Spontaneous hemopneumothorax

Massive haemothorax and haemorrhagic shock due to cervical vascular injury caused by a seat belt

A woman in her 50s was transported to our hospital after experiencing a road traffic crash that led to a massive haemothorax and haemorrhagic shock due to a cervical vascular injury caused by the seat belt. Contrast-enhanced CT of the chest showed extravascular leakage of the contrast medium from the vicinity of the right subclavicular area and fluid accumulation in the thoracic cavity. The patient was intubated, and a thoracic drainage catheter was placed. She underwent angiography and embolisation of the right costocervical trunk, right thyrocervical trunk and right suprascapular artery using a gelatine sponge and 25% N-butylcyanoacrylate-Lipiodol. She was extubated on the second day after stabilisation of the respiratory and circulatory status. In cases where the bleeding vessel is known and an emergency thoracotomy can serve as a backup, embolisation by interventional radiology should be considered the initial treatment approach.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

A Case Report of Life-Threatening Hemopneumothorax as a Result of Spinal Manipulation Performed by Chiropractor

Chiropractic is a very popular alternative medicine practice in the United States. Despite that, this practice has been associated with several complications raising concerns for its safety. We report the case of an otherwise healthy 36-years-old, tall and thin male who presented with sudden onset shortness of breath associated with chest pain two days after chiropractic spinal manipulation. Chest imaging revealed left-sided hemopneumothorax required treatment with left-sided chest tube placement. Patients with a high risk of developing primary or secondary pneumothorax should consider avoiding chiropractic chest or spinal manipulations due to possible complications.

Massive Spontaneous Haemopneumothorax and Ecstasy Abuse

A 33-year-old man developed spontaneous haemopneumothorax after taking ecstasy in a ‘rave party’. Massive haemorrhage occurred after chest drainage and decompression. Both the adverse effects of ecstasy and risk behaviours at the party might have contributed to the development of the spontaneous haemopneumothorax.

Pneumothorax-associated fibroblastic lesion in combination with localized pleural angiomatosis: A possible cause of juvenile spontaneous hemopneumothorax

Spontaneous hemopneumothorax is an uncommon but potentially life-threatening condition, with a potential for a rapid ventilatory collapse and a large collection of hidden blood loss into the pleural cavity. Here, we report the first case in the literature on pneumothorax-associated fibroblastic lesion in combination with localized pleural angiomatosis in a 19-year-old Caucasian male, resulting in massive spontaneous hemopneumothorax and hypovolemic shock. Our findings support a causal link between this condition and pneumothorax. The possible superimposed hemothorax is explainable by the pleural involvement of large angiomatous vessels, prone to rupture.

Assessment of spontaneous hemopneumothorax: Indications for surgery

BACKGROUND

Although spontaneous hemopneumothorax is rare, emergency surgery may be necessary if massive bleeding is present.

METHODS

We examined therapeutic strategies and outcomes as well as background factors in 16 patients with spontaneous hemopneumothorax treated at our hospital between April 2002 and August 2013.

RESULTS

Emergency surgery was performed in 3 patients, all of whom were hemodynamically unstable. Elective surgery was performed in 7 patients, all of whom showed continuous bleeding from a pleural cavity drain. The surgery consisted of intrapleural hematoma removal, hemostasis, and bullectomy; 3-port thoracoscopy was used in all of the surgical cases. Six patients, none of whom showed continuous bleeding, recovered with conservative therapy. Comparing the conservative therapy and surgery groups revealed the mean continuous bleeding volume and total blood loss to be significantly greater in the latter, but no significant difference was noted between the two groups in terms of the initial bleeding volume following tube thoracostomy. None of the cases required a blood transfusion.

CONCLUSIONS

Spontaneous hemopneumothorax is not necessarily an indication for surgery, and even when the initial volume of blood drained through the chest tube is large, some patients can still be treated conservatively with careful monitoring of vital signs and continuous bleeding volumes. However, it is important not to miss the optimal timing of surgery in order to avoid administering unnecessary blood transfusions to young patients.

