Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: an open-label, parallel-group, prospective, randomised, controlled trial

Rapid increase in the height and width of the upper chest in adolescents with primary spontaneous pneumothorax

BACKGROUND

We determined the chest height in a cohort of patients with primary spontaneous pneumothorax (PSP) who had received chest radiographic examinations prior to the attack. The aim of this study was to determine when their chest height began to change and how this was related to the PSP.

METHODS

From June 2009 to February 2012, the chest posteroanterior radiographs of 156 patients with PSP (Group 1) were reviewed. Among another 3134 patients with PSP, we identified 52 patients who had a chest posteroanterior radiograph prior to the attack (Group 2). We also recruited 196 controls for comparison (Group 3). The chest height and chest width at different levels were measured and analyzed.

RESULTS

Before 14 years of age, the chest height of patients in Group 2 was no different from that of patients in Group 3. By the age of 14 years, however, the chest height and upper chest width of patients with PSP was significantly higher than that of the normal controls. The difference from normal chest height did not increase at adulthood.

CONCLUSION

The rapid increase in chest height and upper chest width is a unique finding in patients with PSP. It might be attributable to the occurrence of PSP. This finding may also help to identify patients who are at risk of PSP.

Intrapleural minocycline pleurodesis for the treatment of primary spontaneous pneumothorax

PURPOSE OF REVIEW

The role of chemical pleurodesis in the treatment of primary spontaneous pneumothorax remains unclear. According to current practice guidelines, chemical pleurodesis is reserved for patients who are unable or unwilling to have surgery. Some recent studies showed that intrapleural minocycline pleurodesis could decrease the rate of pneumothorax recurrence, when used either as the initial treatment for simple pneumothorax after successful aspiration and drainage or as an adjuvant treatment for complicated or recurrent pneumothorax following thoracoscopic surgery. The purpose of this review is to discuss the current available evidence on intrapleural minocycline pleurodesis for the treatment of primary spontaneous pneumothorax.

RECENT FINDINGS

In a recently published prospective, randomized controlled trial, additional minocycline pleurodesis following simple aspiration and drainage was a well tolerated and more effective initial treatment for a first episode of primary spontaneous pneumothorax than simple aspiration and drainage alone. Other prospective, randomized controlled trials showed that additional minocycline pleurodesis after thoracoscopic treatment was a well tolerated and convenient procedure which can reduce the rate of ipsilateral recurrence of primary spontaneous pneumothorax.

SUMMARY

Intrapleural minocycline pleurodesis can be considered an adjunct to standard treatment of primary spontaneous pneumothorax, after either simple aspiration and drainage or after thoracoscopic surgery.

Spontaneous pneumothorax; a multicentre retrospective analysis of emergency treatment, complications and outcomes

BACKGROUND

Spontaneous pneumothorax can be managed initially by observation, aspiration or chest drain insertion.

AIMS

To determine the clinical features of spontaneous pneumothorax in patients presenting to the emergency department (ED), interventions, outcomes and potential risk factors for poor outcomes after treatment.

METHODS

Retrospective chart review from ED of three major referral and two general hospitals in Australia of presentations with primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). Main outcomes were prolonged air leak (>5 days) and pneumothorax recurrence within 1 year.

RESULTS

We identified 225 people with PSP and 98 with SSP. There were no clinical tension pneumothoraces with hypotension. Hypoxaemia (haemoglobin oxygen saturation measured by pulse oximetry ≤92%) occurred only in SSP and in older patients (age >50 years) with PSP. Drainage was performed in 150 (67%) PSP and 82 (84%) SSP. Prolonged air leak occurred in 16% (95% confidence interval 10-23%) of PSP and 31% (21-42%) of SSP. Independent risk factors for prolonged drainage were non-asthma SSP and pneumothorax size >50%. Complications were recorded in 11% (7.5-16%) of those having drains inserted. Recurrences occurred in 5/91 (5%, 1.8-12%) of those treated without drainage versus 40/232 (17%, 13-23%) of those treated by drainage, of which half occurred in the first month after drainage.

CONCLUSION

Pneumothorax drainage is associated with substantial morbidity including prolonged air leak. As PSP appears to be well tolerated in younger people even with large pneumothoraces, conservative treatment in this subgroup may be a viable option to improve patient outcomes, but this needs to be confirmed in a clinical trial.

