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Pneumothorax

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Pneumothorax
Unnati D. Desai1, MD Abstract
Vinaya Karkhanis2, MD Itardvin coined the term pneumothorax in the year 1803 and
Jyotsna M. Joshi3, MD Laennec described its clinical features in 1819. It is defined as
the presence of air or gas in the pleural cavity. Pneumothorax
can be primary or secondary depending on underlying lung
1
Associate Professor condition. This can be further classified as spontaneous, iat-
2
Late Additional Professor rogenic and traumatic. Primary spontaneous pneumothorax
3
Professor and Head
Department of Pulmonary Medicine, described by Kjaergard in 1932; occurs in people without underly-
TN Medical College and BYL Nair Hospital, ing lung disease and in the absence of an inciting event. Secondary
Mumbai, India spontaneous pneumothorax (SSP) occurs in people with a wide va-
riety of parenchymal lung diseases. Occasionally, the amount of air
in the chest increases markedly when a one-way valve is formed by
Key words: an area of damaged tissue leading to a tension pneumothorax and
- Spontaneous can present as a medical emergency. Symptoms are related to the
- Traumatic
- Pigtail
amount of air present in the pleural cavity and underlying etiology.
- Bronchopleural fistula They typically include chest pain and shortness of breath. Diagnosis
by physical examination alone can be difficult or inconclusive par-
ticularly in smaller pneumothoraces and X-ray chest or computed
tomography (CT) scan is usually used to confirm its presence. Small
spontaneous pneumothoraces typically resolve without treatment
and require only monitoring. Larger pneumothoraces where patients
are symptomatic needs intervention with simple needle aspiration,
pigtail catheterization or intercostal drainage tubes.
Pneumon 2019, 32(4):144-154.

INTRODUCTION
The term pneumothorax was first coined by Itardvin, a student of
Laennec in 1803 and its clinical features are described by Laennec in 1819.
Correspondence to: It is defined as the presence of air or gas in the pleural space. Symptoms
Dr. Jyotsna M. Joshi, MD, Professor and Head
Department of Pulmonary Medicine, OPD bldg,
are related to the quantity of pneumothorax and the underlying etiology.
TN Medical College & BYL Nair Hospital, They typically include chest pain and shortness of breath. Diagnosis by
AL Nair Road, Mumbai Central, physical examination alone can be difficult or inconclusive particularly
Mumbai - 400008, India
Tel.: +2223003095 in smaller pneumothoraces and X-ray chest (CXR) or computed tomography
E-mail: drjoshijm@gmail.com (CT) is usually used to confirm its presence. Small spontaneous pneumo-
PNEUMON Number 4, Vol. 32, October - December 2019 145

thoraces typically resolve without treatment and require of the chest. Iatrogenic pneumothorax results from a
only monitoring. Larger pneumothoraces where patients complication of diagnostic or therapeutic intervention.3
are symptomatic need intervention with simple needle Common causes of primary and secondary spontaneous
aspiration, pigtail catheterization or intercostal drainage pneumothorax are enumerated in Table 1.
tubes. Bronchopleural fistula can be considered a special
case of complicated persistent pneumothorax, represent-
ing a challenging management problem associated with Spontaneous Pneumothorax
significant morbidity and even mortality. Spontaneous pneumothorax remains a significant
health problem because the recurrence rate is estimated
to be approximately 10%-20%, even after surgical manage-
TYPES OF PNEUMOTHORAX (Chart 1)
ment is performed.4 Spontaneous pneumothoraces, which
Air may leak from lung to pleural space in three situ- occur in the absence of thoracic trauma, are classified as
ations: (1) arising spontaneously by alveolar rupture; primary or secondary.5 A primary spontaneous pneu-
(2) introduced following trauma; (3) generated by gas mothorax (PSP) is a pneumothorax that occurs without
forming organisms. Accordingly pneumothorax can a precipitating event in a person who does not have any
be spontaneous and non-spontaneous. Spontaneous known lung disease. The incidence of primary spontane-
pneumothoraces occur without any preceding trauma or ous pneumothorax (PSP) in men varies geographically,
obvious precipitating causes. It is classified as primary or from 7.4 per 100,000 population per year in the United
secondary. Primary spontaneous pneumothorax described States to 37 per 100,000 population per year in the United
by Kjaergard in 1932; occurs in people without underlying Kingdom. The incidence is substantially less in women
lung disease and in the absence of any inciting event.1 than in men, ranging from 1.2 per 100,000 population per
Secondary spontaneous pneumothorax (SSP) occurs in year in the United States to 15.4 per 100,000 population
patients with pre- existing lung diseases such as COPD, per year in the United Kingdom.6 Primary spontaneous
cystic fibrosis, or pneumocystis carinii pneumonia.2 Non- pneumothoraces usually occurs in tall, thin men between
spontaneous pneumothoraces are also known as traumatic the ages of 20 and 30 years. Smoking increases a healthy
and are subdivided into non-iatrogenic and iatrogenic. male’s lifetime risk of developing a pneumothorax from
Non-iatrogenic pneumothoraces can develop following 0.1 to 12%. Height is thought to be a risk factor because
direct or indirect trauma, such as penetrating or blunt the pleural pressure gradient increases from the base
trauma to the chest, with air entering the pleural space to the apex of the lung. Consequently, apical alveoli in
directly through the chest wall; visceral pleural penetra- taller patients are subject to far greater distending pres-
tion; or alveolar rupture due to sudden compression sures, which may precipitate subpleural cyst formation.7

