Pneumothorax Treatment

Pneumothorax is the partial or complete collapse of the lung as a result of air leaking into the pleural space between the lung and the chest wall. This condition may present with sudden chest pain and shortness of breath. It is a serious clinical condition requiring emergency intervention.

The causes and types of pneumothorax are divided into three categories: spontaneous, traumatic, and iatrogenic. While spontaneous pneumothorax is generally seen in young and thin individuals without underlying lung disease, secondary pneumothorax is associated with chronic diseases such as COPD.

Diagnostic and imaging methods are primarily established with a chest X-ray; in some cases, thoracic CT may be required. On physical examination, decreased breath sounds and asymmetry in chest movements may be detected. The diagnosis should be made rapidly and an intervention plan should be created.

Treatment options and prevention of recurrence risk depend on the size of the pneumothorax and the clinical condition of the patient. Observation, oxygen therapy, chest tube drainage, or surgical intervention may be applied. To reduce the risk of recurrence, treatment of the underlying causes is essential.

What Is Pneumothorax?

Pneumothorax is the partial or complete collapse of the lung as a result of air entering the pleural space between the lung and the chest wall. It may develop due to trauma, lung diseases, or spontaneously. Sudden chest pain and shortness of breath are the most common findings. Treatment varies according to the type and severity of the pneumothorax; observation, needle aspiration, or chest tube insertion may be required. Early intervention is of vital importance.

What are the types of pneumothorax (collapsed lung) and their mechanisms of formation?

To manage the disease correctly, we must first determine which type of pneumothorax we are dealing with. Because the causes and treatment approaches of lung collapse in a young university student are quite different from the picture we see in an elderly patient who has smoked for many years. As physicians, we basically examine this disease in two main groups: “Spontaneous,” meaning those that develop on their own, and “Acquired,” meaning those that develop due to an external factor. We also divide the spontaneous group into two according to whether the patient’s lungs were previously healthy or not.

First, I would like to talk about Primary Spontaneous Pneumothorax. This condition generally occurs in individuals who appear completely healthy and have no obvious underlying lung disease. However, the definition of “healthy” may be somewhat misleading here. Because in the lungs of these people, especially in the upper parts, there are tiny air sacs that we call “bullae” or “blebs,” the size of a grape seed or even smaller. These sacs may be congenital or may have developed later. When one of these weak-walled bubbles ruptures while the person is sitting, resting, or doing a simple activity, the air inside the lung leaks into the chest cavity and collapse occurs.

Secondary Spontaneous Pneumothorax, on the other hand, refers to the patient group whose condition is a little more complicated. Here, there is already an existing lung disease in the background. Since the lung tissue is already damaged, it is much easier for air to leak from this tissue. In this group of patients, since lung reserves, that is, capacities, are already limited, even if the collapsed part is small, the shortness of breath felt by the patient is much more severe and may be life-threatening.

The diseases that predispose to spontaneous pneumothorax are as follows:

• Chronic Obstructive Pulmonary Disease (COPD)
• Pulmonary tuberculosis
• Cystic fibrosis
• Lung cancer or metastases
• Interstitial lung diseases
• Sarcoidosis
• Lymphangioleiomyomatosis

Which physical characteristics and risk factors increase the likelihood of pneumothorax?

One of the most curious subjects related to this disease is who is at risk. We encounter a very typical profile in patients with primary spontaneous pneumothorax who come to our clinic. The vast majority of these patients are young men. Statistics show us that this condition peaks especially between the ages of 16 and 25. In terms of physical appearance, they also have quite characteristic features; they are generally tall and thin. There is a scientifically proven relationship between low body mass index and lung collapse. It is thought that one of the reasons for this condition is that during the period of rapid height growth, the blood supply to the upper parts of the lung remains relatively low and the tissue there becomes more delicate, forming air bubbles.

However, among the modifiable risk factors, the most important one and the one we must emphasize repeatedly is tobacco products. Smoking is the biggest culprit that increases the risk of lung collapse. Cigarette smoke initiates an inflammatory process in the airways of the lung and paves the way for small airway obstruction and therefore air trapping and bubble formation. The risk of pneumothorax in a smoker is many times higher than in a non-smoker. Moreover, this risk increases in direct proportion to the amount and duration of smoking. Although it is seen less frequently in women than in men, we sadly observe that this gap has begun to close in recent years with the increase in smoking among women.

