Pneumothorax surgery: Difference between revisions

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{{Pneumothorax}}
{{Pneumothorax}}
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==Overview==
==Overview==
Pneumothoraces which are too small to require tube thoracostomy and too large to leave untreated, have been aspirated with a needle to remove the pressure, although this technique is usually reserved for tension pneumothoraces.
[[Surgery]] is the mainstay of treatment for the management of [[pneumothorax]]. The type of surgical modality opted depends on various conditions such as the size of the pneumothorax, underlying disease/procedure causing it and the type (open/closed vs simple/tension). Initially, airway, breathing and circulation should be maintained along with high concentration oxygen therapy. Tube [[thoracotomy]] used to be the preferred surgical procedure. Nowadays, video assisted thoracoscopic surgery (VATS) has widely replaced the open surgical procedure.
 
==Indications==
Surgical intervention is recommended for the management of pneumothorax.<ref name="pmid17502684">{{cite journal| author=Gudbjartsson T, Tómasdóttir GF, Björnsson J, Torfason B| title=[Spontaneous pneumothorax: a review article]. | journal=Laeknabladid | year= 2007 | volume= 93 | issue= 5 | pages= 415-24 | pmid=17502684 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17502684  }} </ref><ref name="pmid21213209">{{cite journal| author=Haynes D, Baumann MH| title=Management of pneumothorax. | journal=Semin Respir Crit Care Med | year= 2010 | volume= 31 | issue= 6 | pages= 769-80 | pmid=21213209 | doi=10.1055/s-0030-1269837 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21213209  }} </ref><ref name="pmid22191997">{{cite journal| author=Galbois A, Zorzi L, Meurisse S, Kernéis S, Margetis D, Alves M et al.| title=Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes. | journal=Acta Anaesthesiol Scand | year= 2012 | volume= 56 | issue= 4 | pages= 507-12 | pmid=22191997 | doi=10.1111/j.1399-6576.2011.02602.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22191997  }} </ref><ref name="pmid17098099">{{cite journal| author=Tsai WK, Chen W, Lee JC, Cheng WE, Chen CH, Hsu WH et al.| title=Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adults. | journal=Am J Emerg Med | year= 2006 | volume= 24 | issue= 7 | pages= 795-800 | pmid=17098099 | doi=10.1016/j.ajem.2006.04.006 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17098099  }} </ref>
 
The choice of intervention depends on the following factors:
* Size of the pneumothorax
* Underlying disease/procedure causing pneumothorax
* Associated comorbid condition
* Type of pneumothorax (open/closed vs simple/tension)
 
==Initial management==
===First aid===
In all patients with [[chest]] [[Physical trauma|trauma]] along with [[Respiratory system|respiratory]] difficulty, following measures ahould be taken as the first line management:
* Maintaining the [[airway]] patency
* Assessment of [[breathing]]
* Prevention of [[Circulatory system|circulatory]] collapse
* [[Oxygen]] therapy
*Patient should be positioned upright, unless there is a contraindication to it, such as spinal injury.
===Oxygen therapy===
* Immediate administration of 100% oxygen results in accelerated resorption of pleural air.<ref name="pmid6836190">{{cite journal| author=Chadha TS, Cohn MA| title=Noninvasive treatment of pneumothorax with oxygen inhalation. | journal=Respiration | year= 1983 | volume= 44 | issue= 2 | pages= 147-52 | pmid=6836190 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6836190  }} </ref><ref name="pmid2742485">{{cite journal| author=Delius RE, Obeid FN, Horst HM, Sorensen VJ, Fath JJ, Bivins BA| title=Catheter aspiration for simple pneumothorax. Experience with 114 patients. | journal=Arch Surg | year= 1989 | volume= 124 | issue= 7 | pages= 833-6 | pmid=2742485 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2742485  }} </ref>
*Patients who have contraindications to simple aspiration or tube thoracotmy can be given high concentration supplemental [[oxygen]].
 
