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Pneumothorax

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Updated 2024 ERN GENTURIS guidelines for the diagnosis and management of Birt-Hogg-Dubé syndrome.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of pneumothorax are prepared by our editorial team based on guidelines from the European Association for Cardio-Thoracic Surgery (EACTS/ERS/ESTS 2024), the European Reference Network on GENetic TUmour RIsk Syndromes (ERN GENTURIS 2024), the British Thoracic Society (BTS 2023,2017,2011), the French Society of Thoracic and Cardiovascular Surgery (SFCTCV/SFMU/SFAR/SRLF/SPLF 2023), and the Society ...
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Classification and risk stratification

Classification
As per SFAR/SFCTCV/SFMU/SPLF/SRLF 2023 guidelines:
Consider classifying primary spontaneous pneumothorax as large in the presence of a visible rim along the entire axillary line, ≥ 2 cm between the lung margin and the chest wall at the hilum level.
C
Classify pneumothorax as tension pneumothorax when it results in respiratory distress or hemodynamic failure.
B
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Diagnostic investigations

Diagnostic imaging, X-ray: as per SFAR/SFCTCV/SFMU/SPLF/SRLF 2023 guidelines, consider obtaining a frontal CXR acquired in inspiration, without expiratory films, in patients with suspected primary spontaneous pneumothorax to diagnose pneumothorax and assess its size.
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  • Diagnostic imaging (CT)

  • Diagnostic imaging (ultrasound)

  • Diagnostic imaging (prediction)

Respiratory support

Supplemental oxygen: as per SFAR/SFCTCV/SFMU/SPLF/SRLF 2023 guidelines, do not administer supplemental oxygen systematically in patients treated for primary spontaneous pneumothorax.
D
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Medical management

Setting of care
As per EACTS/ERS/ESTS 2024 guidelines:
Consider offering outpatient management for the initial treatment of primary spontaneous pneumothorax in centers with appropriate expertise and pathways to manage patients as outpatients.
C
Avoid using small bore (8 Fr) outpatient devices for the initial treatment of secondary spontaneous pneumothorax.
D
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  • Observation

  • Pain management

  • Management of tension pneumothorax

Nonpharmacologic interventions

Smoking cessation: as per EACTS/ERS/ESTS 2024 guidelines, advise smoking cessation in patients with pneumothorax, as smoker patients are more likely to have a recurrent episode.
B
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  • Physical activity restrictions

Therapeutic procedures

Needle aspiration
As per EACTS/ERS/ESTS 2024 guidelines:
Perform needle aspiration over chest tube drainage for the initial management of primary spontaneous pneumothorax.
B
Insufficient evidence to recommend for or against needle aspiration as an alternative to chest tube drainage for secondary spontaneous pneumothorax.
I
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  • Chest tube drainage (indications)

  • Chest tube drainage (technical considerations)

  • Chest tube drainage (periprocedural analgesia)

  • Chest tube drainage (considerations for transportation)

  • Medical pleurodesis

  • Autologous blood patch

  • Endobronchial valve

  • Suction

Perioperative care

Perioperative locoregional analgesia: as per SFAR/SFCTCV/SFMU/SPLF/SRLF 2023 guidelines, consider administering perioperative locoregional analgesia to reduce postoperative pain in patients undergoing pneumothorax surgery. Consider preferring peripheral locoregional analgesia (paravertebral block, serratus plane block, or intercostal block) over thoracic epidural analgesia.
C
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Surgical interventions

Indications for surgery
As per EACTS/ERS/ESTS 2024 guidelines:
Consider offering early surgical intervention for the initial management of primary spontaneous pneumothorax in patients prioritizing recurrence prevention.
C
Insufficient evidence to recommend for or against early surgical intervention for the initial management of secondary spontaneous pneumothorax.
I
Consider taking into account the following factors when considering surgery in patients with secondary spontaneous pneumothorax and persistent air leak: age, comorbidities, type of underlying lung disease, performance status, ASA score, and degree of emphysema on CT.
I
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  • Surgical pleurodesis (indications)

  • Surgical pleurodesis (technical considerations)

Specific circumstances

Patients with hemopneumothorax: as per SFAR/SFCTCV/SFMU/SPLF/SRLF 2023 guidelines, consider contacting an expert center (center with a thoracic surgery department) for patients with hemopneumothorax (regardless of its size) as soon as possible to discuss the treatment approach and possibly transfer patients to this center.
E
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  • Patients with pleural adhesions

  • Patients with Birt-Hogg-Dubé syndrome (diagnosis)

  • Patients with Birt-Hogg-Dubé syndrome (genetic testing)

  • Patients with Birt-Hogg-Dubé syndrome (diagnostic imaging)

  • Patients with Birt-Hogg-Dubé syndrome (management)

  • Patients with Birt-Hogg-Dubé syndrome (surveillance for malignancy)

Patient education

Counseling on air travel
As per EACTS/ERS/ESTS 2024 guidelines:
Advise patients with untreated spontaneous pneumothorax to refrain from air travel.
B
Advise patients to wait at least 7 days after radiological resolution of spontaneous pneumothorax before air travel due to the risk of early recurrence/treatment failure.
B
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  • Counseling on diving

  • Counseling on playing wind instruments

Follow-up and surveillance

Indications for specialist referral: as per SFAR/SFCTCV/SFMU/SPLF/SRLF 2023 guidelines, consider contacting an expert center (center with a thoracic surgery department) for patients with any of the following as soon as possible to discuss the treatment approach and possibly transfer patients to this center:
hemopneumothorax
simultaneous bilateral primary spontaneous pneumothorax
primary spontaneous pneumothorax with confirmed pleural adhesion.
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  • Follow-up