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Pneumologie 2005; 59(12): 879-889
DOI: 10.1055/s-2005-919071
Serie: Pleuraerkrankungen (8)
© Georg Thieme Verlag Stuttgart · New York

Das Management des Spontanpneumothorax

The Management of Spontaneous PneumothoraxJ.-M.  Tschopp1 , W.  Frank2 , M.  Noppen3
  • 1Walliser Klinik für Lungenkrankheiten, Crans-Montana/Schweiz
  • 2Dr. W. Frank, Caputh/Deutschland
  • 3Interventional Endoscopy Unit, Academic Hospital AZ VUB, Bruxelles/Belgium
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Publication History

Publication Date:
27 December 2005 (online)

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Zusammenfassung

Das optimale Management des Spontanpneumothorax (SPTX) beinhaltet konservative wie interventionelle, internistische wie chirurgische Optionen, bleibt aber hinsichtlich Akutbehandlung und Präventivstrategien wegen unzulänglicher Datenlage z. T. umstritten. Nach aktuellen Konsensusempfehlungen kann beim gering ausgedehnten und asymptomatischen Pneumothorax die Spontanresorption abgewartet werden. Ausgedehnte und symptomatische Pneumothoraxes können zu etwa 2/3 mit einer einfachen Aspiration oder englumigen Kathetern (< 16 F) erfolgreich behandelt werden. Die höchste Erfolgsquote bieten mit bis zu 96 % weitlumige Drainagen (> 20 F), die beim Versagen der einfachen Absaugung und bei Patienten mit sekundärem SPTX insbesondere im fortgeschrittenen Lebensalter bereits primär zu empfehlen sind - am besten in Verbindung mit der Thorakoskopie (Pleuroskopie). Eine Präventivtherapie ist spätestens beim 1. Rezidiv und primär beim Nachweis prädisponierender pleuropulmonaler Veränderungen wie beim sekundären PTX indiziert. Die derzeitige Datenlage erlaubt bezogen auf die Effektivität als primärer Endpunkt keine klare Präferenz zwischen einer internistischen Talkpoudrage und chirurgischen Strategien (üblicherweise VATS-gestützte partielle Pleurektomie ± Bullaablation bzw. Parenchymresektion). Die Therapieentscheidung bleibt daher ermessensabhängig. Die internistische thorakoskopische Talkpleurodese ist jedoch als hocheffektiv und sicher in der Prävention von Rezidiven anzusehen. Hierfür sprechen auch die niedrigen Kosten, die praktisch denen einer konservativen Behandlung mittels weitlumiger Pleuradrainage entsprechen.

Abstract

The optimum management of spontaneous pneumothorax (SPTX) includes medical and surgical approaches but remains somewhat controversial due to inconclusive data background both in the treatment of the acute episode and preventive strategies. Current consensus recommendations suggest, that small and asymptomatic pneumothoraces can be managed conservatively by observation. Large and symptomatic pneumothoraces will respond to simple aspiration or small size catheter (< 16 F) insertion in about 2/3 of cases. Otherwise, and in secondary SPTX, particularly in the elderly patient, large size (> 20 F) chest drainage, optimally combined with thoracoscopy (pleuroscopy), is the treatment of choice allowing success rates up to 96 %. Preventive strategies are indicated after the first recurrence and when predisposing pleuropulmonary lesions as in secondary SPTX are evident. With efficacy as a primary endpoint, currently available data do not provide clear evidence-based preference criteria between medical thoracoscopic talc pleurodesis and surgical strategies (usually VATS-based partial pleurectomy ± parenchymal resection). Therefore selection of the appropriate procedure remains influenced by expert opinion. However simple talc poudrage under medical thoracoscopy has been shown to be highly effective, safe and cheap at a cost level virtually not exceeding that of large size chest drainage.

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Bereits publizierte Beiträge zu dieser Serie:

Dr. Wolfgang Frank

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14548 Caputh/Deutschland

Email: wolfgangfrank@gmx.net

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