Spontaneous hemopneumothorax: Our experience with surgical management

Background

Spontaneous hemopneumothorax is rare, accounting for only 1%–12% of patients presenting with spontaneous pneumothorax. The optimal management of these patients remains controversial with no definitive guidelines on patient selection and timing of surgery. The aim of this study was to review our institution’s surgical experience in the management of patients with spontaneous hemopneumothorax.

Methods

We performed a retrospective review of all patients with spontaneous hemopneumothorax who underwent surgery from January 2000 to June 2013. Patient data were obtained from our institution’s primary spontaneous pneumothorax database.

Results

Of 510 patients who underwent surgery for spontaneous pneumothorax, 33 (6.4%) developed spontaneous hemopneumothorax. The mean age was 24.0 years (range 16–40 years). In 30 (90.9%) patients, it was their first presentation of pneumothorax. There were 25 (75.8%) patients with Vanderschueren stage III spontaneous pneumothorax. Blood loss ranged from 250 to 3000 mL (mean 1280 mL). In 28 patients, a torn adhesion band was the source of bleeding. Thoracotomy was the surgical approach in 9 (27.3%) patients, and video-assisted thoracic surgery was used in 24 (72.7%). One patient required reoperation for retained clots. There was no mortality.

Conclusion

Our results suggest that surgical management of spontaneous hemopneumothorax can be undertaken with minimal morbidity and mortality. With the increasing use of video-assisted thoracic surgery, definitive surgical management of spontaneous hemopneumothorax can be instituted earlier.

Spontaneous hemopneumothorax: epidemiological details and clinical features

PURPOSES

Spontaneous hemopneumothorax (SHP) may cause life-threatening blood loss. The objective of this study was to elucidate the epidemiological and clinical features of SHP.

METHODS

We reviewed the records of 26 patients who underwent surgery for SHP between 1989 and 2010. We evaluated their epidemiology and clinical features by comparing them with those of 681 patients with spontaneous pneumothorax treated during the same period.

RESULTS

The proportion of smokers in the SHP group was higher than that in the spontaneous pneumothorax group (P < 0.01). Seventeen cases (65.4 %) of SHP occurred on the left side. The most frequent bleeding area was the superior thoracic aperture (STA:17 cases, 65.4 %), followed by the left superior mediastinum (six cases, 23.1 %). Ten cases had intrathoracic clots greater than 500 mL, which could not be drained preoperatively. The postoperative stay of patients treated with video-assisted thoracic surgery (VATS) was shorter than that of patients treated with open thoracotomy (21 versus five cases; P < 0.05).

CONCLUSIONS

A higher proportion of smokers was revealed in the SHP patients. VATS shortened the hospital stay of the patients. The particular areas that should be observed intraoperatively are the STA and the left superior mediastinum.

A case of hemothorax following seat-belt injury with a bulla in the apex of the lung: a subtype of spontaneous hemopneumothorax

We experienced a case of a subtype of spontaneous hemopneumothorax caused by external forces associated with a seat-belt injury. A female aged 39 years sustained a minor collision with an oncoming car while she was driving. Although pneumothorax was not detected, hemothorax and bleeding from the area surrounding the subclavian artery were observed on contrast-enhanced chest computed tomography (CT). After confirming continuous bleeding into the thoracic cavity after superselective arterial embolization, we performed emergency open surgery. We found a bulla in the apex of the lung, and the thoracic stump of the bulla was considered the source of bleeding. In this case, the direct cause of hemothorax was considered to be the external force associated with the seat-belt injury. When a bulla in the apex of the lung and continuous bleeding are both observed on CT, spontaneous hemopneumothorax should be suspected, necessitating open chest surgery in cases where pneumothorax is not observed.

Hemopneumothorax caused by vascularized bullae and a pulmonary hemangioma in an adolescent boy

Spontaneous hemopneumothorax is a rare, potentially life-threatening condition occurring in adolescence. In general, spontaneous hemopneumothorax has not been associated with other pulmonary vascular malformations in adolescents. We present a case of a 17-year-old adolescent boy with hemopneumothorax from vascularized pleural blebs who was also noted to have a pulmonary hemangioma.

Idiopathic massive spontaneous hemothorax: adhesion disruption

BACKGROUND

Hemothorax has been reported to occur along with spontaneous pneumothorax due to adhesion disruption. Rupture of pleural adhesions spontaneously or after unnoticeable trivial trauma causing massive hemothorax alone is rare.