Mechanical pleurodesis does not reduce recurrence of spontaneous pneumothorax: a randomized trial

BACKGROUND

Mechanical pleurodesis is widely used to treat primary spontaneous pneumothorax to decrease postoperative recurrence after thoracoscopic bullectomy, but it is unclear whether it actually reduces primary spontaneous pneumothorax recurrence. We aimed to investigate the effectiveness of mechanical pleurodesis after thoracoscopic treatment of primary spontaneous pneumothorax.

METHODS

In our parallel-group, prospective, randomized, controlled trail at 2 hospitals in China, 289 patients were enrolled from January 2010 to January 2013. Patients were randomly assigned (1:1) to receive thoracoscopic wedge resection only (WR group) or thoracoscopic wedge resection and mechanical pleurodesis (WR+MP group). This trial is registered with ClinicalTrial.gov (NCT01463553).

RESULTS

Intraoperative bleeding and postoperative pleural drainage were significantly lower in the thoracoscopic WR only group. Postoperative recurrence rate did not significantly differ between groups (log-rank test p=0.791; Breslow test p=0.722). In the thoracoscopic WR only group, no recurrences were found when bullae were isolated or limited; recurrence was 7.5% with the presence of multiple bullae. Younger patients had an increased risk of recurrence (relative risk 3.015; 95% confidence interval 1.092 to 8.324).

CONCLUSIONS

Thoracoscopic mechanical pleurodesis did not significantly decrease primary spontaneous pneumothorax recurrence compared with simple wedge resection, but intraoperative bleeding and postoperative pleural drainage rates were higher. Younger age increases the risk of recurrence.

Role of computed tomographic scanning prior to thoracoscopic surgery for primary spontaneous pneumothorax

BACKGROUND/PURPOSE

The role computed tomography (CT) performed prior to thoracoscopic surgery for primary spontaneous pneumothorax (PSP) remains unclear.

METHODS

We retrospectively reviewed medical records of all patients who underwent thoracoscopic surgery for PSP during 2008-2012. Patients were stratified into two groups: CT group (patients who received preoperative CT scanning) and control group (patients who did not receive preoperative scanning). Short-term postoperative results and long-term pneumothorax recurrence rates were compared.

RESULTS

A total of 298 patients were studied. Preoperative CT scanning was performed in 140 of them. The duration of operation, incidence of bullae formation, number of excised specimens, rate of complications, and postoperative hospital stay were similar between the two groups. After a mean follow-up of 20 months, the recurrence rates were 8.6% (12/140) in the CT group and 5.7% (9/158) in the control group (p = 0.371). In the CT group, five patients had unexpected pulmonary findings and three of them (60%) developed pneumothorax recurrence, the rate of which was significantly higher than that in patients without unexpected pulmonary findings (9/135, 6.7%, p = 0.004). Unexpected pulmonary lesions were more commonly noted in females (4/19, 21.1%) than in males (1/121, 0.8%; p < 0.001).

CONCLUSION

Preoperative CT scanning was not associated with better results after thoracoscopic surgery for PSP and is, therefore, not justified as a routine examination prior to the operation. In female patients, however, preoperative CT scanning might be needed because these patients tended to have a higher incidence of unexpected pulmonary lesions, which were associated with a higher rate of recurrence.

Chemical pleurodesis for spontaneous pneumothorax

Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is sub-divided into primary and secondary. The severity of pneumothorax could be varied from asymptomatic to hemodynamically compromised. Optimal management of this benign disease has been a matter of debate. In addition to evacuating air from the pleural space by simple aspiration or chest tube drainage, the management of spontaneous pneumothorax also focused on ceasing air leakage and preventing recurrences by surgical intervention or chemical pleurodesis. Chemical pleurodesis is a procedure to achieve symphysis between the two layers of pleura by sclerosing agents. In the current practice guidelines, chemical pleurodesis is reserved for patients unable or unwilling to receive surgery. Recent researches have found that chemical pleurodesis is also safe and effective in preventing pneumothorax recurrence in patients with the first episode of spontaneous pneumothorax or after thoracoscopic surgery and treating persistent air leakage after thoracoscopic surgery. In this article we aimed at exploring the role of chemical pleurodesis for spontaneous pneumothorax, including ceasing air leakage and preventing recurrence. The indications, choice of sclerosants, safety, effects, and possible side effects or complications of chemical pleurodesis are also reviewed here.