Pneumothorax
Collapsed Lung — Diagnosis & Surgical Treatment, London

A pneumothorax happens when air escapes into the space between the lung and the chest wall, called the pleural space. As air builds up there, the pressure stops the lung expanding and it collapses — partly or completely.

Most spontaneous collapses begin from tiny air-filled blisters on the surface of the lung, called blebs or bullae. When one bursts, air leaks out with each breath. There are four broad patterns:

• →Primary spontaneous — in people with otherwise healthy lungs, classically tall, slim younger adults, and more often men. There can be a family tendency.
• →Secondary spontaneous — on a background of existing lung disease such as COPD, asthma or emphysema, where the lung is already weakened.
• →Traumatic — after an injury to the chest, a broken rib, or occasionally as a complication of a medical procedure.
• →Catamenial — collapses that recur around menstruation, caused by thoracic endometriosis.

Knowing which pattern applies matters, because it changes both the risk of a further collapse and the right treatment.

A pneumothorax is usually confirmed on a chest X-ray, which shows the edge of the collapsed lung and the air around it, and gives a sense of how much the lung has come down.

A CT scan of the chest is sometimes added — particularly when the diagnosis is unclear, when there may be underlying lung disease, when blebs or bullae need to be mapped before surgery, or when a collapse keeps coming back. A CT gives a far more detailed picture of the lung surface and helps plan keyhole surgery precisely.

Dr Okiror reviews your imaging personally before the consultation, so the appointment can focus on what the findings mean for you and what to do next, rather than on gathering the information.

Most small pneumothoraces in otherwise well people settle on their own or with a short period of observation. Where the lung needs help to re-expand, the first steps are usually aspiration — drawing the air out through a fine tube — or a chest drain, sometimes with a small one-way (Heimlich) valve so you can be looked after as an outpatient. National guidance updated in 2023 shifted the emphasis from the size of the collapse to how the patient is affected, so a comfortable person with a moderate pneumothorax may safely be watched, while a breathless person, or someone whose work or health makes a recurrence dangerous, may be offered earlier treatment.

Surgery is generally considered when:

• →the pneumothorax comes back — a further collapse on the same side (a recurrence)
• →both lungs are affected (a bilateral pneumothorax)
• →there is bleeding into the chest at the same time (a haemothorax)
• →the first episode was a tension pneumothorax — where trapped air builds up dangerous pressure in the chest
• →your work or activities make a further collapse particularly dangerous — for example pilots and divers
• →a first episode does not settle — the lung keeps leaking air for more than about four days (a persistent air leak), or the lung fails to re-expand

Collapses that follow the menstrual cycle (catamenial pneumothorax) are a separate situation, also treated surgically once the pattern is recognised — covered below.

Where an air leak is slow to settle, options beyond a standard drain include suction, a one-way endobronchial valve, or a blood patch — the focus of the PRO-SEAL trial, for which Dr Okiror is Co-PI at Guy’s and St Thomas’. How a persistent air leak is managed →

Surgery for pneumothorax is carried out by keyhole technique — known as VATS, or video-assisted thoracoscopic surgery — under a general anaesthetic, through a small number of tiny incisions rather than an open cut. The operation usually takes around an hour.

Two things are done together. First, the blebs or bullae responsible for the air leak — the weak area of lung at the top, or apex — are removed; this is called a bullectomy, and it deals with the source of the problem directly. Second, the space around the lung is sealed so it cannot collapse in the same way again. Dr Okiror does this by removing the lining of the chest wall — a pleurectomy — in the large majority of patients, and reserves talc, a sterile powder that seals the space, for older patients and for redo operations.

A chest drain is left in for a short period afterwards to clear any remaining air and let the lung seal. Because the approach is keyhole rather than open, most people are comfortable quickly and have only small scars. Dr Okiror performs this surgery at London Bridge Hospital and The Lister Hospital Chelsea.

Most people stay in hospital for a few days after keyhole surgery, mainly to manage the chest drain while the lung seals. Discomfort is usually well controlled and eases steadily over the first week or two.

Return to desk-based work is typically possible within two to three weeks. More physical work, heavy lifting and vigorous exercise take a little longer, and Dr Okiror will give clear guidance tailored to your job and lifestyle.

Two activities deserve specific advice. Flying is generally avoided for a period after a pneumothorax until the lung has fully healed, and the timing should be confirmed individually. Diving is different again: a history of spontaneous pneumothorax has lasting implications for scuba diving, so anyone who dives should discuss this directly, as surgery may change what is safe. If your collapse was related to your job or sport, that conversation is part of planning treatment, not an afterthought.

Without surgery, a spontaneous pneumothorax has a high chance of returning — around one in three people have a further collapse after a first episode, rising to roughly six in ten after a second. This is the main reason surgery is recommended after a second pneumothorax, and sometimes after the first.

Keyhole surgery substantially reduces that risk — to around one in twenty (about 5%). No operation can promise a collapse will never happen again, but combining a bullectomy with sealing of the space around the lung is the most reliable way to prevent a recurrence, and far more effective than non-surgical treatment alone.

A pneumothorax that recurs around the time of menstruation is called catamenial pneumothorax. It is caused by thoracic endometriosis — tissue similar to the lining of the womb that is present in the chest, most often on or through the diaphragm. It is frequently mistaken for ordinary recurrent pneumothorax for years before the pattern is recognised.

The clue is timing: collapses that cluster within about three days (72 hours) of a period starting, usually on the right side. Treatment is keyhole surgery to remove the endometrial deposits and repair any defects in the diaphragm — direct suture for small defects, a patch for larger ones — alongside hormonal management and gynaecology input. Recognising the pattern is the key step, and it is worth raising if your collapses seem to follow your cycle. Full thoracic endometriosis page →