Time course of resolution of persistent air leak in spontaneous pneumothorax

Prevalence, risk factors, and recurrence risk of persistent air leak in patients with secondary spontaneous pneumothorax

Background

Persistent air leak (PAL) is common in secondary spontaneous pneumothorax (SSP), with risk factors only been determined for post-pulmonary resection PAL. Information about its risk factors and long-term outcome is, however, necessary to enable selection of treatment modalities for elderly SSP patients with comorbid conditions.

Methods

A retrospective observational study was performed on chest drain-treated SSP patients from 2009 to 2018. The risk factors, long-term recurrent pneumothorax, and mortality rates of those with and without PAL were evaluated.

Results

Of 180 non-surgical SSP patients, PAL prevalence for >2 days and >7 days were 81.1% and 43.3%, respectively. Bulla was associated with PAL >7 days (OR: 2.32; P: 0.027) and serum albumin negatively associated (OR: 0.94; P: 0.028). PAL resulted in longer hospitalization in the index episode (P: <0.01). PAL >7 days was associated with a higher pneumothorax recurrence rate in three months (HR: 2.65; P: 0.041), one year (HR: 2.50; P: 0.040) and two-year post-discharge (HR: 2.40; P: 0.029). Patients treated with medical pleurodesis were significantly older (P: <0.01), had higher Charlson Co-morbidity index scores (P: <0.01), and 77.8% of those who had PAL >7 days were considered unfit for surgery. Of these, pneumothorax had not recurred in 69.4% after two years (HR: 0.47; P: 0.044).

Conclusion

Bulla was positively associated with PAL over seven days in SSP patients while albumin was negatively associated. PAL over seven days increased future recurrent pneumothorax risks, while elderly SSP patients unfit for surgery had acceptable recurrence rates after medical pleurodesis.

Pressure-dependent persistent air leak in a patient with secondary spontaneous pneumothorax

An air leak lasting more than 5-7 days (persistent air leak, PAL) can complicate up to 40% of patients with secondary spontaneous pneumothorax. Chronic obstructive pulmonary disease is the most common cause of secondary spontaneous pneumothorax, and early surgical intervention has been recommended for patients with PAL. Bullectomy or blebectomy with concomitant mechanical pleurodesis by medical thoracoscopy or video assisted thoracoscopic surgery is considered definitive therapy. Unfortunately, the perioperative course following lung resection can also be complicated by air leaks leading to worse clinical outcomes. Post lung resection air leak can be pressure independent or pressure dependent (also known as drainage-related air leak). The distinction between these two entities is crucial as the management varies drastically. Pleural manometry may play an important role in the early diagnosis of pressure-dependent PAL preventing further unnecessary surgical procedures from being performed.

Endobronchial valves for persistent air leak all-cause mortality and financial impact: US trend from 2012-2016

Background: Endobronchial valves (EBV) are considered an innovation in the management of the persistent air leak (PAL). They offer a minimally invasive alternative to the traditional approach of pleurodesis and surgical intervention. We examined trends in mortality, length of stay (LOS), and resources utilization in patients who underwent EBV placement for PAL in the US.

Methods: We utilized discharge data from the Nationwide Inpatient Sample (NIS) for five years (2012–2016). We included adults diagnosed with a pneumothorax who underwent EBV insertion at ≥ 3 days from the day of chest tube placement; or following invasive thoracic procedure. We analyzed all-cause mortality, LOS, and resources utilization in the study population.

Results: A total of 1,885 cases met our inclusion criteria. Patients were mostly middle-aged, males, whites, and had significant comorbidities. The average LOS was 21.8 ± 20.5 days, the mean time for chest tube placement was 3.8 ± 5.9 days, and the mean time for EBV insertion was 10.5 ± 10.3 days. Pleurodesis was performed before and after EBV placement and in 9% and 6%, respectively.

Conclusions: Our study showed that the all-cause mortality rate fluctuated throughout the years at around 10%. Despite EBV being a minimally invasive alternative, its use has not trended up significantly during the study period. EBVs are also being used off-label in the US for spontaneous pneumothorax. This study shall provide more data to the scarce literature about EBV for PAL.

New insights and improved strategies for the management of primary spontaneous pneumothorax

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema-like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta-analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of 'at risk patients' is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost-effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice.