METHODS

We present a series of seven cases of idiopathic massive spontaneous hemothorax due to adhesion disruption, of which all required emergency thoracotomy with ligation or cauterization of bleeding adhesions.

RESULTS

Six patients had bleeding pleural lung adhesions of which five involved the upper lobes. Another had bleeding from pleuropericardial adhesions. All patients are doing well on follow-up.

CONCLUSIONS

Disruption of pleural adhesions may cause massive hemothorax, requiring early surgical intervention. After thoracotomy the outcome in these patients is excellent.

Spontaneous hemothorax following anticoagulation with low-molecular-weight heparin

OBJECTIVE

To report a case of spontaneous hemothorax following anticoagulation with low-molecular-weight heparin (LMWH) for the management of suspected pulmonary embolism.

CASE SUMMARY

A 66-year-old man with a background history of breast carcinoma was admitted with pleuritic chest pain. He was initially managed as a suspected case of pulmonary embolism. Dalteparin, an LMWH, was started at a maximum dose of 18,000 units subcutaneously once daily, according to British national prescribing guidelines. On day 4, following 3 doses of dalteparin, the patient developed acute respiratory distress attributable to a massive right hemothorax confirmed by computed tomography pulmonary angiography (CTPA) and intercostal drainage of 1500 mL of frank blood. CTPA identified no pulmonary embolus or vascular abnormalities. Reaccumulation of hemothorax occurred over the 48 hours following drain removal, necessitating insertion of a second drain, which removed 1400 mL of blood-stained fluid. The patient's hemoglobin decreased from 12.7 to 8.5 g/dL and he received a 3-unit blood transfusion. Histologic assessment of pleural fluid revealed no malignancy and results of video-assisted thoracoscopic surgery were normal. Discontinuation of dalteparin on day 4 led to resolution of symptoms.

DISCUSSION

The causal association between anticoagulant therapy and spontaneous hemothorax remains relatively uncommon. The striking temporal relationship between commencing dalteparin on day 1 and subsequent development of effusion on day 4, following 3 doses of LMWH, led us to believe that the bleed occurred as a result of the therapy. Exclusion of other causes strengthened this conclusion. Application of the Naranjo probability scale categorized this adverse reaction as being probably due to LMWH.

CONCLUSIONS

Spontaneous hemothorax is a rare phenomenon in conjunction with LMWH but should be considered in cases of acute respiratory distress following commencement of LMWH.

An unusual clinical case of haemoptysis in spontaneous pneumothorax: blood clots within emphysematous bulla

We report an unusual case of spontaneous haemopneumothorax associated with haemoptysis due to blood clots within emphysematous bulla in a 42-year-old man. Haemoptysis disappeared after surgery.

Video-assisted thoracic surgery for spontaneous haemopneumothorax

BACKGROUND AND OBJECTIVE

The aim of this study was to review the treatment options for spontaneous haemopneumothorax (SHP) by video-assisted thoracoscopic surgery (VATS).

METHODS

Records from 16 patients (14 male, age 16-38 years, mean age 26.1 years) with prominent SHP (blood loss over 400 cc in the first 24 h) undergoing VATS from July 1994 to December 2005 and treated by one thoracic surgeon in four medical centres or community hospitals of North and Mid-Taiwan were reviewed retrospectively.

RESULTS

Thirteen patients (81.3%) were identified to have a prominent bleeding source intraoperatively. Torn engorged vessels from the parietal pleura to adjacent bullae were found in nine patients, and bleeders adjacent or over the parietal part of the adhered pleura were found in the other four. Ruptured bullae/blebs or air leakage were found in 14 (87.5%). All underwent removal of intrapleural blood clot, control of bleeders and their bullae/blebs were resected through three-port VATS (n = 13, 81.2%) or mini-thoracotomy and VATS (n = 3, because of unstable vital signs or conversion because of dense adhesion). Mechanical or chemical pleurodesis was carried out in all patients. The mean operative time was 53.8 +/- 21.7 min. There was no postoperative mortality. However, recurrent bleeding requiring reoperation occurred in one patient, and one other patient had a prolonged air leakage (>7 days) postoperatively and recovered spontaneously. The mean duration of chest tube drainage was 3.8 days and the median follow-up period was 3.2 years.

