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Spontaneous Pneumothorax
There are two broad categories describing collapsed lungs.
Patients with primary pneumothorax tend to be tall, young,
and thin. Patients with secondary pneumothorax tend to be
older, with moderate to severe emphysema, and large bullae.
Primary spontaneous pneumothorax or secondary pneumothorax
which does not resolve with a chest tube, or which recurs,
should be treated surgically. Patients who have primary spontaneous
pneumothorax often can tolerate a pneumothorax with few symptoms.
The source of the pneumothorax is usually a ruptured bleb
from the top of either the upper or lower lobes. Approximately
20% to 40% will experience recurrence after a first episode.
If that second event is similarly treated without surgery,
the probability of a third occurrence is greater than 60%.
Surgery will be necessary in about 20% of patients, usually
because of recurrent pneumothoraces. Less common indications
for surgery are: prolonged air leaks from the chest tube,
and associated hemothorax, or patients at high risk because
of their occupations or lifestyles.
Our preferred surgical approach in patients requiring surgery
for spontaneous pneumothorax is thoracoscopy, with resection
of the apical blebs or bullae, and abrasion of the pleura
producing firm adhesions between the lung and chest wall.
Thoracoscopy affords better visualization of the entire lung
surface, especially the lower lobe which cannot be seen when
the traditional axillary approach is used. We tend to identify
more blebs with the thoracoscopic approach. In our experience,
patients treated for pneumothorax this way seem to experience
less postoperative pain, both immediately after surgery, and
when seen several months afterwards. There has been no difference
in our experience with recurrent pneumothorax provided blebs
are identified and removed. Despite advocating this less invasive
procedure, the indications have not been changed. We reserve
surgery for patients who either have recurrence or a persistent
pneumothorax for five to seven days.
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