In addition, genetic predisposition should not be ignored. We see that a history of lung collapse is frequent in some families. Some genetically inherited connective tissue diseases may cause the lung lining and tissue to be less resistant.

The risk factors in general are as follows:

• Smoking
• Tall and thin body structure
• Male sex
• Age between 20 and 40
• Family history of pneumothorax
• Connective tissue diseases such as Marfan syndrome
• Previous pneumothorax attack

How does pneumothorax develop as a result of trauma and medical interventions?

Apart from spontaneously developing conditions, “Acquired Pneumothorax” cases caused by external factors are also situations we frequently manage in hospitals. Blows to the chest, traffic accidents, falls from height, or penetrating instrument injuries can disrupt the integrity of the chest. The tip of a broken rib may puncture the lung tissue just like bursting a balloon, causing air to leak out, or with a penetrating injury the outside air may directly fill the chest cavity. In such traumatic cases, accumulation of blood in the chest (hemothorax) usually accompanies lung collapse, and we shape our treatment strategy accordingly.

There are also situations that we call “Iatrogenic Pneumothorax,” which develop unintentionally during procedures performed by us healthcare professionals for diagnosis or treatment purposes. With the advancement of medicine, the number of interventional procedures we perform on patients is increasing every day. This also brings the risk of complications. Of course, no physician wants to harm their patient, but this risk exists in the nature of some procedures. Especially during life-saving interventions performed in intensive care units or emergency departments, the pleura may be punctured.

The procedures that most commonly cause iatrogenic pneumothorax are as follows:

• Central venous catheter insertion
• Mechanical ventilation support
• Lung biopsies
• Pleural fluid drainage (thoracentesis)
• Pacemaker implantation
• Bronchoscopy procedures

What are the symptoms of pneumothorax and what does the patient feel?

The way the disease manifests itself is usually quite dramatic. Whatever the patient is doing at that moment, they feel a suddenly starting chest pain described as “like a knife stabbing.” This pain is usually felt on the side where the collapse is and intensifies when trying to take a deep breath. The most important finding accompanying the pain is shortness of breath. Since respiratory capacity decreases with the collapse of the lung, the body increases the respiratory rate to relieve oxygen hunger. However, sometimes, especially in young patients with good lung reserve, if the amount of collapse is small, the symptoms may be very faint. The patient may walk around for days with only a slight stinging sensation or discomfort in the chest.

However, it is vitally important here to mention a special picture called “Tension Pneumothorax,” which requires emergency intervention. In this condition, the tear in the pleura works like a valve in one direction. While inhaling, air enters the chest cavity, but it cannot exit during exhalation. The pressure inside increases with every breath. This high pressure not only completely collapses the lung on that side, but also pushes and compresses the heart and the main vessels to the opposite side. This condition prevents blood from returning to the heart and puts the patient into shock.

The common symptoms of pneumothorax are as follows:

• Sudden chest pain
• Shortness of breath
• Cough
• Rapid pulse
• Bluish discoloration of the lips or fingertips
• Restlessness and fear of death
• Low blood pressure

Which radiological methods are used in the diagnostic process?

When the patient presents to us with the complaints listed above, the first thing we do is a detailed physical examination. When we place our stethoscope on the patient’s back and listen, we hear that the breath sounds on the side of the collapse are reduced or completely absent. In addition, the change in the sound we get when we tap on the chest wall with our fingers gives us a clue that there is air accumulation inside. However, in modern medicine, imaging methods are indispensable to confirm the diagnosis and plan the treatment.

The method we most commonly use in the first step is a simple chest X-ray. On this upright film, we see the pleura separated from the edge of the lung as a thin line. In the area outside this line, the vascular shadows of the lung tissue have disappeared and it appears as a pitch-black empty space. In most emergency situations, this image is sufficient to make the diagnosis and decide to insert a tube.

However, in patients for whom we plan surgery, in recurrent cases, or in people with other underlying diseases, we need Computed Thoracic Tomography (CT). Tomography gives us the three-dimensional map of the lung. It allows us to see the location, number, size of the ruptured bubbles, and the general condition of the lung in the finest detail. Especially before surgery, the surgeon’s seeing the “map” is critical for the success of the operation.

