Summary of guidelines on PSP

Guidelines		Grade of recommendation	Level of evidence
2. Diagnostic strategy, assessment, follow-up method
R 2.1	The group suggests to consider a PSP as large when there is a visible rim along the entire axillary line, ≥ 2 cm between the lung margin and the chest wall at the hilum level.	Conditional recommendation	Low
R 2.2.1	The group proposes that, although the chest CT-scan is superior to CXR for the positive diagnosis of PSP, assessing its size and ruling out a differential diagnosis, its cost, radiation exposure and accessibility do not support its use as a first-line examination.	Expert opinion
R 2.2.1bis	The group proposes to perform frontal CXR acquired in inspiration, without expiratory films, in case of suspected PSP to diagnose it and assess its size.	Expert opinion
R 2.2.2	The group recommends to perform a low-radiation chest CT-scan in case of persistent diagnostic doubt despite the investigations already performed.	Strong recommendation	Low
R 2.2.3	The group suggests not to solely base the diagnosis of PSP on chest ultrasound in the absence of signs of severity.	Conditional recommendation	Low
R 2.3	The group proposes not to solely base on chest ultrasound to assess the size of a PSP.	Expert opinion
	No data in the literature allow concluding on the value of chest ultrasound to rule out the differential diagnoses of PSP.	NA
R 2.4	The group suggests to perform chest ultrasound for the diagnosis of residual pneumothorax in patients drained for pneumothorax. In untrained teams or teams with limited access to ultrasound, CXR may be used as an alternative.	Conditional recommendation	Moderate
3. Therapeutic management
Medical treatment of PSP
R 3.1.1	The group recommends to consider a pneumothorax as tension when it results in respiratory distress or hemodynamic failure.	Strong recommendation	Low
R 3.1.2	In case of confirmed tension PSP, the group recommends: - to perform emergency chest decompression, - through an anterior (mid-clavicular line at the 2nd intercostal space) or axillary (mid-axillary line at the 4th intercostal space) approach, - using dedicated equipment (thoracentesis kit) or any other needle aspiration device available to the operator.	Strong recommendation	Low
R 3.2.1.1	The group recommends to remove air from the pleural space in patients with large PSP without signs of immediate severity.	Strong recommendation	Moderate
R 3.2.1.2	The group recommends to use either needle aspiration or chest tube drainage as first-line treatment in patients with large PSP without signs of immediate severity to remove air from the pleural space. Surgery should not be performed as first-line treatment except in specific situations (see chapter on surgery).	Strong recommendation	Moderate
R 3.2.1.4	The group recommends to prefer the outpatient management in patients with large PSP without signs of immediate severity.	Strong recommendation	Moderate
R 3.2.1.4bis	The group recommends an outpatient management based on needle aspiration or on the placement of a mini-chest tube and a one-way valve, if the following criteria are met: - the patient is stable after removal of the intrapleural air, - and a dedicated outpatient care system is previously organized, - and a consultation with chest ultrasound or CXR is scheduled at 24 − 72 h to follow the evolution.	Strong recommendation	Low
R 3.2.1.4ter	The group proposes to manage PSP on an outpatient basis only if all of the following conditions are met: - The patient has the procedure to be followed in case of problem 24 h a day, 7 days a week, with the appropriate phone numbers including calling the SAMU-Center 15 (provision of a standardized written document) - Ensuring that the patient has understood the guidelines in case of problems - The patient should not stay alone for the first 24 − 48 h after discharge - The patient should be able to access a medical facility within 1 h, regardless of the means of transportation, in the event of deterioration, The time of discharge does not matter if all of the above criteria are met (i.e. a deep night discharge is possible).	Expert opinion
R 3.2.2	The group recommends to manage conservatively (monitoring) patients with small PSP and without signs of poor tolerance.	Strong recommendation	Low
R 3.2.2bis	The group recommends to implement an outpatient, conservative management for small PSP if the following criteria are met: - the patient is clinically and radiologically stable after 4 h, - and a dedicated outpatient care system is previously organized, - and a consultation with chest ultrasound or CXR is scheduled at 24 − 72 h to follow the evolution.	Strong recommendation	Low
R 3.4.1	In case of simultaneous bilateral PSP, regardless of its size, the group proposes to contact as soon as possible an expert center, i.e. a center with a thoracic surgery department, to discuss the treatment approach and consider a possible transfer to this center.	Expert opinion
R 3.4.1bis	In case of simultaneous bilateral PSP with signs of severity or large PSP, the group proposes to perform emergency chest tube drainage.	Expert opinion
R 3.4.2	In case of haemopneumothorax, regardless of its size, the group proposes to contact as soon as possible an expert center, i.e. a center with a thoracic surgery department, to discuss the treatment approach and consider a possible transfer to this center.	Expert opinion
R 3.4.2bis	In case of haemopneumothorax with signs of severity or large haemopneumothorax, the group proposes to perform emergency chest tube drainage.	Expert opinion
R 3.4.3	In case of PSP with confirmed pleural adhesion, regardless of its size, the group proposes to contact as soon as possible an expert center, i.e. a center with a thoracic surgery department, to discuss the treatment approach and consider a possible transfer to this center.	Expert opinion
R 3.4.3bis	In case of PSP with confirmed pleural adhesion and signs of severity or large PSP, the group proposes to perform emergency chest tube drainage.	Expert opinion
R 3.5.1	The group suggests to use a small-bore chest tube (≤ 14 Fr) for chest drain insertion of PSP.	Conditional recommendation	Low
