Decision Making in the Management of Secondary Spontaneous Pneumothorax in Patients with Severe Emphysema

In patients who have advanced emphysema, development of a spontaneous pneumothorax can be a life-threatening event, warranting more aggressive management. Patients who have the most advanced stages of emphysema are at the highest risk to develop spontaneous pneumothoraces, have recurrences, and are the most difficult patients to treat. Early surgical intervention should be recommended for patients who have persistent or large air leaks or those who lack parietal-to-visceral pleural apposition after a trial of nonoperative management. Video-assisted thoracoscopy with resection of the offending bulla and pleurodesis or pleurectomy also should be considered to prevent recurrences in all patients with chronic obstructive pulmonary disease who are safe operative candidates.