title: Three-step management of pneumothorax: time for a re-think on initial management.
abstract: Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Kansai Medical University Hirakata Hospital, Osaka, Japan. kanedah@hirakata.kmu.ac.jp
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Kaneda
authors.forename: Takahito
authors.initials: T
authors.lastname: Nakano
authors.forename: Yohei
authors.initials: Y
authors.lastname: Taniguchi
authors.forename: Tomohito
authors.initials: T
authors.lastname: Saito
authors.forename: Toshifumi
authors.initials: T
authors.lastname: Konobu
authors.forename: Yukihito
authors.initials: Y
authors.lastname: Saito
mesh_terms: D015505:Chest Tubes; D004322:Drainage / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D019317:Evidence-Based Medicine; D006801:Humans; D008168:Lung / Q000503:physiopathology*; D016017:Odds Ratio; D018700:Pleurodesis; D011030:Pneumothorax / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D013510:Pulmonary Surgical Procedures; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D013396:Suction; D016896:Treatment Outcome