Pneumothorax

Spontaneous Non- spontaneous

(traumatic)

Primary Secondary Iatrogenic Non iatrogenic

No underlying Underlying Medical interventions Direct or indirect

Lung disease Lung disease such as like thoracocentasis, trauma
COPD, Cystic fibrosis, central line insertions,
Peumocystis carinii ventilator barotrauma

Chart 1. Classification of pneumothorax.

146 PNEUMON Number 4, Vol. 32, October - December 2019

Table 1. Causes of pneumothorax cystis carinii pneumonia. Due to the underlying lung
Common causes of Pneumothorax disease, they can present with compromised respiratory
Primary spontaneous Sub pleural Blebs reserves and can be life threatening also.9 The diagnosis
can usually be made on CXR, however CT is sometimes
Secondary spontaneous
necessary to differentiate pneumothoraces from large
Airway diseases COPD
thin-walled bullae.10
Cystic fibrosis
Status asthmaticus
Infection Necrotising pneumonias Non-Spontaneous/Traumatic
Granulomas Pneumothorax
Neoplastic diseases Carcinoma with ball valve They occur due to trauma which is either non-iatro-
obstruction
genic or iatrogenic in nature. A non-iatrogenic traumatic
Secondary to bronchial pneumothorax can result from either penetrating or
obstruction non-penetrating chest trauma.11 With penetrating chest
Tumor necrosis due to cytotoxic trauma; the wound allows air to enter the pleural space
or radiation therapy via the chest wall or via the visceral pleura from the
Interstitial lung diseases Idiopathic pulmonary fibrosis tracheobronchial tree. With non-penetrating trauma,
NSIP a pneumothorax may develop if the visceral pleura is
Histiocytosis X lacerated secondary to a rib fracture or dislocation. In
Lymphangiomyomatosis the majority of patients with pneumothorax second-
Dube syndrome ary to non-penetrating trauma, however, there are no
Sarcoidosis associated rib fractures. It is thought that the sudden
Pneumoconiosis chest compression abruptly increases the alveolar pres-
sure, which may cause alveolar rupture. Air then enters
Connective tissue disease Rheumatoid arthritis
the interstitial space and dissects toward either the vis-
scleroderma
ceral pleura or the mediastinum to produce mediastinal
ankylosing spondylitis
emphysema. A pneumothorax results when either the
Marfan’s syndrome visceral or mediastinal pleura ruptures. The incidence
Ehlers Danlos syndrome of iatrogenic traumatic pneumothorax is also high. In a
Iatrogenic Central venous catheterization study of 3430 patients in 12 intensive care units in France,
Thoracocentesis, pleural biopsy 3.0% developed a pneumothorax. The etiologies of the
Transthoracic, transbronchial pneumothoraces in this study were mechanical ventilation
biopsies in 42, central venous catheters in 28, thoracentesis in 21,
Intercostal block and miscellaneous in 3.12 Currently, the leading cause of
Use of high PEEP iatrogenic pneumothorax is transthoracic needle aspira-
Non iatrogenic Blunt and penetrating injuries tion. The incidence of iatrogenic pneumothorax with this
such as procedure is about 25%, and about 10% of the patients
Rib fracture Rupture of bleb, with pneumothorax receive tube thoracostomy.13 This
Rupture of bronchus, lung tear procedure is more likely to result in a pneumothorax if
the patient has COPD, if the lesion is deep within the lung,
or if the angle of the needle route is wide.14
Male gender, tall stature, low body weight, and failure to Pneumothorax is also classified as closed, open, and
stop smoking have been associated with an increased valvular based on the pathology. In a closed pneumo-
risk of recurrence.8 The risk of recurrence is reduced in thorax the communication between the pleura and
patients who undergo chemical pleurodesis. Secondary lung seals off as the lung collapses and does not reopen.
spontaneous pneumothorax (SSP) occurs in patients with Pleural pressures remain negative and air is gradually
pre- existing lung disease such as chronic obstructive reabsorbed. An open pneumothorax has a persistent ‘air
pulmonary disease (COPD), cystic fibrosis, or Pneumo- leak.’ Pleural pressures equal atmospheric pressure and
PNEUMON Number 4, Vol. 32, October - December 2019 147

