Spontaneous pneumothorax: remaining controversies.

Despite many guidelines issued by national and professional societies, a detailed literature survey between the late 1940s and 2010 clearly demonstrates that several aspects of pneumothorax pathogenesis and treatment still remain controversial. Related to pathogenesis of primary pneumothorax, the current manuscript highlights why further studies are needed to explain 1) mechanism of the oxygenation impairment in presence of a large pneumothorax; 2) oxygenation differences between age and sex-matched patients with a pneumothorax of the same size; and 3) sequence of events in tension pneumothorax. Concerning the overall therapeutic approach, video-assisted technology provides a minimally invasive operative treatment. For this reason methods of recurrence prevention are now shared between interventional pulmonologists and thoracic surgeons. Although a significantly higher recurrence rates was reported in patients with primary spontaneous pneumothorax after simple pleural drainage versus thoracoscopic talc poudrage, (34% and 5% respectively), such a policy is still not widely adopted. Certain concerns that relate to the use of talc in relapse prevention are also discussed, showing that they are mostly dependent on the type of the talc used. Concerning secondary pneumothorax, specificities of different forms related to diagnostics and therapeutic approach are also pointed out. Lung tuberculosis as the underlying cause is particularly addressed, due to the challenge of the timely recognition of specific lesions and prompt initiation of the antituberculous medical treatment . Similarly, lung cancer is mentioned as a possible underlying cause in patients with delayed lung expansion.