What Is Pneumothorax?
Pneumothorax is a condition caused by rupture of the alveoli, allowing air to accumulate in the pleural space. This trapped air prevents the lung from fully expanding and may compress the lung, leading to partial or complete collapse.

When the lung is significantly compressed, patients may suddenly experience chest pain, chest tightness, shortness of breath, and a sensation of being unable to inhale sufficient air, potentially resulting in hypoxia. Some patients may also develop cough, shoulder pain, neck discomfort, or upper back soreness.

If a large volume of air accumulates rapidly, it may cause mediastinal shift, impaired venous return to the heart, hypotension, and shock. This life-threatening condition is known as tension pneumothorax and requires immediate emergency treatment.

Types and Causes of Pneumothorax
In addition to traumatic pneumothorax caused by blunt or penetrating chest injury, primary spontaneous pneumothorax commonly occurs in young, tall, slender, otherwise healthy males, often due to rupture of apical lung blebs or bullae.

Although the exact mechanism is not fully understood, forceful coughing, sneezing while covering the nose and mouth, and cigarette smoking significantly increase the risk of bleb formation and rupture. Smoking cessation is the most important preventive measure.

Secondary spontaneous pneumothorax is more frequently seen in older patients or those with underlying lung diseases such as emphysema, chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis, pneumoconiosis, or cystic fibrosis.



Clinical Symptoms and Warning Signs
Common symptoms of pneumothorax include:

·Sudden onset chest pain or chest tightness

·Shortness of breath or difficulty breathing

·Cough, shoulder pain, or back pain

·In severe cases: cyanosis, cold sweats, tachycardia, or hypotension

Patients presenting with severe chest tightness, low blood pressure, or altered consciousness should seek immediate medical attention due to the risk of tension pneumothorax.

Treatment Goals of Pneumothorax
The primary goals of treatment are to:

1.Relieve symptoms

2.Promote lung healing

3.Prevent recurrence

Most mild pneumothoraces may resolve spontaneously. However, patients with severe symptoms, lung collapse greater than 20%, or persistent air leakage require chest tube drainage and possibly surgical intervention.

Management of First-Episode Unilateral Primary Spontaneous Pneumothorax
·Lung collapse < 20% with mild symptoms:
→ Outpatient observation with instructions to return if symptoms worsen

·Lung collapse > 20% or dyspnea present:
→ Placement of a pigtail catheter for drainage and monitoring

·Persistent air leak or failure of lung re-expansion after 48 hours:
→ Consider video-assisted thoracoscopic surgery (VATS)

Indications for Primary Surgical Treatment
Immediate or early surgery is recommended in the following situations:

·Life-threatening conditions: pneumothorax with hemothorax, bilateral pneumothorax

·Second ipsilateral recurrence or contralateral pneumothorax

·Persistent air leak after chest tube insertion

·High-risk occupations (e.g., pilots, flight attendants, divers)

·Limited access to medical care or remote residence

VATS and Pleurodesis
Video-assisted thoracoscopic surgery (VATS) is currently the most effective method for reducing recurrence. The procedure involves:

·Identification and resection or ligation of lung bullae (bullectomy)

·Pleurodesis, which promotes adhesion between the lung and chest wall

Pleurodesis techniques include:

1.Mechanical pleurodesis – pleural abrasion or partial pleurectomy

2.Chemical pleurodesis – instillation of agents such as talc, minocycline, OK-432, or hypertonic glucose

3.Artificial pleural mesh coverage (commonly used in our institution), which thickens the pleural surface and reduces recurrence with fewer side effects such as fever or pain

Recent studies demonstrate that pleural mesh coverage for postoperative air leak is safe, effective, shortens hospital stay, and lowers recurrence rates.

Postoperative Care and Recurrence Prevention
To reduce the risk of recurrence, patients should:

·Avoid strenuous exercise and forceful coughing for 3 months

·Attend scheduled follow-up visits with chest X-rays at 2 weeks, 1 month, 3 months, and 6 months

·Completely stop smoking

Conclusion
Primary spontaneous pneumothorax is an acute but highly treatable thoracic condition. With appropriate management, most patients can fully recover and return to normal daily activities. VATS combined with pleurodesis remains the most effective strategy for preventing recurrence. Adherence to postoperative care, smoking cessation, and regular follow-up significantly improve quality of life and long-term outcomes.