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SJ Mackenzie, A Gray
Journal Issue: 
Volume 37: Issue 4: 2007




The management of PSP continues to be a source of debate. There are few  randomised  control  trials  comparing  treatment  options,  and  current guidelines  based  on  specialist  opinion  vary  in  their  recommendations.   Initial management options include observation, aspiration, intercostal drainage with and without  pleurodesis,  and  video-assisted  thoracoscopic  surgery. Primary spontaneous  pneumothoraces  arise  in  patients  without  clinically  apparent  lung disease, and no obvious precipitating factor. It is a relatively common presentation with a reported incidence of 18 to 28 per 100,000 men per year and 1·2 to 6 per 100,000 women per year.  Primary spontaneous pneumothorax usually occurs in young, tall males between the ages of 15 and 34.

The BTS and ACCP have both published guidelines on the treatment of PSP. While they agree on the management of small asymptomatic PSP (observation and out-patient  review)  and  clinically  unstable  PSP  (intercostal  drain  insertion  and admission), they differ on the management of symptomatic small PSP and clinically stable large PSP.  The ACCP advise that simple aspiration is rarely appropriate in the  treatment  of  PSP, while  the  BTS  recommend  simple  aspiration  as  a  first-line treatment.  A 2007 Cochrane report, which systematically reviewed all published randomised  control  trials  comparing  aspiration  to  intercostal  drain  insertion, concluded that there was no difference in the immediate success rate, early failure rate,  or  one-year  success  rate  between  the  two  interventions. However, aspiration  resulted  in  a  lower  number  of  patients  requiring  admission,  and decreased the duration of hospital stay.  Current evidence supports the 2003 BTS guidelines,  and  simple  aspiration  as  first-line  treatment  in  clinically  stable pneumothoraces.    Until  a  large  randomised  control  trial  is  performed,  and provides  a  conclusive  evidence  base  for  the  most  appropriate  management  of spontaneous pneumothorax, confusion will remain over first-line treatment.