Spontaneous pneumothorax etiology and the efficacy of interventional surgery as first-line treatment
OA Version
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Abstract
Spontaneous pneumothorax presents as a prevalent health problem across the globe with rates of occurrence being higher in young adults and males. The occurrence is clinically defined as air outside of the lung and in the pleural space. This presence of air in the pleural cavity occurs due to many possible etiologies, including genetics, bullae formation, morphological body characteristics, and underlying disease. Air in the pleural space disrupts pressure gradients in the thoracic cavity and puts pressure on the lung, causing collapse and interference with normal breathing support. Two major types of pneumothorax occur: primary and secondary. Primary spontaneous pneumothorax (PSP) occurs due to no direct or known cause with no concurrent pathology. A major aspect of the clinical significance of PSP stems from highly prevalent recurrence rates after the first episode. Many patients who receive conservative treatment return with repeated pneumothorax events, pushing for a more definitive strategy at initial stages. Current treatment methodologies provide an inconsistent first-line approach with shifts in focus between symptoms first and the level of respiratory distress. Guidelines provide no clear emphasis on long term success with initial treatments that promote a reduction in recurrence rate. Numerous treatments exist today, beginning with conservative observation and simple bedside needle aspiration or chest tube placement to promote lung reinflation. More lasting treatments extend into interventional thoracoscopic surgery that works to not only remove intrapleural air but also remove blebs or bullae present on the visceral pleura surface. Additionally, a pleurodesis or pleurectomy procedure may be performed to support adherence of the pleural layers to prevent future rupture or collapse. The various treatment approaches are evaluated based on an array of patient factors. Physicians today have no widespread consensus on the best treatment decision for first-time primary spontaneous pneumothorax occurrences. Many continue to observe the conservative management strategy with a focus on observation and minimally invasive steps to achieve lung reinflation. These steps often do not consider long term outcomes and the numerous patient-specific factors that can contribute to elevated recurrence possibilities, such as morphological body type, genetic features, and the possibility of underlying pathology. Other physician teams follow a more interventional approach from onset with outcomes displaying lower rates of recurrence and shorter hospital lengths of stay. Evaluation of current literature surrounding primary spontaneous pneumothorax incidence, etiology, and initial treatment choices has been undertaken to compare the long-term efficacies of conservative versus interventional approaches. Comparison of results from several studies supports indications for the most efficacious first-line treatment that maximizes the success of long-term patient outcomes.
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2024