Which of the following approaches is/are currently acceptable for the management of spontaneous pneumothorax?

A. Chest tube replacement alone for the patient with a first episode.

C. Video-assisted thoracic surgery (VATS) bleb excision and pleurodesis for recurrent pneumothorax on the same side.

D. Thoracotomy with bleb excision and pleurodesis for unilateral recurrent pneumothorax.

E. Operation after a first episode in an airline pilot.

DISCUSSION: Primary spontaneous pneumothorax typically occurs in young patients with congenital blebs at the apices of the lungs. Rupture of these blebs causes pneumothorax, which recurs in about 30% of patients. Standard care on initial presentation is chest tube placement alone. Operation traditionally has been performed during the initial episode only if there is prolonged air leakage (longer than 7 days); in patients with bilateral pneumothorax; those who live in an area where prompt medical care, if needed, is not available; and those frequently exposed to extremes of pressure (e.g., airline pilots). Both VATS and thoracotomy approaches to excision of blebs and pleurodesis have been shown to be effective. The availability of the apparently safer VATS approach has led some to favor earlier operation.