OK-432 pleurodesis for the treatment of pneumothorax in patients with interstitial pneumonia

BACKGROUND

Pneumothorax occasionally develops in patients with interstitial pneumonia (IP) and is often intractable. As there exists no well-established treatment for pneumothorax with IP, we evaluated the efficacy and safety of pleurodesis with OK-432, a lyophilized preparation of Streptococcus pyogenes Su strain that has been inactivated by benzylpenicillin.

METHODS

We retrospectively evaluated the efficacy and safety of pleurodesis using OK-432 in 39 patients treated for IP-related pneumothorax between January 2006 and May 2017. Five to 10 Klinische Einheit (KE) of OK-432 was injected through the chest tube of each patient. Pleurodesis was considered successful if 1) the chest tube was removed without air leaks and 2) there was no recurrence of pneumothorax within 4 weeks after tube removal, and no additional treatment was required.

RESULTS

OK-432 pleurodesis was performed 46 times in 39 patients. The median number of OK-432 intrapleural injections received was 1 (range, 1-6), and median dose was 10 KE (range, 5-55 KE). The success rate was 63% (29/46) and recurrence rate was 17.4% (8/46). Grade 5 adverse events were observed in eight patients, including two patients who developed acute exacerbation of IP. Patients in whom the first OK-432 pleurodesis was successful had a significantly longer median survival time than patients in whom it was unsuccessful (322 days vs. 70 days, p = 0.036).

CONCLUSIONS

Our results show that OK-432 pleurodesis is an effective treatment for pneumothorax associated with IP; however, clinicians should be aware of the possibility of adverse events, especially in patients who are critically ill.

Persistent air leaks: a review with an emphasis on bronchoscopic management

Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.

Acute Pneumothorax

Pneumothorax is defined as the abnormal presence of air within the pleural space (cavity) that results in the partial or complete collapse of a lung. It can occur spontaneously or due to a traumatic event. Symptoms can vary from a nondescriptive complaint of shortness of breath or chest pain to complete cardiopulmonary collapse. Diagnosis is based on a combination of clinical suspicion along with supporting imaging studies. Treatment often involves surgical or nonsurgical approaches with goal to alleviate symptoms and prevent recurrence.

Spontaneous pneumothorax: time to rethink management?

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

Pneumothorax

Pneumothorax-either spontaneous or iatrogenic-is commonly encountered in pulmonary medicine. While secondary pneumothorax is caused by an underlying pulmonary disease, the spontaneous type occurs in healthy individuals without obvious cause. The British Thoracic Society (BTS, 2010) and the American College of Chest Physicians (ACCP, 2001) published the guidelines for pneumothorax management. This review compares the diagnostic and management recommendations between the two societies. Patients diagnosed with primary spontaneous pneumothorax (PSP) may be observed without intervention if the pneumothorax is small and there are no symptoms. Oxygen therapy is only discussed in the BTS guidelines. If intervention is needed, BTS recommends a simple aspiration in all spontaneous and some secondary pneumothorax cases, whereas ACCP suggests a chest tube insertion rather than a simple aspiration. BTS and ACCP both recommend surgery for patients with a recurrent pneumothorax and persistent air leak. For patients who decline surgery or are poor surgical candidates, pleurodesis is an alternative recommended by both BTS and ACCP guidelines. Treatment strategies of iatrogenic pneumothorax are very similar to PSP. However, recurrence is not a consideration in iatrogenic pneumothorax.

Advances in the management of pleural disease

Pleural disease affects over 3000 people per million population annually. Consequently, it represents a significant proportion of the respiratory physician's workload and can present to clinicians of all backgrounds in primary and secondary care. Pleural effusions have been reported in association with over 50 different conditions; some related to specific pulmonary pathologies, but many being manifestations of multisystem disease. The burden that conditions such as pleural infection; malignant pleural disease; and pneumothorax impose on patients and health care systems is enormous and growing. As such, a clear understanding of these key conditions is crucial to any physician regardless of the specialty. This article addresses a number of areas relating to pleural disease, providing an overview of the diagnostic and therapeutic advances that have been made in our understanding of pleural pathology in recent years. The directions that future research in this important area of respiratory medicine might take will also be discussed.