CONCLUSION

SHP complicated by severe bleeding is a surgical emergency. VATS is a reasonable treatment for patients with SHP.

Massive Spontaneous Hemopneumothorax Complicating Rheumatoid Lung Disease

Spontaneous hemopneumothorax is characterized by an accumulation of air and blood in the pleural space without any apparent cause. Massive spontaneous hemopneumothorax is a rare, life-threatening situation and requires an operation in the early stage. The most common manifestation of rheumatoid disease in the lung is pleural disease. This can occur with or without pleural effusion. Hemopneumothorax is very rarely seen as the pulmonary manifestations of rheumatoid disease. We present a case of massive spontaneous hemopneumothorax in a young patient with rheumatoid lung disease as an unusual complication.

Early Video-Assisted Thoracic Surgery for Primary Spontaneous Hemopneumothorax

INTRODUCTION

Primary spontaneous hemopneumothorax (PSHP) is a rare surgical emergency. The aim of this study was to compare the previous strategy of tube thoracostomy followed by thoracotomy when complications developed with early video-assisted thoracic surgery (VATS) for PSHP.

METHODS

Between November 1989 and May 2005, a total of 24 consecutive patients with PSHP were retrospectively reviewed. Before January 2000, there were 13 patients who were subjected to the treatment strategy of initial tube thoracostomy and underwent operation if the condition deteriorated or later complications occurred (group T). Under this strategy, all of these patients later required operations. After January 2000, another 11 patients were treated with VATS as soon as their condition stabilized after tube thoracostomy and resuscitation (group V). The data for the two groups were compared: sex, age, involved side, initial heart rate (HR) and mean blood pressure (BP), initial hemoglobin (Hb), preoperative blood loss, operating time, amount of blood transfusion, period of chest tube drainage (POD), length of hospital stay (LOS), complications, and length of follow-up.

RESULTS

The sex, age, involved side, and the initial HR, BP, and Hb of the two groups were similar. The patients of group V had a significantly longer operating time [group V, 111 minutes (mean); group T, 85 minutes, P = 0.002]; less preoperative blood loss (group V, 946 ml; group T, 1687 ml, P = 0.003); less blood transfusion (group V, 465 ml; group T, 1044 ml, P = 0.002); shorter POD (group V, 4 days; group T, 7 days, P = 0.011); and shorter LOS (group V, 5 days; group T, 10 days, P = 0.002). No mortality or recurrence was noted in the entire series.

CONCLUSIONS

Our study suggests that surgery should be undertaken for PSHP as soon as possible after the clinical condition has stabilized. Under this strategy, VATS is an acceptable approach. It allows a shorter hospital stay and is exempt from unnecessary blood transfusion. Later complications, such as empyema and impaired lung reexpansion, can also be avoided.

Spontaneous hemopneumothorax in children: case report and review of literature

Spontaneous hemopneumothorax is rare, occurs in young adolescents, and can be life threatening secondary to massive bleeding. An adolescent with spontaneous hemopneumothorax and shock managed by tube thorascostomy is described here. We compared our case with published data of spontaneous hemopneumothorax in the pediatric age group. Spontaneous hemopneumothorax involves the accumulation of air and blood in the pleural space in the absence of trauma or other obvious causes. Spontaneous hemopneumothorax is usually seen in adolescents, more common in males than females. The common clinical features of spontaneous hemopneumothorax include dyspnoea and chest pain, and 30% present with hypovolemic shock. The bleeding can result from a torn adhesion between the parietal and visceral pleurae, from a rupture of vascularized bullae, or from torn congenital aberrant vessels. Over the last 6 decades, the treatment has progressed from the thoracotomy to minimally invasive techniques such as video assisted thoracoscopic surgery, with great reduction in mortality and recurrence rates. Although a rare entity, diagnosis of spontaneous hemopneumothorax must be considered in young adolescents presenting with spontaneous onset of chest pain and dyspnoea with radiograph findings of hydropneumothorax and/or signs of shock.