lung cannot re-expand. The term open is also applied to entity called occult pneumothorax has been defined. It
pneumothorax resulting from penetrating wound of the is a pneumothorax that was not suspected clinically nor
chest wall. A valvular pneumothorax occurs when the was evident on the plain radiograph but rather identified
communication between the pleura and lung persists, on computed tomography scan.
but is small and act as a one- way valve, which allows air
to enter during inspiration but prevents it from escaping
during expiration. Tension pneumothorax usually results CLINICAL PRESENTATION
and pleural pressures are always positive. Pleuritic chest pain and dyspnoea are main symptoms.
Other types of pneumothorax described in literature In patients with underlying lung disease, dyspnoea is
are as follows. Tension pneumothorax is a pneumothorax severe and significant hypoxaemia can occur, even with
complicated by cardio respiratory embarrassment due to a small pneumothorax. Arterial blood gas measurements
decreased cardiac output. There will be mediastinal shift typically show an increase in the alveolar–arterial oxygen
to opposite side. The intrapleural pressure exceeds atmo- gradient and acute respiratory alkalosis. Patients with a
spheric pressure throughout expiration and often during small pneumothorax (<15% of the hemithorax) often have
inspiration as well. Patients present with tachycardia, a normal physical finding on examination. Tachycardia
tachypnea, cyanosis, diaphoresis and marked hypoxemia is the most common physical finding. In patients with
with respiratory alkalosis or acidosis. A pneumothorax a larger pneumothorax, examination shows decreased
may be associated with a bronchopleural fistula. Bron- movement of the chest, a hyper-resonant percussion
chopleural fistulas (BPFs) are communications between note, tracheal shift to opposite side, and decreased or
the bronchial tree and the pleural space. They represent absent breath sounds on the affected side. Coin test can
a challenging management problem and are associated be demonstrated. The physical findings are often subtle
with significant morbidity and even mortality. The term and may be masked by the underlying lung disease,
bronchopleural fistula is often used synonymously with particularly in patients with COPD. Pneumothorax may
open pneumothorax or ‘persistent air leak’ but constitutes be associated with complications (Table 2). In case of a
a distinct clinical entity. A large bronchopleural fistula tension pneumothorax, there will be cardio respiratory
facilitates transmission of infection from air passages embarrassment; BPF/large pneumothorax is associated
into the pleural space and empyema results. Some use with amphoric bronchial breath sounds on auscultation.
terminologies as alveolar pleural fistula (APF) and bron- A hydropneumothorax may have the signs denoted by
chopleural fistula (BPF).APF (synonym: parenchymal- 4S i.e. straight line dullness, shifting dullness, succu-
pleural fistulae), defined as persistent air leak for more sion splash and sound of coin percussion. Associated
than 24 hours after the development of an abnormal mediastinal emphysema (pneumomediastinum) can
communication between the pulmonary parenchyma cause subcutaneous emphysema, palpable crepitus and
distal to a segmental bronchus and the pleural space. Hamman’s sign. It is characterized by precordial systolic
This is best distinguished from a BPF, which is a commu- crepitations and diminution of heart sounds.
nication between the lobar or segmental bronchi and
the pleural space, since aetiology and management are
different.15 BPF presents with cough, copious purulent
sputum and amphoric bronchial breath sounds on aus- Table 2. Complications of pneumothorax
cultation. Methylene blue injected in the pleural space is Complications of pneumothorax
seen in the expectorated sputum (methylene blue test).
Tension pneumothorax
CT with maximum intensity projection (MIP) images
help to identify presence of BPF. The term complicated Mediastinal emphysema
pneumothorax is suggested for pneumothorax with Bronchopleural fistula
fluid (hydropneumothorax), pus (pyopneumothorax) or Chronic pneumothorax
blood (heamopneumothorax). All these conditions re- Loculated pneumothorax
quire chest drainage as an initial management. A chronic Pyopneumothorax
pneumothorax results from formation of ‘pleural peel’
Persistent air leak
due to associated empyema and a persistent air leak.
With increasing utilization of advanced radioimaging an Re-expansion pulmonary edema
148 PNEUMON Number 4, Vol. 32, October - December 2019