Spontaneous pneumothorax with persistent air leakage and invasive procedures

OBJECTIVE

Prolonged air leaks in patients with spontaneous pneumothorax are not infrequent. The aim of this study was to assess the duration of air leaks and define the clinical variables associated with the therapeutic success of chest tube drainage for spontaneous pneumothorax.

METHODS

A total of 441 patients with spontaneous pneumothorax treated with chest tube drainage between 2008 and 2012 were retrospectively evaluated. The clinical differences between the patients successfully treated with drainage and those who required more invasive procedures were analyzed.

RESULTS

Invasive procedures, such as video-assisted thoracic surgery (n=121), fibrin glue administration through a chest tube (n=8) and pleurodesis with OK-432 (n=21), were performed in 34% (150/441) of the patients. The treatment rate of chest drainage alone was higher in the patients with initial pneumothorax (72%; 124/170) than in those with recurrent pneumothorax (62%; 167/271) (p=0.015). In addition, this rate was higher in the patients with moderate lung collapse (70%; 167/237) than in those with severe lung collapse (61%; 124/204) (p=0.032).

CONCLUSION

Patients with recurrent pneumothorax or severe lung collapse associated with prolonged air leakage are more likely to receive invasive procedures.

Spontaneous pneumothorax from cryptococcal pneumonia in systemic sclerosis: a case report

INTRODUCTION

Spontaneous pneumothorax is usually found in people with systemic sclerosis who have extensive pulmonary fibrosis with enlarged sub-pleural blebs. We report a case of spontaneous pneumothorax caused by cryptococcal pneumonia in a patient with systemic sclerosis with minimal sub-pleural emphysema.

CASE PRESENTATION

A 49-year-old Thai man with underlying limited cutaneous systemic sclerosis presented with acute low-grade fever, progressive dyspnea and right pleuritic chest pain for five days. Our patient had pulmonary fibrosis with bronchiectasis of both lower lungs related to this underlying disease. He received only low-dose steroid therapy, without any immunosuppressant. A chest radiograph revealed right lung pneumothorax with cloudy yellow color pleural fluid. Cryptococcal pneumonia was diagnosed by positive identification of the cryptococcal antigen in the serum and pleural fluid. His symptoms improved after intercostal drainage and fluconazole therapy.

CONCLUSION

Infection can exacerbate symptoms in patients with systemic sclerosis with sub-pleural emphysema, thereby triggering a spontaneous pneumothorax. Pleural fluid--present but not initially seen because of the pneumothorax--could be a clue to a pre-existing pulmonary infection.

Management of spontaneous pneumothorax

Management of patients with a spontaneous pneumothorax continues to challenge clinicians. Recent guidelines help provide care pathways for these patients and highlight the many areas in need of additional study. Management options for spontaneous pneumothoraces should be selected based primarily upon a patient's clinical status. Observation or pleural air drainage, in selected patients, plays a significant role in patients with primary spontaneous pneumothorax. By contrast, pleural air drainage plays the central role in patients with a secondary spontaneous pneumothorax. Surgically directed recurrence prevention and air leak management are preferred for both primary and secondary spontaneous pneumothorax patients.

[Persistent air leak (PAL): conservative vs. invasive approach?]

INTRODUCTION

An air leak following pulmonary resection is generally defined as persistent, or prolonged, if it fails to resolve within the first post-operative week. The precise definition has varied from study to study.

STATE OF ART

Persistent air leak represents the most frequent complication in patients undergoing general thoracic procedures. The groups most at risk are elderly patients, patients with chronic obstructive pulmonary disease (COPD), and those who have general risk factors such as diabetes mellitus or who are taking oral steroids. The surgical procedures most commonly affected are upper lobectomies and lung volume reduction surgery for end-stage emphysema.

PERSPECTIVES

Technically, performing a pleural tent at the time of an upper lobectomy may decrease the incidence of prolonged air leak. Reinforcement or buttressing of the staple line has been shown to decrease both the incidence and the duration of air leaks, but this increases costs and should thus be reserved for patients with lung parenchyma at the highest risk. The use of biological glues can be helpful in reducing the duration of chest tube drainage when applied intraoperatively for moderate and/or severe parenchymal air leaks, however, their systematic use in not recommended. The management of chest tube drainage after pulmonary resection varies widely from one institution to another. Most recent reports have favoured early discontinuation of negative pressure drainage and a move to underwater seal drainage (from the second post-operative day), however, no large scale randomised study is yet available to compare this with a more conservative approach.