Spontaneous hemopneumothorax

PURPOSE OF REVIEW

Spontaneous hemopneumothorax can be life threatening, and is a cause of patients presenting with unexplained signs of significant hypovolemia. The debate relating to patient selection and timing of surgery in patients with spontaneous hemopneumothorax remains unresolved.

RECENT FINDINGS

Our experience together with the latest series published over the last decade on the conservative and surgical management of spontaneous hemopneumothorax are presented and discussed.

SUMMARY

Surgery should be performed early in the management of spontaneous hemopneumothorax to reduce morbidity. In particular, video-assisted thoracic surgery, which is associated with potentially fewer post-operative complications and shorter hospital stays compared with thoracotomy, should be considered in patients with spontaneous hemopneumothorax who are hemodynamically stable.

Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature

BACKGROUND

Spontaneous hemopneumothorax, defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax, is a rare entity occurring in young patients and may be life threatening. Although many reports of case studies and series have been published in the world literature, the lack of consistent intraoperative findings and varying surgical methods require a review study.

METHODS

We discuss the clinical features, management, surgical findings, and outcomes of our own patients with spontaneous hemopneumothorax.

RESULTS

From September 1997 to September 2003, 488 patients with spontaneous pneumothorax were treated at our hospital. Of these patients, 27 (5.5%) had spontaneous hemopneumothorax develop. These 27 patients were comprised of 25 men and 2 women ranging in age from 15 to 39 years (mean age, 22.3 years). The amount of blood that was drained ranged from 400 to 1,700 mL (mean, 1,012 mL). Twenty-one patients underwent video-assisted thoracoscopic surgery within 1 day after admission; the remaining 6 patients were treated conservatively with tube thoracostomy alone. On arrival at our emergency room, 9 patients (33.3%) experienced hemodynamic instability with hypovolemic shock. In a review of 6,396 patients with spontaneous pneumothorax in the literature and in our current study, 201 patients (3.1%) had spontaneous hemopneumothorax develop. One hundred seventy-six patients (87.6%) were treated surgically, whereas video-assisted thoracoscopic surgery has been performed in 48.9% of patients (86 of 176). There was no recurrence of hemopneumothorax in any of the 201 patients with spontaneous hemopneumothorax after treatment during the follow-up period.

CONCLUSIONS

Thus one-third of the patients with spontaneous hemopneumothorax had shock symptoms develop. Video-assisted thoracoscopic surgery may be considered as an initial treatment procedure for patients with spontaneous hemopneumothorax, whereas conservative treatment is effective and may be performed in selected patients.

Indicators of haemothorax in patients with spontaneous pneumothorax

OBJECTIVES

To identify indicators and possible risk factors of haemothorax in patients with spontaneous pneumothorax.

METHODS

All patients presenting to the emergency department of Chi-Mei Foundation Medical Center, Tainan, Taiwan with primary spontaneous pneumothorax between 1 January 1997 and 31 December 2002 were screened for inclusion in the present study. Of the 211 patients who qualified, eight had spontaneous haemopneumothorax (SHP) (3.79%). The clinical data and demographic characteristics of these patients were similar to those of patients with spontaneous pneumothorax without haemothorax (SP).

RESULTS

All eight SHP patients were thin and young men (mean age 24 years and mean weight 56.1 kg). Seven were smokers. The patients with SHP were taller that the patients with SP (177.4 cm v 170.3 cm, respectively; p < 0.01), and tended to have a lower body mass index (BMI) (17.9 kg/m2 v 19.6 kg/m2, respectively; p = 0.06) and higher heart rate (101.0 v 88.0 beats/min, respectively; p = 0.09). Clinically, patients with SHP were more likely to have dyspnoea compared with SP patients (62.5% v 26.6%, respectively; p = 0.04) and lower levels of haemoglobin (12.8 v 14.7 g/dl, respectively; p = 0.01) and haematocrit (38.1% v 44.1%, respectively; p < 0.01). Chest x rays revealed pleural effusion in all patients with SHP but in none with SP.

CONCLUSIONS

Patients with SHP are taller, with lower levels of haemoglobin and haematocrit, and are more likely to have dyspnoea than patients without haemothorax. The chest x ray finding of pneumothorax with an ipsilateral air-fluid level is a strong indicator of SHP.