RADIOLOGY
Various radiodiagnostics helps in diagnosis and man-
agement of pneumothorax. The diagnosis of pneumo-
thorax can be confirmed in the majority of cases on an
CXR –Postero-Anterior (PA) view (Figure 1) which also
allows an estimation of the pneumothorax size.16 Air in
the pleural space accumulates in the highest part of the
thoracic cavity because air is less dense than the lung. A
definitive radiologic diagnosis of pneumothorax can only
be made when a visceral pleural line is evident as a faint
but sharply defined line separating the lung parenchyma
from the remainder of the thoracic cavity, which is clear
and devoid of lung markings. An enlarged hemithorax,
a depressed diaphragm, and a shifted mediastinum do
not mean that a tension pneumothorax is present. In
case of small pneumothoraces full expiratory film can
be obtained in upright position. With full expiration the
lung volume is reduced, and therefore the percentage
of the hemithorax occupied by air increases, making Figure 2. X-ray chest postero-anterior view showing loculated
identification of the visceral line much easier. Another pneumothorax.
option is to obtain lateral decubitus film with the side of
the suspected pneumothorax superior. This increases the
distance between the lung and the chest wall. Chronic pneumothoraces into small or large depending on the
lung conditions give rise to adhesions between parietal degree of lung collapse; however, they differ in their
and visceral pleura restricting lung collapse. In such situ- absolute definition. The BTS guidelines state that a 2 cm
ations, a pneumothorax may be loculated and localized radiographic pneumothorax extending throughout the
rather than spreading throughout the pleural space; thus lung field on a CXR-PA occupies approximately 50% of the
altering the radiologic appearance of pneumothoraces hemithorax. When the visible rim between the lung margin
(Figure 2). Both the BTS and ACCP guidelines divide and the chest wall is less than 2 cm the pneumothorax is
defined as small, and when the rim is greater than 2 cm
it is termed large. The ACCP define a pneumothorax as
small when the distance from apex to cupola is less than
3 cm, and large when the distance is greater than 3 cm.17
Ultrasonography has been shown to have high sensitivity
(95%), specificity (100%), and diagnostic effectiveness
(98%) for pneumothorax when compared with CT as a
standard. It is useful for detecting small collections not
seen on plain films and the extent of the air collection can
be estimated by tracking the presence of the ‘sliding lung
sign’ over the chest wall. Experience in the use of ultra-
sound for this indication is required to be confident in its
application. It is difficult or impossible to visualize pleural
structures with ultrasound through surgical emphysema.
A typical ‘comet tailing’ phenomenon of the movement
of the lung tissue against the pleura during respiration
can be seen in bullous disease, but is absent when the
Figure 1. X-ray chest postero-anterior view showing pneu- lung is collapsed as in pneumothorax.18
mothorax. CT thorax (Figure 3) is gold standard for confirmation
PNEUMON Number 4, Vol. 32, October - December 2019 149

Figure 3. Computed Tomography thorax showing pneumo-

thorax.
Figure 4. Computed Tomography thorax showing double
wall sign with bulla.
of a pneumothorax. It also differentiates a pneumothorax
from complex bullous lung disease; when aberrant chest
tube placement is suspected. It allows definitive diagnosis
of other pleural and lung pathologies and should be con-
sidered early when doubt exists. CT scanning is regarded
as the best means of establishing the size of a pneumo-
thorax.19 CT also help in distinction of pneumothorax
from emphysematous bullae. The bullae of emphysema
can be very large and, when situated in the periphery of
the lung, can mimic a loculated pneumothorax. A chest
drain inserted into a bulla in the mistaken belief that it
is a pneumothorax is not uncommon. The lack of a lung
edge, the round nature of the bulla, and the presence of Figure 5a. Measurement of pneumothorax.
multiple bullae elsewhere in the lung are all clues to the
diagnosis. In difficult cases, CT is helpful in distinguishing
between the two. The double wall sign is a valuable sign
to help distinguish a pneumothorax from adjacent giant
bulla20 (Figure 4). This sign occurs due to the air outlin-
ing both sides of the bulla wall parallel to the chest wall.
Another classical differential diagnosis not be missed
is air-filled stomach or bowel in the chest secondary to
diaphragmatic hernia. Ventilation scintigraphy can be
used to localize the air leak in patients presenting with
Figure 5b. Measurement of pneumothorax.
persistent air leak.21