The diagnostic imaging methods are as follows:

• Posteroanterior chest X-ray
• Computed thoracic tomography
• Bedside ultrasonography

How do non-surgical treatment options and the observation process work?

We do not operate on every patient diagnosed with pneumothorax, and in fact, we may not even have to insert a tube in every patient. The main factors that determine our treatment approach are the patient’s general condition, the severity of shortness of breath, and the percentage of lung collapse. If our patient is experiencing their first attack, their general condition is stable, their vital signs are normal, and the amount of collapse is less than 20%, we may choose the path of observation, which we call “conservative treatment.”

In this process, we usually hospitalize the patient and apply high-flow oxygen therapy. The reason we provide oxygen support is not only to increase the oxygen level in the blood. Breathing pure oxygen changes the pressure difference between the blood and the air in the pleural cavity, accelerating the absorption of the leaked air by the body. While the body absorbs this air at a rate of approximately 1.25% per day in normal room air, this rate can increase up to 4 times with oxygen support.

Another minimally invasive method is “Simple Aspiration.” In this procedure, under local anesthesia, a thin catheter is inserted into the chest cavity and the air inside is withdrawn with the help of a syringe. If the lung expands, the patient can be sent home after 6–8 hours of observation.

However, if the amount of collapse is large or if the patient is symptomatic, the most standard treatment is “Tube Thoracostomy,” that is, insertion of a chest tube. A tube placed between the ribs under local anesthesia is connected to a special box that we call the underwater drainage system. This system allows the air inside to exit while preventing air from entering from outside.

The conditions in which non-surgical treatments are applied are as follows:

• First attack primary spontaneous pneumothorax
• Small-volume collapses
• Patients with no symptoms or minimal symptoms
• Patients too frail to tolerate surgery

In which situations and why is a surgical decision made?

Our primary role as thoracic surgeons is to prevent the disease from recurring. Because pneumothorax is a disease that likes to recur. While the recurrence risk after the first attack is around 20–30%, when the patient experiences a second attack, this risk jumps to 50%. After the third attack, recurrence is almost inevitable. In light of these statistics, we consider certain criteria when making the surgical decision.

Our most definite surgical indication is “recurrence.” In other words, if the patient experiences lung collapse for the second time in their life, it is no longer enough to simply evacuate the air; a permanent solution must be provided. In addition, even if it is the first attack, surgery becomes inevitable in situations such as the air leak continuing for more than 5–7 days despite the inserted chest tube (prolonged air leak), the lung failing to expand, or both lungs collapsing at the same time.

There is also a special group that we call “social indication.” For pilots, divers, sailors, or people living in rural areas where access to healthcare is difficult, we recommend surgery even at the first attack. Imagine if a pilot experienced a recurrence during flight or a diver experienced it meters below the water; this could end in disaster not only for themselves but also for those around them. Since we cannot take this risk, we present protective surgery as the first option in these occupational groups.

The situations requiring surgery are as follows:

• Experiencing pneumothorax for the second time
• Prolonged air leak
• Failure of the lung to fully expand
• Bilateral pneumothorax
• Accompanying hemothorax (bleeding)
• High-risk occupational groups
• Previous removal of the opposite lung

What do modern surgical methods and the VATS technique offer the patient?

With the development of technology, the concept of “open surgery” in thoracic surgery has largely given way to closed methods. Today, the gold standard in pneumothorax surgery is the “Video-Assisted Thoracoscopic Surgery,” or VATS method. In this technique, instead of opening the patient’s chest cavity from end to end, we perform the procedure through usually 1 or 2, at most 3, small holes (ports). Through one of these holes, we insert a high-resolution camera. This camera reflects the inside of the chest onto giant screens, and we surgeons obtain a much more detailed and magnified view than we could see with the naked eye.

The comfort that the VATS method provides to the patient is indisputable. Since no large muscle incisions are made, postoperative pain is much less, the risk of infection is low, and the cosmetic results are excellent. Our patients can usually be discharged 2–3 days after surgery and return to their daily lives much more quickly. During the operation, our main goal is to find the small bubbles (bullae) that cause the air leak and cut them out with special stapling devices (staplers).

