Tratamento do pneumotórax espontâneo primário em adultos

Abstract

Introduction: A primary spontaneous pneumothorax (PSP) is traditionally defined as a pneumothorax that presents without a precipitating external event, in the absence of clinical lung disease. The majority of affected patients have unrecognized pulmonary abnormalities (primarily subpleural blebs) that predispose to the condition. It has a higher prevalence in men than in women (three to six times more when spontaneous). Subpleural blebs can develop, but smoking and genetic predisposition may also play a role. Objective: to discuss the treatment of primary spontaneous pneumothorax in adults. Methodology: Literature review from Scielo, PubMed and VHL databases, from March to May 2024, with descriptors; "Spontaneous pneumothorax", "adults" AND "treatment". Articles from 2019-2024 (total 41) were included, excluding other criteria and choosing 5 full articles. Results And Discussion: After radiographic identification, clinicians must quickly estimate patient stability and symptom burden. The primary focus of is to alleviate symptoms and stop the air leak, rather than rapidly expanding the lung to achieve radiographic resolution (i.e., "treat chest x-ray"), which does not necessarily stop the leak. Size assessment, although reasonable, is less important in determining a treatment strategy. All patients with PSP should receive resuscitation focused on airway stabilization (if necessary), supplemental oxygen to treat hypoxemia (if present), and provision of adequate analgesia (if indicated). PSP is rarely fatal, and the associated shortness of breath is typically mild with little discomfort; some patients may also experience pain.  Subsequent treatment is directed toward deciding whether air needs to be removed from the pleural space and, if so, by what means.  The patient is considered stable: respiratory rate <24 breaths per minute; heart rate <120 and >60 beats per minute; Normal blood pressure (not defined); Ambient air oxygen saturation >90% and ability to speak in complete sentences. For most patients with PSP who are clinically stable and have minimal dyspnea after adequate analgesia, we recommend conservative management (e.g., monitored observation) rather than aspiration or catheter/chest tube insertion. The patient should be observed and a repeat chest x-ray obtained four to six hours later. If the x-ray demonstrates improvement or rules out progression of the pneumothorax and the patient has access to emergency medical services, the patient may be discharged home. For most patients with PSP who are clinically stable and have moderate or significant dyspnea after adequate analgesia, we suggest a simple aspiration drainage procedure (typically with a catheter) rather than a catheter or thoracic thoracostomy. For unstable patients, severe dyspnea, tension pneumothorax, bilateral pneumothorax, concomitant hemothorax, pleural effusion requiring drainage, or complex locked pneumothorax, a definitive drainage procedure (e.g., catheter or chest tube thoracostomy) is indicated instead of a simple aspiration procedure. The justification for this strategy is based on the supposed high probability of clinical worsening and the greater risk of recurrence in these patients. Conclusion: Most pneumothoraces resolve with these initial thoracostomy management strategies. Intervention to prevent recurrence depends on whether it is a first or recurrent event, the expected risk of recurrence after each event, and the patient's values ​​and preferences.  After treatment, patients should be evaluated in approximately two to four weeks as outpatients.