Autologous salvaged blood transfusion in spontaneous hemopneumothorax

Spontaneous hemopneumothorax (SHP) is a rare clinical entity, and an emergent operation due to continuous bleeding or hypovolemic shock is at times necessary. Although allogeneic blood transfusions are urgently required for significant blood loss, autologous blood transfusions can also be considered in patients with SHP. We herein report two cases of successful autologous blood transfusions using blood in the pleural space, decreasing or obviating the need for allogeneic blood transfusion.

Spontaneous massive haemopneumothorax: case reports

Spontaneous haemopneumothorax is an infrequently reported entity. We report here on two patients with spontaneous haemopneumothorax complicated by massive haemorrhage. Sources of bleeding were caused by torn pleural adhesion and ruptured apical bullae. Inappropriate management can lead to an increase in mortality and morbidity. We emphasize the importance of close monitoring, early recognition, prompt resuscitation and thoracotomy because of the possible lethal implications.

Justifying video-assisted thoracic surgery for spontaneous hemopneumothorax

STUDY OBJECTIVES

Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgery practice. This study discusses the clinical aspects and utility of VATS in spontaneous hemopneumothorax (SHP).

PATIENTS

Of 363 spontaneous pneumothorax (SP) cases, 24 patients presented with SHP (6.6%). The clinical features, surgical indications, emergency VATS technique, and patient outcomes are discussed.

RESULTS

All 24 patients were male (mean age, 25.3 years). Eleven patients were in hypovolemic shock, and their hemoglobin levels ranged from 6.7 to 12.7 g/dL; therefore, they received fluid resuscitation and blood transfusion. The amount of blood drained through the chest tube varied from 200 to 3,500 mL. Emergency VATS revealed that 5 cases were simple hemothoraces and 19 cases were associated with pneumothorax. The cause of bleeding was identified by thoracoscopy, as from an aberrant vessel (n = 11), torn parietal pleura (n = 4), ruptured vascularized bullae (n = 2), and lung parenchyma (n = 1). Six patients had no evidence of an obvious bleeding site. Bullous lesions were at the apex of the upper lobe in 14 patients, and multiple lobar involvement was seen in 2 patients. All the bullae were resected with endoscopic stapler in eight patients and ligated with a homemade endoloop in eight patients. The mean operation time was 42 min. The mean chest tube removal time was 3.5 days after insertion, and mean postoperative stay was 4.5 days. There is no recurrence of SHP or SP during the follow-up period.

CONCLUSION

SHP complicated by severe bleeding presents a potentially grave emergency. VATS may be considered as feasible treatment for patients with SHP.

Alpha-1-antitrypsin deficiency and a pleural shadow

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[Video-assisted thoracoscopic surgery in spontaneous hemopneumothorax]

We retrospectively studied the safety and utility of video-assisted thoracoscopic surgery (VATS) in the treatment of spontaneous hemopneumothorax. Of 128 cases of spontaneous pneumothorax operated on our hospital from April 1988 to October 1997, hemopneumothorax developed in 8 cases (2 cases treated by thoracotomy and 6 by VATS). In all 8 cases, bleeding points and pulmonary bullae were easily found and hemostasis and resection of pulmonary bullae conducted quickly and safely. Two cases of VATS involved elective surgery. Of surgical emergent cases, the duration from visit our hospital to operation and surgical duration in VATS were almost as long as those in thoracotomy. The mean duration of postoperative chest drainage and postoperative hospital stay in VAST were less than in thoracotomy except for a VAST case with persistent air leakage. Blood loss from onset to operation and blood transfusion for VATS were almost equal to thoracotomy. Postoperative duration of analgesic use for VATS were shorter than that for thoracotomy. The VATS case with persistent air leakage should be necessary to reinforce the pulmonary stapled line or to convert to thoracotomy. In all cases, residual hematoma was found in the thoracic cavity. We conclude that early surgical repair should be performed once spontaneous hemopneumothorax is diagnosed and confirmed, and that VATS may be the first choice of surgery because it provides a better view and more facilitated manipulation during surgery than thoracotomy, and is a safe, nonaggressive therapeutic option.