PERSISTENT AIR-LEAK IN SPONTANEOUS PNEUMOTHORAX - CLINICAL COURSE ANDOUTCOME

Persistent air-leak in patients with spontaneous pneumothorax (SP) is not uncommon and may present a management dilemma in those who are unf it or unwilling for surgery. Video-assisted thoracoscopic surgery (VAT S) has been advocated in the management of patients with broncho-pleur al fistulae (air-leak persisting beyond 7 days): however the optimum t ime for surgical intervention remains unclear. We reviewed the records of 130 episodes of SP in 115 patients over a 2-year period to determi ne clinical course and outcome, particularly with respect to duration of air-leak. There were 90 first episodes and 40 recurrent episodes. E ighty-one episodes (62%) occurred in patients with underlying lung dis ease (secondary pneumothorax). Initial management consisted of chest-t ube drainage in 104 episodes (80%) occurring in 90 patients, percutane ous needle aspiration in five patients (4%) and observation in 21 epis odes (16%) in 20 patients. In the group treated with chest-tube draina ge, there was spontaneous resolution of air leak and lung re-expansion in 90 episodes (87%). The overall incidence of broncho-pleural fistul a was 34.6%. In the primary SP group, 75% of air-leaks ceased by 7 day s and 100% by 15 days. In the secondary SP group, 61% of air-leaks res olved by 7 days and 79%, by 14 days, after which time resolution of ai r-leak proceeded at a much slower rate. Five patients underwent surger y while nine patients were discharged with residual pneumothoraces. Th ere were no major complications or mortality. Based on our findings: w e advocate surgery for patients with air-leak persisting beyond 14 day s, while favouring a conservative approach before this time, as the ma jority of air-leaks (especially in patients with primary pneumothorax) would resolve by 14 days.