R 3.5.2	The group suggests to obtain an ultrasound visualization before performing needle aspiration or chest tube drainage using the anterior or axillary approach, in order to reduce the risk of complications.	Conditional recommendation	Low
	The literature does not provide sufficient data to choose between the anterior and axillary approach.	NA
R 3.5.3	The group recommends to initiate drainage with passive air removal (one-way valve or free flow) and to start suction at − 5 to − 20 cm H2O as a second step only if reexpansion is not achieved	Strong recommendation	Moderate
R 3.5.4	In patients under chest tube suction, in the absence of bubbling and with lung re-expansion, the group proposes to allow a free flow for 6 − 8 h before chest tube removal to avoid a new drainage procedure in case of early recurrence.	Expert opinion
	The data in the literature do not allow concluding on the interest of performing a clamping trial before chest tube removal once the lung is re-expanded.	N/A
R 3.6.1	The group recommends not to systematically administer oxygen therapy in patients treated for PSP.	Strong recommendation	Moderate
R 3.6.2	The group suggests not to prescribe strict bed rest in PSP patients.	Conditional recommendation	Low
R 3.6.2bis	The group proposes to limit intense or contact sports activities until complete resolution of the pneumothorax.	Expert opinion
R 3.7	To reduce the risk of tension pneumothorax, the group proposes to arrange the transportation of patients with drained SP as follows: - In the absence of bubbling: with a chest tube attached to a one-way valve; - In the presence of bubbling: by continuing continuous suction with fitting of a stand-alone suction pump connected to the 3-compartment drainage system.	Expert opinion
Surgical approach of PSP
R 3.8.1	The group recommends to perform pleurodesis after a second episode of PSP (ipsi- or contralateral) regardless of the management method used for the first episode.	Strong recommendation	Low
R 3.8.1bis	The group suggests to perform pleurodesis through the first episode of PSP in the following cases: - Hemopneumothorax, - Simultaneous bilateral PSP, - Presence of signs of severity, - Persistent air leaks or persistent pneumothorax despite aspiration drainage, - Risky occupation or leisure activity (pilot, isolated workplace, etc.), - PSP occurring during pregnancy (surgery after birth),	Conditional recommendation	Low
R 3.8.1ter	The group proposes to respond to the patient’s request for surgery after a first episode of PSP after informing him/her of the risks and benefits of pleurodesis.	Expert opinion
R 3.8.2	If pleurodesis is indicated in a patient with PSP, the group recommends to use a minimally invasive technique.	Strong recommendation	High
R 3.8.3	The group suggests to induce mechanical and/or chemical pleurodesis as a first-line procedure rather than to perform pleurectomy if there is a indication for pleurodesis surgery.	Conditional recommendation	Moderate
Analgesic treatment of PSP
R 3.3.1	The group recommends to perform local anesthesia of the chest wall before removing air from the pleural space, either through needle aspiration or chest tube drainage.	Strong recommendation	Low
R 3.3.2	The group recommends to base pain management on multimodal analgesia in patients medically treated for PSP (needle aspiration, drainage, conservative management).	Strong recommendation	Low
R 3.3.3	The group recommends to use a multimodal analgesic approach including local cold treatment to reduce pain associated with large-bore chest tube removal (≥ 16 Fr) or in patients operated on for PSP.	Strong recommendation	Low
R 3.3.3bis	The group proposes to use analgesia during small-bore chest tube removal, but the current literature does not allow defining a preferred analgesia. Dedicated studies are needed.	Expert opinion
R 3.8.4.1	The group suggests to use a perioperative locoregional analgesia technique in pneumothorax surgery to reduce postoperative pain.	Conditional recommendation	Moderate
R 3.8.4.1bis	The group suggests to prefer peripheral locoregional analgesia (paravertebral block, serratus plane block, intercostal block) over thoracic epidural analgesia.	Conditional recommendation	Moderate
R 3.8.4.2	The group suggests to use non-steroidal anti-inflammatory drugs for a few days after pneumothorax surgery in case of insufficient locoregional analgesia and non-morphine systemic analgesia to reduce or prevent the use of morphine. The use of non-steroidal anti-inflammatory drugs does not seem to decrease the efficacy of surgical pleurodesis.	Conditional recommendation	Moderate
4. Follow-up procedures
R 4.1	The group recommends to offer smoking (and any other smoked substances) cessation support to patients to minimize the risk of PSP recurrence.	Strong recommendation	High
R 4.2	The group proposes to schedule a consultation with a pulmonologist after each episode of PSP to detect any underlying lung disease.	Expert opinion
R 4.2bis	The group suggests not to systematically perform a chest CT-scan after a PSP, except in case of bilateral or recurrent PSP or in a context suggestive of an underlying disease (secondary spontaneous pneumothorax).	Conditional recommendation	Moderate
R 4.3.1	The group proposes to wait at least two weeks after PSP resolution before flying.	Expert opinion
R 4.3.1bis	The group proposes to perform pleurodesis from the first episode of PSP in aircrew.	Expert opinion
R 4.3.2	The group proposes to perform pleurodesis after the first episode of pneumothorax in sport skydivers and to perform a chest CT-scan and PFT before resuming their activity.	Expert opinion
R 4.3.3	The group proposes to strongly contraindicate scuba diving in patients with a history of PSP, even if the patient has undergone pleurodesis, due to the risk of fatal barotrauma.	Expert opinion
R 4.3.4	The group proposes not to limit sports resumption/practice after an episode of PSP.	Expert opinion
R 4.3.5	The group proposes not to limit the practice of wind instruments after an episode of PSP.	Expert opinion