MEASUREMENT OF PNEUMOTHORAX (Figure 5a, small rim of air around the lung, 2) Moderate: Lung col-
lapsed half way towards the heart border, 3) Complete:
b, c)
Airless lung, separate from the diaphragm. The volume
The size of a pneumothorax, in terms of volume is of pneumothorax approximates to the ratio of the cube
difficult to assess accurately from a chest radiograph of the lung diameter to the hemithorax diameter. Thus,
which is a two dimensional image. In 1993 guidelines one can estimate the degree of collapse by measuring
pneumothorax was classified into 3 groups: 1) Small: A an average diameter of the lung and the hemithorax,
150 PNEUMON Number 4, Vol. 32, October - December 2019

of pneumothorax. Rhea and associates have described

an alternate method for estimating the percentage of
collapse. With their method; the average interpleural
distance is calculated. This is the mean of the maximum
apical interpleural distance and two measurements of
interpleural distances in the mid points of the upper and
lower halves of the lung. When this average interpleural
distance is obtained, a scale is used to calculate the per-
Figure 5c. Measurement of Pneumothorax. centage of the lung that is collapsed.

MANAGEMENT
cubing these diameters, and finding the ratios. For ex-
ample, a pneumothorax of 1cm on CXR-PA film occupies Treatment of pneumothorax (Chart 2) depends on
about 27% of hemithorax volume; i.e. if the lung is 9cm the size, type of pneumothorax, presence of dyspnea,
in diameter and the hemithorax 10 cm (103- 93/103= state of underlying lung, associated complications and
27%). This is commonly used method for quantification recurrence. Various treatment modalities are simple

Chart 2. Management of pneumothorax.

PNEUMON Number 4, Vol. 32, October - December 2019 151

needle aspiration, pigtail catheterization or intercostal in all PSP requiring intervention. A recent Cochrane report
drainage tubes, thoracoscopy or surgery (Table 3). A be- in 2007 systematically reviewed all published randomised
nign spontaneous pneumothorax that is small (less than control trials that compared simple aspiration versus
15%) can be treated with observation alone. The rate of intercostal tube drainage for spontaneous pneumotho-
absorption of air is about 1.25% of the total radiographic rax in adults.23 It concluded that there was no difference
area per day, so that a 50% pneumothorax may take in the immediate success rate of the procedure, early
4-6 weeks to resolve. Administrating large quantities of failure rate, or one year success rate between the two
oxygen can decrease the rate of resolution. As the rate of groups. However, simple aspiration conferred a number
absorption is very slow, for larger pneumothorax, simple of advantages including; lower percentage of patients
aspiration with small canula or intercostal drainage tube hospitalised, decreased duration of stay, and the fact
should be used. The role of needle aspiration is limited to it is a relatively simple procedure to perform. There has
emergency treatment of tension pneumothorax to be fol- been extensive debate regarding the optimal size of the
lowed as quickly as possible by intercostal tube drainage intercostal drain. Evidence now suggests that small-bore
(ICD). Large spontaneous pneumothorax, SSP, traumatic pleural catheters are as effective as larger bore intercostal
pneumothorax, complicated and recurrent pneumotho- drains in the treatment of spontaneous pneumothorax.
rax is drained by intercostal tube drainage. Precautions No significant correlation has been found between drain
should be taken so that there is gradual withdrawal of size and complication rate, recurrence rate, and length
air especially in longstanding larger pneumothoraces, of hospital stay. However, small caliber catheters may
to avoid re-perfusion pulmonary edema. Re-expansion not be suitable in the presence of pleural fluid (where
pulmonary edema is due to increased permeability of they could block) or a large or persistent air leak (owing
the pulmonary vasculature which occurs following tho- to inadequate re-expansion). ICD can be connected to
racocentesis or chest tube placement. For drainage of a Heimlich valve,24 a chest drainage bag or an under-
pneumothorax, ICD is usually inserted between the 4th water seal drainage bottle (Figure 6). Aurosac, used for
and 7th intercostal spaces and between the mid and
anterior axillary lines (The “Safe Triangle”).22 The tip of the
tube should be directed upwards. It is a fallacy that drain
must be put in a basal position to drain fluid and apical
position to drain air. The anterior approach in the second
interspace transfixes two major accessory respiratory
muscles- the pectoralis major and minor. In case an apical
drain is required for an apical loculation of air, the true
apical approach above the scapula into the first interspace
posteriorly should be preferred. BTS and ACCP have both
published guidelines for the treatment of PSP; however
they give contradictory recommendations for first-line
treatment. The ACCP17 advises that simple aspiration is
rarely appropriate in the treatment of PSP, while the BTS
recommend simple aspiration as the first-line treatment Figure 6. Intercostal Drainage with underwater seal.