==Surgical techniques==
Following surgical techniques are used to treat pneumothorax:<ref name="pmid15311535">{{cite journal| author=Hilton P| title=Evaluating the treatment options for spontaneous pneumothorax. | journal=Nurs Times | year= 2004 | volume= 100 | issue= 28 | pages= 32-3 | pmid=15311535 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15311535  }} </ref><ref name="pmid10819376">{{cite journal| author=Chan SS| title=Current opinions and practices in the treatment of spontaneous pneumothorax. | journal=J Accid Emerg Med | year= 2000 | volume= 17 | issue= 3 | pages= 165-9 | pmid=10819376 | doi= | pmc=1725386 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10819376  }} </ref><ref name="pmid3137850">{{cite journal| author=Vallee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M| title=Sequential treatment of a simple pneumothorax. | journal=Ann Emerg Med | year= 1988 | volume= 17 | issue= 9 | pages= 936-42 | pmid=3137850 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3137850  }} </ref>
*Simple aspiration
*Open [[thoracotomy]]
*Video-assisted thoracoscopic surgery (VATS)


==Surgery==
==Surgery==
'''Larger pneumothoraces''' may require tube thoracostomy, also known as [[chest tube]] placement. If a thorough anesthetizing of the parietal pleura and the intercostal muscles is performed, the only major pain experienced should be either the injury that caused the pneumothorax or the re-expanding of the lung. Proper anesthetizing will come about after the needle has been inserted into the chest cavity and a negative pressure is created in the syringe. While air bubbles rise into the syringe, the needle should be pulled out of the cavity until the bubbles cease. The tip of the syringe that contains the anesthetic is now in the intercostal muscles. A proper and sizable injection should ensue. This will allow the patient to be fairly comfortable despite a hemostat or finger being inserted into the chest cavity. A tube is then inserted into the chest wall outside the lung and air is extracted using a [[flutter valve|simple one way valve]] or vacuum and a water valve device, depending on severity. This allows the lung to re-expand within the chest cavity. This re-expansion usually lasts for approximately 15-30 seconds depending on the size of the pneumothorax and feels as if your breath has been taken away. This response is normal and should pass fairly quickly. The pneumothorax is followed up with repeated [[X-ray]]s. If the air pocket has become small enough, the vacuum drain can be clamped temporarily or removed. If during the time that the tube is still in the chest the lung manages to not contiue to collapse once suction is turned off, but will diminish if actually clamped off, a heimlich valve may be used. This flutter valve allows air and fluid in the pleural cavity to escape the pleura into a drainage bag while not letting any air or fluid back in. This method was developed by the military in order to get soldiers with lung injuries stable and out of the battle field faster. It is a rarely used medical device in treatment in patients these days, but will be used in order to allow the patient to leave the hospital.
*Simple aspiration
*Open [[thoracotomy]] used to be the most commonly used surgical procedure along with [[Wedge resection (lung)|wedge]] resection of the leaking part of the lung.  
*Nowadays, video-assisted thoracoscopic (VATS) [[surgery]] has widely replaced the open surgical procedure for spontaneous pneumothorax.
===Simple aspiration===
'''Indications:'''
*Mostly done in small spontaneous pneumothorax.<ref name="pmid25264729">{{cite journal| author=Swierzy M, Helmig M, Ismail M, Rückert J, Walles T, Neudecker J| title=[Pneumothorax]. | journal=Zentralbl Chir | year= 2014 | volume= 139 Suppl 1 | issue=  | pages= S69-86; quiz S87 | pmid=25264729 | doi=10.1055/s-0034-1383029 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25264729  }} </ref>
 