CONCLUSIONS

The management of persistent air leak following surgery requires identification of risk factors, good surgical technique and appropriate chest tube management.

Centromere DNA, proteins and kinetochore assembly in vertebrate cells

The centromere is a specialized region of the chromosome that is essential for faithful chromosome segregation during mitosis and meiosis in eukaryotic cells. It is the site at which the kinetochore, the functional nucleoprotein complex responsible for microtubule binding and chromosome movement, is assembled through complex molecular mechanisms. Herein, I review recent advances in our understanding of centromeric DNAs as sites for kinetochore assembly and the mechanisms underlying kinetochore assembly in vertebrate cells.

An evidence-based approach to drainage of the pleural cavity: evaluation of best practice

Recent surveys have uncovered major variations in key aspects of intercostal drain management, suggesting that decisions are being made on individual preferences without resorting to sound evidence. We provide an up-to-date review of the best practice with evidence-based recommendations and expert consensus views. The following aspects of chest drain management have been addressed: indications for drainage, insertion technique, complications, management of an indwelling chest drain, indications and technique for removal. The emphasis in this review is that safe intercostal drain practice relies upon adherence to a few important principles. Furthermore, when in doubt, particularly with a complex thoracic problem, one should seek prompt specialist advice.

Predictors of alveolar air leaks

Persistent air leaks are caused by the failure of the postoperative lung to achieve a configuration that is physiologically amenable to healing. The raw pulmonary surface caused by the dissection of the fissure often is separated from the pleura, and the air leak fails to close. Additionally, higher air flow thorough an alveolar-pleural fistula seems to keep the fistula open. Other factors that interfere with wound healing, such as steroid use, diabetes, or malnutrition, can result in persistence of the leak. A thoracic surgeon can minimize the incidence of air leak through meticulous surgical technique and can identify patients in whom the balance of risks (Table 1) and benefits warrant operative intervention based on an understanding of the underlying pathophysiology.

Management of spontaneous pneumothorax-a Welsh survey

The authors sought to determine to what degree current practice by hospital physicians and accident and emergency (A&E) departments in Wales conformed to the British Thoracic Society's guidelines for the management of spontaneous pneumothorax. Questionnaires were posted to all consultants involved in emergency medical admissions in Wales (149 consultant physicians and 23 A&E consultants) of whom 101 (59%) replied. Only 45% used the classification, "small, moderate, or complete" to describe the size of pneumothorax. Just 44% would do as recommended by the British Thoracic Society and discharge an asymptomatic patient with a primary pneumothorax and 34% would discharge a patient with a primary pneumothorax after successful aspiration. Only 20% were prepared to try aspiration initially for a secondary pneumothorax with a complete lung collapse. Thirty four per cent would follow the recommendation to remove a chest drain without prior clamping of the tube 24 hours after bubbling had stopped. In the event of a persistent air leak 69% would refer patients or seek a specialist opinion. Physicians with an interest in respiratory medicine tolerated persistent air leaks for significantly longer than did non-respiratory physicians (median of 7 v 5 days, p=0.001). The survey indicates that fewer than expected consultant physicians and A&E consultants in Wales manage spontaneous pneumothoraces in the way recommended by the guidelines. Physicians with an interest in respiratory medicine tended to comply with these guidelines more than general physicians with interests other than respiratory medicine or A&E consultants but the trend was not significant at the 5% level. It is felt that the guidelines should be disseminated more widely, ensuring that emergency admissions units and A&E departments have copies on display or easily accessible, and that they could be expanded to cover other aspects such as timing for surgery.

Treatment of spontaneous pneumothorax

Spontaneous pneumothorax (SP) continues to be a frequent management problem. The lack of universally accepted management guidelines and a myriad of treatment options contribute to the current heterogeneous approach to SP. Forthcoming guidelines may improve management. Meantime, simple observation in stable patients with a primary spontaneous pneumothorax (PSP) is reasonable, and encouraging smoking cessation is paramount. More aggressive management of a patient with a secondary spontaneous pneumothorax (SSP) is advisable and should include at least chest tube drainage with chest tube size selection key. Careful assessment of recurrence risk and early corrective intervention for patients with a persistent air leak will improve care of both PSP and SSP patients. If chest tube-directed pleurodesis is chosen for recurrence prevention, talc is the most successful agent available. However, no more than 5 g of talc should be utilized, given the potential increased risk for acute respiratory failure at higher doses, and patients should be advised of alternatives such as doxycycline. No overwhelming clinical outcome advantages for a thoracoscopic over a limited thoracotomy approach to SP management has been reported in any randomized controlled trial. Institutional experience with and the availability of thoracoscopy or limited thoracotomy should dictate the operative approach to SP recurrence prevention and air leak correction until further study clarifies the choice.