Table 3. Treatment modalities and approach in management of pneumothorax

Primary Secondary Iatrogenic Traumatic
Observation <20% - <30% -
Tube thoracostomy >20% All >60% All
Small tube with one-way valve - - 20-60% -
Pleurodesis Recurrence × 3 Recurrence × 2-3 - -
Persisting (2 weeks)
Surgical exploration and repair - - Persisting Persisting
152 PNEUMON Number 4, Vol. 32, October - December 2019

drainage of urine is easily available and can be used as

a pneumosac25,26 (Figure 7). They are effective and have
the advantage of being less bulky, cheap and allow early
mobility. Drains are removed after the lung has expanded
fully and does not collapse on clamping and fluid drainage
if any is less than 50cc of serous fluid in 24 hours. Patients
with bronchopleural fistula needs prolonged drainage. In
postoperative leaks, BPFs with small to moderate air leak
requiring prolonged drainage or after accidental slipping
or removal of ICDs, where pleuro- cutaneous fistula is
formed; stoma bags with non-return valves can be used
for drainage27 (Figure 8). It helps in reducing duration of
hospital stay and chance of infection. The role of Asherman
chest seals, sterile occlusive dressing for treating open
pneumothorax and preventing tension pneumothorax
in chest injuries from gun shots, stab wounds and other
penetrating chest trauma is studied.28 This has a same
principle as Helmlich valve except there is no intrathoracic
component to this device and is just adherent to the chest
wall. This could be successfully used in the management
of a complicated post- operative leak. Drainable stoma
bags also offer a non-return valve mechanism, do not Figure 8. Stoma bag with non-return valve used for drainage
have an intra-thoracic component and are just adherent of pneumothorax.
to the chest wall. For selected patients with persistent air
leak not amenable to surgical intervention, identification
targeted radiotherapy can be considered. This seals the
of air leak site with ventilation scintigraphy followed by
leak via radiation induced fibrosis.29
Associated BPF is essentially treated by tube drainage;
closure of the BPF being the long term goal. Surgical
therapy in the form of decortications and closure of BPF
with a transposed muscle flap, the pericardial fat pad, or an
omental pedicle flap, lobectomy, pleura pneumonectomy
or the thoracoplasty are performed depending on patient’s
condition and the surgeon’s skills. Bronchoscopic closure
of smaller BPFs with tissue glue, fibrin glue, gel foam, lead
plugs, balloon catheter or autologous blood patch can
be attempted. The appropriate time for surgery is not
known, and it is possible that lung expansion may occur
after several weeks of tube drainage. Hence prolonged
tube drainage is an alternative approach in selected cases.
Patients with BPF requiring ventilator support should be
put on high frequency jet ventilators to decrease flow
through bronchopleural fistula.

Role of Pleurodesis
The aim of pleurodesis is to achieve symphysis be-
tween visceral and parietal pleural layers, in order to
Figure 7. Urosac as a drainage bag (pneumosac). prevent accumulation of air in the pleural space in cases
PNEUMON Number 4, Vol. 32, October - December 2019 153

of recurrent pneumothorax or in patients with persistant chanically with pleural abrasion or partial pleurectomy.
air leaks following chest tube drainage. The complete Flourescence- enhanced autoflourescence thoracoscopy
removal of air from the pleural space is needed to keep is a new technique; which identify lesions not visible at
the visceral and parietal pleural layers in close contact. In routine thoracoscopy.
a prospective randomized study Almind et al30 compared
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