High-resolution computed tomography in the management of the first episode of primary spontaneous pneumothorax: are we sure that more is better?

We read with interest the article by Olesen et al. [1]. In their multicentre, randomized trial, authors enrolled young (range 18–40 years) healthy patients with the first episode of primary spontaneous pneumothorax (PSP). One of the critical messages of the article was a recommendation for high-resolution computed tomography (HRCT) following the first episode of PSP [1]. This article demonstrated, with the best possible methodological quality (a randomized controlled trial), the indications derived from previous articles published in the literature. Kim et al. [2], using the chest HRCT to evaluate the number and size of the blebs, suggested video-assisted thoracic surgery bullectomy as the treatment for the first-episode primitive spontaneous pneumothorax, if any significant blebs were visible. Casali et al. [3] also described the blebs detected on HRCT after the first episode of primitive spontaneous pneumothorax as being significantly related to the development of an ipsilateral recurrence or a contralateral episode, suggesting early surgical treatment after the first episode of PSP.

In recent years, the demand for chest HRCT following the first episode of PSP has grown for several reasons. At the same time, computed tomography is now performed more often than previously in young patients. The risks due to radiation exposure are more significant for young patients than for adult patients due to the radiosensitivity of tissues and the longer life expectancy of younger patients during which radiation-related effects may develop. As an indirect consequence of the technological progress in more sensitive faster scanners, a more significant number of patients will be exposed to radiation, contributing to increasing public health problems [4].

Nevertheless, the role of HRCT in the management of the first episode of PSP is still unclear. In the 2010 British Thoracic Society Guidelines, the computed tomography scan, other than being the gold standard in the detection of small pneumothorax and size estimation, was defined as useful in the presence of bullous disease. However, practical constraints precluded its general use as the initial diagnostic modality [5]. In the last European Respiratory Society’s task force statement on the diagnosis and treatment of the PSP, even if computed tomography is more sensitive than chest radiographs in the detection of pneumothorax, it is not required in most of the cases. The diagnosis of pneumothorax could be made using a simple chest radiograph, and according to the task force members, excessive exposure to radiation should be avoided in this young patient population [6].

However, at our current level of understanding, it appears unwise to assume that there is no increased risk and, thereby, to expose patients to doses that future study may reveal to be critical. New guidelines, correctly prepared following a strict methodology, should indeed guide the clinical practice of our surgical community.

In conclusion, the HRCT in the management of the first episode of PSP will require further research. Thoracic surgeons should minimize patient exposure to imaging-associated radiation through the use of appropriate criteria and careful decision making.

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