Persistent air-leak in spontaneous pneumothorax--clinical course and outcome

Persistent air-leak in patients with spontaneous pneumothorax (SP) is not uncommon and may present a management dilemma in those who are unfit or unwilling for surgery. Video-assisted thoracoscopic surgery (VATS) has been advocated in the management of patients with broncho-pleural fistulae (air-leak persisting beyond 7 days): however the optimum time for surgical intervention remains unclear. We reviewed the records of 130 episodes of SP in 115 patients over a 2-year period to determine clinical course and outcome, particularly with respect to duration of air-leak. There were 90 first episodes and 40 recurrent episodes. Eighty-one episodes (62%) occurred in patients with underlying lung disease (secondary pneumothorax). Initial management consisted of chest-tube drainage in 104 episodes (80%) occurring in 90 patients, percutaneous needle aspiration in five patients (4%) and observation in 21 episodes (16%) in 20 patients. In the group treated with chest-tube drainage, there was spontaneous resolution of air leak and lung re-expansion in 90 episodes (87%). The overall incidence of broncho-pleural fistula was 34.6%. In the primary SP group. 75% of air-leaks ceased by 7 days and 100% by 15 days. In the secondary SP group, 61% of air-leaks resolved by 7 days and 79% by 14 days, after which time resolution of air-leak proceeded at a much slower rate. Five patients underwent surgery while nine patients were discharged with residual pneumothoraces. There were no major complications or mortality. Based on our findings, we advocate surgery for patients with air-leak persisting beyond 14 days, while favouring a conservative approach before this time, as the majority of air-leaks (especially in patients with primary pneumothorax) would resolve by 14 days.

Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) is now the generally preferred surgical treatment for spontaneous pneumothorax but is more difficult once pleural adhesions have developed. To test the hypothesis that VATS is under-used because of prolonged pleural intubation, we have audited the effect of preoperative management on subsequent surgical outcome.

METHOD

Data are expressed as median (range). A prospective audit of clinical outcome in 42 consecutive patients (30 male, 12 female, aged 39 [19-81] years) referred to a Regional Unit for non-elective pneumothorax surgery. VATS was attempted whenever possible.

RESULTS

VATS was successful in 32 patients (group V) but 10 (24%) patients (group T) required thoracotomy and decortication of an empyema thoracis. Only seven (17%) patients were operated upon within 7 days of presentation, and 10 patients (24%) waited for more than 21 days. The delay from presentation to operation was significantly longer in group T (22 days vs. 10 days, P < 0.05, Wilcoxon). There were significantly more preoperative pleural interventions in patients in group T than in group V (P < 0.05, Wilcoxon). Postoperative stay was longer in group T (7 days vs. 3 days, P < 0.05) and there was a significant overall correlation between preoperative delay and postoperative stay (r = 0.64).

CONCLUSION

Delayed referral for pneumothorax surgery and multiple pleural interventions predispose to pleural sepsis and preclude VATS detrimentally affecting clinical outcome. Changes in referral practice are advocated.

Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: a case series

This is a case series of 14 consecutive patients treated as outpatients for spontaneous pneumothorax (SP) (1 January 1992 to 31 December 1995) by one surgeon in a community hospital setting. The purpose of this study was to examine the appropriateness and financial implications of routine outpatient management of SP with closed tube thoracostomy and the Heimlich valve. All 14 patients reviewed were successfully managed as outpatients, although 3 required an overnight admission because of anxiety, pain, or vasovagal reaction. The routine outpatient treatment of all cases of SP not requiring definitive surgical intervention may have saved more than $16,000.00 for the hospital and an estimated $500,000.00 for the province of Ontario during the 1993-1994 fiscal year. Our findings suggest that the Heimlich valve is an appropriate alternative for the management of SP in a nonteaching community hospital setting, with benefits to the patient and to the health care system.