'''Procedure:'''
* A plastic IV [[cannula]] is inserted into the second [[intercostal]] space along the [[Midclavicular line|midclavicular]] line.<ref name="pmid11807188">{{cite journal| author=Mendis D, El-Shanawany T, Mathur A, Redington AE| title=Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed? | journal=Postgrad Med J | year= 2002 | volume= 78 | issue= 916 | pages= 80-4 | pmid=11807188 | doi= | pmc=1742255 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11807188  }} </ref><ref name="pmid8374466">{{cite journal| author=Ireland AJ, Dorward AJ| title=Management of pneumothorax. Consider ATLS guidelines. | journal=BMJ | year= 1993 | volume= 307 | issue= 6901 | pages= 444 | pmid=8374466 | doi= | pmc=1678430 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8374466  }} </ref><ref name="pmid21186751">{{cite journal| author=Pallin M, Open M, Moloney E, Lane SJ| title=Spontaneous pneumothorax management. | journal=Ir Med J | year= 2010 | volume= 103 | issue= 9 | pages= 272-5 | pmid=21186751 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21186751  }} </ref>
* Alternatively, it can be inserted into the fifth [[intercostal]] space along the mid [[axillary]] line.<ref name="pmid11555554">{{cite journal| author=Miller AC, Harvey J| title=Pneumothorax: what's wrong with simple aspiration? | journal=Chest | year= 2001 | volume= 120 | issue= 3 | pages= 1041-2 | pmid=11555554 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11555554  }} </ref><ref name="pmid15250222">{{cite journal| author=Devanand A, Koh MS, Ong TH, Low SY, Phua GC, Tan KL et al.| title=Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review. | journal=Respir Med | year= 2004 | volume= 98 | issue= 7 | pages= 579-90 | pmid=15250222 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15250222  }} </ref>
{{#ev:youtube|Clw5H_t_u00}}
'''Advantages:'''
* Least [[Invasive (medical)|invasive]] procedure<ref name="pmid17961959">{{cite journal| author=Chan SS| title=The role of simple aspiration in the management of primary spontaneous pneumothorax. | journal=J Emerg Med | year= 2008 | volume= 34 | issue= 2 | pages= 131-8 | pmid=17961959 | doi=10.1016/j.jemermed.2007.05.040 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17961959  }} </ref><ref name="Chan2008">{{cite journal|last1=Chan|first1=Stewart Siu-Wa|title=The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax|journal=The Journal of Emergency Medicine|volume=34|issue=2|year=2008|pages=131–138|issn=07364679|doi=10.1016/j.jemermed.2007.05.040}}</ref>
* Reduced hospital stay
* Cost-saving
* Complication rate is low<ref name="pmid11991872">{{cite journal| author=Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A| title=Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. | journal=Am J Respir Crit Care Med | year= 2002 | volume= 165 | issue= 9 | pages= 1240-4 | pmid=11991872 | doi=10.1164/rccm.200111-078OC | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11991872  }} </ref>
'''Disadvantages:'''
* Not recommended for larger size pneumothorax.


In the situation that the chest tube does not seem to be helping the healing of the lung or if CAT scans show the presence of "blebs" on the surface of the lung orthoscopic surgery may be done in order to staple the lung closed. Two small incisions are made in the back, one for a small camera and one for the tool used to seal the lung. When finished the wound is covered with a steri-strip and bandaged up.
===Tube thoracostomy===
*Recommended if thoracoscopy is not readily available and simple aspiration fails.<ref name="pmid17583135">{{cite journal| author=Makris D, Marquette CH| title=[Management of pneumothorax]. | journal=Rev Prat | year= 2007 | volume= 57 | issue= 5 | pages= 503-11 | pmid=17583135 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17583135  }} </ref>
{{#ev:youtube|9HZTpBIB9Fg}}


In case of penetrating wounds, these require attention, but generally only after the airway has been secured and a chest drain inserted. Supportive therapy may include [[mechanical ventilation]].
===Complications of the procedure===
*Injury to [[lung]] or [[mediastinum]]
* Excessive [[bleeding]] most likely from intercostal artery injury
* [[Neurovascular bundle|Neurovascular]] bundle injury
* [[Infection]]
* [[Bronchopleural fistula|Bronchopleural]] fistula
* Re-expansion pulmonary edema


