The term ‘pneumothorax’ was first coined by Itard and then Laennec in 1803 and 1819 respectively,1 and refers to air in the pleural cavity (ie, interspersed between the lung and the chest wall). At that time, most cases of pneumothorax were secondary to tuberculosis, although some were recognised as occurring in otherwise healthy patients (‘pneumothorax simple’). This classification has endured subsequently, with the first modern description of pneumothorax occurring in healthy people (primary spontaneous pneumothorax, PSP) being that of Kjaergaard2 in 1932. It is a significant global health problem, with a reported incidence of 18–28/100 000 cases per annum for men and 1.2–6/100 000 for women.3

Secondary pneumothorax (SSP) is associated with underlying lung disease, in distinction to PSP, although tuberculosis is no longer the commonest underlying lung disease in the developed world. The consequences of a pneumothorax in patients with pre-existing lung disease are significantly greater, and the management is potentially more difficult. Combined hospital admission rates for PSP and SSP in the UK have been reported as 16.7/100 000 for men and 5.8/100 000 for women, with corresponding mortality rates of 1.26/million and 0.62/million per annum between 1991 and 1995.4

With regard to the aetiology of pneumothorax, anatomical abnormalities have been demonstrated, even in the absence of overt underlying lung disease. Subpleural blebs and bullae are found at the lung apices at thoracoscopy and on CT scanning in up to 90% of cases of PSP,5 6 and are thought to play a role. More recent autofluorescence studies7 have revealed pleural porosities in adjacent areas that were invisible with white light. Small airways obstruction, mediated by an influx of inflammatory cells, often characterises pneumothorax and may become manifest in the smaller airways at an earlier stage with ‘emphysema-like changes’ (ELCs).8

Smoking has been implicated in this …

https://thorax.bmj.com/content/thoraxjnl/65/Suppl_2/ii18.full.pdf

Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010

These guidelines have been replaced by BTS Pleural Disease Guideline 2010 Superseded By BTS Pleural Disease Guideline 2010: BTS Guidelines for the Management of Pleural Disease. Thorax 2003 May; 58(Suppl 2): 1–59.

/pdf/bts-guidelines-for-the-management-of-spontaneous-3ekex0o583.pdf

BTS guidelines for the management of spontaneous pneumothorax.

Pneumothorax is classified as spontaneous (not caused by trauma or any obvious precipitating factor), traumatic, or iatrogenic (Table 1). Primary spontaneous pneumothorax occurs in persons without clinically apparent lung disease; secondary spontaneous pneumothorax is a complication of preexisting lung disease. Iatrogenic pneumothorax results from a complication of a diagnostic or therapeutic intervention. Traumatic pneumothorax is caused by penetrating or blunt trauma to the chest, with air entering the pleural space directly through the chest wall; visceral pleural penetration; or alveolar rupture due to sudden compression of the chest. In this review we focus on spontaneous pneumothorax.Primary Spontaneous PneumothoraxEpidemiology . . . 

Spontaneous Pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

https://erj.ersjournals.com/content/erj/46/2/321.full.pdf

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax.

https://journal.chestnet.org/article/S0012-3692(16)31752-4/pdf

Treatment of Spontaneous Pneumothorax: A More Aggressive Approach?

https://www.annalsthoracicsurgery.org/article/0003-4975(93)91001-4/pdf

Secondary spontaneous pneumothorax

Asymptomatic cor triatriatum incidentally revealed by computed tomography.

We herein report the rare case of a patient with coronary artery fistula (CAF) between the left circumflex coronary artery and persistent left superior vena cava (PLSVC) with a complete absence of the right superior vena cava (SVC).

Coronary artery fistula into a persistent left superior vena cava: report of a case.

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Secondary spontaneous pneumothorax

Asymptomatic cor triatriatum incidentally revealed by computed tomography.

Coronary artery fistula into a persistent left superior vena cava: report of a case.