé syndrome or severe emphysema, can make surgery a more suitable first-line treatment. For women, catamenial pneumothorax, which occurs during menstruation and is associated with endometriosis, might also require surgery if hormone therapy is ineffective.
Surgical Approaches
The main surgical technique for spontaneous pneumothorax is Video-Assisted Thoracoscopic Surgery (VATS), a minimally invasive procedure that has become the preferred approach for many surgeons. During VATS, a surgeon makes small incisions, typically two to three, in the chest wall. A tiny camera, or thoracoscope, is inserted through one incision, providing a magnified view of the lung and pleural cavity on a monitor. Surgical instruments are then inserted through the other small incisions to perform the necessary repairs.
The main goals of VATS are to address the source of the air leak and to prevent future lung collapse. A common step involves identifying and resecting subpleural blebs or bullae, which are small, air-filled sacs on the lung surface often causing spontaneous pneumothorax. Following this, pleurodesis is performed to make the lung adhere to the chest wall. This can be achieved through mechanical pleurodesis, where the outer layer of the lung lining (parietal pleura) is abraded or removed (pleurectomy) to create inflammation and scarring, promoting adhesion.
Alternatively, chemical pleurodesis may be performed by introducing an irritant, such as talc, into the pleural space to induce scarring. The combination of blebectomy and pleurodesis significantly reduces recurrence. Open thoracotomy, involving a larger incision, is a less common alternative reserved for complex cases or when VATS is not feasible.
Recovery and Aftercare
Following spontaneous pneumothorax surgery, patients remain in the hospital for a few days, often between one to seven days, depending on the condition’s severity and surgical method. During this initial period, a chest tube is in place to drain air or fluid from the pleural space and help the lung fully re-expand. Pain management is an important aspect of early recovery, with medications provided to ensure comfort as incision sites heal. Many individuals report sharp or persistent pain at the chest tube site, which subsides within about two weeks after the tube’s removal.
The chest tube is removed once the air leak has resolved and the lung remains fully expanded, often within a few days post-surgery. Wound care involves monitoring the small incisions, which may be covered with a clear adhesive dressing or gauze removed within 48 to 72 hours. Patients are encouraged to gradually increase activity, starting with short daily walks to promote blood flow and lung function.
Strenuous activities, such as heavy lifting or vigorous exercise, are restricted for several weeks to allow adequate healing and adhesion of the lung to the chest wall. Full incision healing takes about three to four weeks, although a small scar may remain and fade over time. Patients should be vigilant for signs of complications, such as increased pain, fever, or difficulty breathing, and report them to their healthcare provider.
Preventing Recurrence and Long-Term Outlook
Spontaneous pneumothorax surgery, particularly VATS with pleurodesis or pleurectomy, reduces future lung collapse compared to non-surgical treatments. While conservative management alone can lead to a recurrence rate ranging from 20% to 60%, surgical intervention lowers this risk. The recurrence rate after VATS treatment has been reported to range from 0% to 11% depending on the pleurodesis technique, with some studies showing an overall recurrence rate of approximately 10%. Factors that may increase recurrence risk after surgery include younger age, female gender, active smoking, and prolonged postoperative air leaks.
Patients are advised to avoid activities involving pressure changes, such as scuba diving or high-altitude flying, as these can increase the risk of another pneumothorax. Regular follow-up appointments with the surgeon are important to monitor lung function and ensure continued recovery. These appointments are scheduled three to four weeks after discharge. Although surgery diminishes recurrence, it does not eliminate it entirely. Despite the possibility of recurrence, most individuals experience a favorable long-term outlook and can return to normal activities within several weeks to a few months, with many regaining full lung function over time.