Recurrent pneumothorax may require further corrective and/or preventive measures such as ''[[pleurodesis]]''. If the pneumothorax is the result of bullae, then bullectomy (the removal or stapling of ''bullae'' or other faults in the lung) is preferred. Chemical pleurodesis is the injection of a chemical irritant that triggers an [[inflammation|inflammatory]] reaction, leading to adhesion of the lung to the parietal pleura. Substances used for pleurodesis include talc, blood]], tetracycline and [[bleomycin]]. Mechanical pleurodesis does not use chemicals.  The surgeon "roughs" up the inside chest wall ("parietal pleura") so the lung attaches to the wall with scar tissue.  This can also include a "parietal" pleurectomy, which is the removal of the "parietal" pleura; "parietal" pleura is the serous membrane lining the inner surface of the thoracic cage and facing the "visceral" pleura, which lies all over the lung surface. Both operations can be performed using keyhole surgery to minimise discomfort to the patient.
===Video assisted thoracoscopic surgery===
*Morbidity associated with thoracotomy can be avoided by using VATS for persistent primary spontaneous pneumothorax..<ref name="pmid10893385">{{cite journal| author=Ayed AK, Al-Din HJ| title=The results of thoracoscopic surgery for primary spontaneous pneumothorax. | journal=Chest | year= 2000 | volume= 118 | issue= 1 | pages= 235-8 | pmid=10893385 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10893385  }} </ref><ref name="pmid15947341">{{cite journal| author=Sawada S, Watanabe Y, Moriyama S| title=Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: evaluation of indications and long-term outcome compared with conservative treatment and open thoracotomy. | journal=Chest | year= 2005 | volume= 127 | issue= 6 | pages= 2226-30 | pmid=15947341 | doi=10.1378/chest.127.6.2226 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15947341  }} </ref>
*VATS has lower morbidity, low invasiveness, and lower cosmetic issues compared to open [[thoracotomy]].  
*VATS is used in recurrent pneumothorax.
{{#ev:youtube|j-m5ZdGWeTA}}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Chest trauma]]
[[Category:Diseases involving the fasciae]]
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]

Latest revision as of 17:26, 10 April 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Surgery is the mainstay of treatment for the management of pneumothorax. The type of surgical modality opted depends on various conditions such as the size of the pneumothorax, underlying disease/procedure causing it and the type (open/closed vs simple/tension). Initially, airway, breathing and circulation should be maintained along with high concentration oxygen therapy. Tube thoracotomy used to be the preferred surgical procedure. Nowadays, video assisted thoracoscopic surgery (VATS) has widely replaced the open surgical procedure.

Indications

Surgical intervention is recommended for the management of pneumothorax.[1][2][3][4]

The choice of intervention depends on the following factors:

  • Size of the pneumothorax
  • Underlying disease/procedure causing pneumothorax
  • Associated comorbid condition
  • Type of pneumothorax (open/closed vs simple/tension)

Initial management

First aid

In all patients with chest trauma along with respiratory difficulty, following measures ahould be taken as the first line management:

  • Maintaining the airway patency
  • Assessment of breathing
  • Prevention of circulatory collapse
  • Oxygen therapy
  • Patient should be positioned upright, unless there is a contraindication to it, such as spinal injury.

Oxygen therapy

  • Immediate administration of 100% oxygen results in accelerated resorption of pleural air.[5][6]
  • Patients who have contraindications to simple aspiration or tube thoracotmy can be given high concentration supplemental oxygen.

Surgical techniques

Following surgical techniques are used to treat pneumothorax:[7][8][9]

  • Simple aspiration
  • Open thoracotomy
  • Video-assisted thoracoscopic surgery (VATS)

Surgery

  • Simple aspiration
  • Open thoracotomy used to be the most commonly used surgical procedure along with wedge resection of the leaking part of the lung.
  • Nowadays, video-assisted thoracoscopic (VATS) surgery has widely replaced the open surgical procedure for spontaneous pneumothorax.

Simple aspiration

Indications:

  • Mostly done in small spontaneous pneumothorax.[10]

Procedure:

{{#ev:youtube|Clw5H_t_u00}} Advantages:

Disadvantages:

  • Not recommended for larger size pneumothorax.

Tube thoracostomy

  • Recommended if thoracoscopy is not readily available and simple aspiration fails.[19]

{{#ev:youtube|9HZTpBIB9Fg}}

Complications of the procedure

Video assisted thoracoscopic surgery

  • Morbidity associated with thoracotomy can be avoided by using VATS for persistent primary spontaneous pneumothorax..[20][21]
  • VATS has lower morbidity, low invasiveness, and lower cosmetic issues compared to open thoracotomy.
  • VATS is used in recurrent pneumothorax.