The advantages of the VATS method are as follows:

• Less postoperative pain
• Short hospital stay
• Fast recovery and return to work
• Better cosmetic results
• Less risk of bleeding
• Lower infection rate

What is the “Pleurodesis” procedure applied to prevent recurrence?

Simply cutting out the leaking bubbles (bullae resection) is an important part of the treatment, but alone it is not 100% guaranteed in preventing recurrence. Because the lung tissue may create a new weak area from another point over time. To eliminate this possibility, we apply the second and perhaps most critical stage of the surgery, the “Pleurodesis” procedure.

Pleurodesis, in the simplest terms, is the “procedure of adhering the pleural layers to each other.” Our aim is to create a sterile, controlled inflammatory reaction between the membrane lining the inside of the chest wall and the membrane covering the lung. As this reaction heals, the two membranes adhere tightly to each other and fuse. When the membranes adhere, there is no longer a potential space in between. Even if there is a tiny air leak from the lung in the future, there will be no space where the air can accumulate and push the lung to collapse, so the lung will not collapse.

We can perform this procedure by mechanical or chemical means. In young and healthy patients, we generally prefer “mechanical pleurodesis.” In this method, the chest wall pleura is irritated (abrasion) with surgical instruments or special pads, or completely stripped (pleurectomy). In cancer patients or those who cannot tolerate surgery, “chemical pleurodesis” is applied by administering “sterile talc powder” or certain medications through the tube.

The pleurodesis methods are as follows:

• Mechanical abrasion
• Apical pleurectomy
• Talc powder application
• Chemical agent injection

What is the postoperative recovery process and the long-term outcome like?

When you come out of surgery, there is usually one drain (tube) in your chest. This drain allows the air remaining inside and the small amount of fluid that may leak from the surgical field to be evacuated. It is normal to feel pain in the first days, but we make this process quite comfortable with epidural catheters or intravenous painkillers. Our most important request is that the patient get up and walk as soon as possible, even on the evening of the surgery. Early mobilization and breathing exercises (use of a triflow device) allow the lung to expand and prevent complications such as pneumonia.

When the air flow from the drain stops and the lung is seen to be fully expanded on the X-ray, the drain is removed. Usually, discharge is performed one day after the drain is removed. After successful surgery and well-performed pleurodesis, the recurrence rate drops to below 1%. This means the patient can completely forget the disease and return to normal life. In the long term, there is no significant loss in lung function that would affect the patient’s exercise capacity.

The things to pay attention to after discharge are as follows:

• Regular use of prescribed painkillers
• Continuation of breathing exercises
• Keeping the wound site clean and dry
• Avoiding heavy lifting
• Avoiding sudden movements

What lifestyle changes should a patient who has had pneumothorax make?

The question our patients ask us most frequently while being discharged is, “Doctor, what should I change in my life?” The clearest and non-negotiable answer we can give here is: you must say goodbye to cigarettes. Continuing to smoke not only increases the risk of recurrence, but also keeps alive the possibility of a new pneumothorax developing in the opposite lung. If the patient does not quit smoking, the success of the surgery may be overshadowed.

Another important restriction concerns pressure changes. Until healing is complete, that is generally for the first 3–4 weeks after surgery, we do not recommend air travel. Sudden changes in cabin pressure may cause problems in lung tissue that has not yet fully healed. However, a more permanent and serious prohibition applies to “scuba diving.” The high pressure in the depths of the water and the pressure changes during ascent pose a vital risk for a lung that has had pneumothorax. Therefore, professional or amateur diving is generally among the activities prohibited for life.

As for sports; after the healing process is complete (about 1 month), activities such as brisk walking and surface swimming can be started. For returning to weight lifting or contact sports, it may be necessary to wait a little longer with your doctor’s approval. Pneumothorax can be a frightening experience, but with the right treatment and a conscious lifestyle, it can be left completely behind.

The lifestyle recommendations are as follows:

• Complete smoking cessation
• Avoiding scuba diving
• Postponing air travel for a while
• Not playing wind instruments for a while
• Not neglecting regular doctor check-ups
• Taking a break from sports requiring excessive effort

Frequently Asked Questions