{{#ev:youtube|j-m5ZdGWeTA}}

References

  1. ↑ Gudbjartsson T, Tómasdóttir GF, Björnsson J, Torfason B (2007). "[Spontaneous pneumothorax: a review article]". Laeknabladid. 93 (5): 415–24. PMID 17502684.
  2. ↑ Haynes D, Baumann MH (2010). "Management of pneumothorax". Semin Respir Crit Care Med. 31 (6): 769–80. doi:10.1055/s-0030-1269837. PMID 21213209.
  3. ↑ Galbois A, Zorzi L, Meurisse S, Kernéis S, Margetis D, Alves M; et al. (2012). "Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes". Acta Anaesthesiol Scand. 56 (4): 507–12. doi:10.1111/j.1399-6576.2011.02602.x. PMID 22191997.
  4. ↑ Tsai WK, Chen W, Lee JC, Cheng WE, Chen CH, Hsu WH; et al. (2006). "Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adults". Am J Emerg Med. 24 (7): 795–800. doi:10.1016/j.ajem.2006.04.006. PMID 17098099.
  5. ↑ Chadha TS, Cohn MA (1983). "Noninvasive treatment of pneumothorax with oxygen inhalation". Respiration. 44 (2): 147–52. PMID 6836190.
  6. ↑ Delius RE, Obeid FN, Horst HM, Sorensen VJ, Fath JJ, Bivins BA (1989). "Catheter aspiration for simple pneumothorax. Experience with 114 patients". Arch Surg. 124 (7): 833–6. PMID 2742485.
  7. ↑ Hilton P (2004). "Evaluating the treatment options for spontaneous pneumothorax". Nurs Times. 100 (28): 32–3. PMID 15311535.
  8. ↑ Chan SS (2000). "Current opinions and practices in the treatment of spontaneous pneumothorax". J Accid Emerg Med. 17 (3): 165–9. PMC 1725386. PMID 10819376.
  9. ↑ Vallee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M (1988). "Sequential treatment of a simple pneumothorax". Ann Emerg Med. 17 (9): 936–42. PMID 3137850.
  10. ↑ Swierzy M, Helmig M, Ismail M, Rückert J, Walles T, Neudecker J (2014). "[Pneumothorax]". Zentralbl Chir. 139 Suppl 1: S69–86, quiz S87. doi:10.1055/s-0034-1383029. PMID 25264729.
  11. ↑ Mendis D, El-Shanawany T, Mathur A, Redington AE (2002). "Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?". Postgrad Med J. 78 (916): 80–4. PMC 1742255. PMID 11807188.
  12. ↑ Ireland AJ, Dorward AJ (1993). "Management of pneumothorax. Consider ATLS guidelines". BMJ. 307 (6901): 444. PMC 1678430. PMID 8374466.
  13. ↑ Pallin M, Open M, Moloney E, Lane SJ (2010). "Spontaneous pneumothorax management". Ir Med J. 103 (9): 272–5. PMID 21186751.
  14. ↑ Miller AC, Harvey J (2001). "Pneumothorax: what's wrong with simple aspiration?". Chest. 120 (3): 1041–2. PMID 11555554.
  15. ↑ Devanand A, Koh MS, Ong TH, Low SY, Phua GC, Tan KL; et al. (2004). "Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review". Respir Med. 98 (7): 579–90. PMID 15250222.
  16. ↑ Chan SS (2008). "The role of simple aspiration in the management of primary spontaneous pneumothorax". J Emerg Med. 34 (2): 131–8. doi:10.1016/j.jemermed.2007.05.040. PMID 17961959.
  17. ↑ Chan, Stewart Siu-Wa (2008). "The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax". The Journal of Emergency Medicine. 34 (2): 131–138. doi:10.1016/j.jemermed.2007.05.040. ISSN 0736-4679.
  18. ↑ Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A (2002). "Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study". Am J Respir Crit Care Med. 165 (9): 1240–4. doi:10.1164/rccm.200111-078OC. PMID 11991872.
  19. ↑ Makris D, Marquette CH (2007). "[Management of pneumothorax]". Rev Prat. 57 (5): 503–11. PMID 17583135.
  20. ↑ Ayed AK, Al-Din HJ (2000). "The results of thoracoscopic surgery for primary spontaneous pneumothorax". Chest. 118 (1): 235–8. PMID 10893385.
  21. ↑ Sawada S, Watanabe Y, Moriyama S (2005). "Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: evaluation of indications and long-term outcome compared with conservative treatment and open thoracotomy". Chest. 127 (6): 2226–30. doi:10.1378/chest.127.6.2226. PMID 15947341.

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