Prediction of recurrent spontaneous pneumothorax: CT scan findings versus management features

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

OBJECTIVES

The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

METHODS

This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

RESULTS

The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

CONCLUSIONS

With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

SHAREABLE ABSTRACT

This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax

BACKGROUND

The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP.

METHODS

This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations.

RESULTS

The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis.

CONCLUSIONS

With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

DAWTran: dynamic adaptive windowing transformer network for pneumothorax segmentation with implicit feature alignment

Objective. This study aims to address the significant challenges posed by pneumothorax segmentation in computed tomography images due to the resemblance between pneumothorax regions and gas-containing structures such as the trachea and bronchus.Approach. We introduce a novel dynamic adaptive windowing transformer (DAWTran) network incorporating implicit feature alignment for precise pneumothorax segmentation. The DAWTran network consists of an encoder module, which employs a DAWTran, and a decoder module. We have proposed a unique dynamic adaptive windowing strategy that enables multi-head self-attention to effectively capture multi-scale information. The decoder module incorporates an implicit feature alignment function to minimize information deviation. Moreover, we utilize a hybrid loss function to address the imbalance between positive and negative samples.Main results. Our experimental results demonstrate that the DAWTran network significantly improves the segmentation performance. Specifically, it achieves a higher dice similarity coefficient (DSC) of 91.35% (a larger DSC value implies better performance), showing an increase of 2.21% compared to the TransUNet method. Meanwhile, it significantly reduces the Hausdorff distance (HD) to 8.06 mm (a smaller HD value implies better performance), reflecting a reduction of 29.92% in comparison to the TransUNet method. Incorporating the dynamic adaptive windowing (DAW) mechanism has proven to enhance DAWTran's performance, leading to a 4.53% increase in DSC and a 15.85% reduction in HD as compared to SwinUnet. The application of the implicit feature alignment (IFA) further improves the segmentation accuracy, increasing the DSC by an additional 0.11% and reducing the HD by another 10.01% compared to the model only employing DAW.Significance. These results highlight the potential of the DAWTran network for accurate pneumothorax segmentation in clinical applications, suggesting that it could be an invaluable tool in improving the precision and effectiveness of diagnosis and treatment in related healthcare scenarios. The improved segmentation performance with the inclusion of DAW and IFA validates the effectiveness of our proposed model and its components.

Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions

For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.

Meta-analysis of the association between emphysematous change on thoracic computerized tomography scan and recurrent pneumothorax

OBJECTIVES

At least a third of patients go on to suffer a recurrence following a first spontaneous pneumothorax. Surgical intervention reduces the risk of recurrence and has been advocated as a primary treatment for pneumothorax. But surgery exposes patients to the risks of anaesthesia and in some cases can cause chronic pain. Risk stratification of patients to identify those most at risk of recurrence would help direct the most appropriate patients to early intervention. Many studies have addressed the role of thoracic computerized tomography (CT) in identifying those individuals at increased risk of recurrence, but a consensus is lacking.

AIM

Our objective was to clarify whether CT provides valuable prognostic information for recurrent pneumothorax.

DESIGN

Meta-analysis.

METHODS

We conducted an exhaustive search of the literature for thoracic CT imaging and pneumothorax, and then performed a meta-analysis using a random effects model to estimate the common odds ratio and standard error.

RESULTS

Here, we show by meta-analysis of data from 2475 individuals that emphysematous change on CT scan is associated with a significant increased odds ratio for recurrent pneumothorax ipsilateral to the radiological abnormality (odds ratio 2.49, 95% confidence interval 1.51-4.13).

CONCLUSIONS

The association holds true for primary spontaneous pneumothorax when considering emphysematous changes including blebs and bullae. Features, such as bullae at the azygoesophageal recess or increased Goddard score similarly predicted recurrent secondary pneumothorax, as shown by subgroup analysis. Our meta-analysis suggests that CT scanning has value in risk stratifying patients considering surgery for pneumothorax.

Effect of meteorological factors on first episode and recurrence of primary spontaneous pneumothorax

OBJECTIVE

In this study, we evaluated the clinical characteristics and seasonal distribution of patients with primary spontaneous pneumothorax and examined the relationships between meteorological factors and pneumothorax development overall and in terms of first episode and recurrence.

METHODS

The hospital records of 168 pneumothorax patients treated in our clinic between January 2016 and December 2020 were reviewed retrospectively. A cluster was defined as two or more patients with pneumothorax presenting within three consecutive days. Meteorological factors were compared between days with and without pneumothorax patients. This comparison was based on meteorological data from the day of symptom onset (D), the day before symptom onset (D1), and the difference between those days (D-D1). Meteorological data from the index day (D) were also compared between patients with first episode and recurrence of pneumothorax.

RESULTS

The study included 149 (88.7%) men and 19 (11.3%) women. The mean age was 25.02±6.97 (range, 17-35; median, 26) years. Of note, 73 (43.4%) patients underwent surgery. The highest number of patients presented in November (n=19, 11.3%). In terms of season, most presentations occurred in autumn. Humidity was significantly lower on recurrence days compared with first episode (p=0.041).

CONCLUSION

Our results indicated that meteorological factors (i.e., atmospheric pressure, humidity, wind speed, temperature, and precipitation) were not associated with pneumothorax development. By comparing the patients with first episode and recurrence, the humidity was significantly lower in the recurrence group.

Management of primary spontaneous pneumothorax: Our single-center, five-year experience

BACKGROUND

In this study, we aimed to analyze the effects of admission time to the hospital and different variables on the treatment efficiency and to evaluate the recurrence during the clinical management process in patients with the diagnosis of primary spontaneous pneumothorax.

METHODS

A total of 149 patients with primary spontaneous pneumothorax (131 males, 18 females; mean age: 24.8±6.8 years; range, 17 to 35 years) treated in our clinic between January 2015 and December 2019 were retrospectively analyzed. Time from symptom onset to hospital admission (admission time) was classified as three periods: <24 h, between 24 and 72 h, and >72 h. Data including admission time, demographic and clinical characteristics, smoking history, body mass index, the use of pleurectomy or pleural abrasion during surgery were collected from the charts of the patients.

RESULTS

Admission time had no statistically significant effect on the length of hospital stay, recurrence, and the need for surgery. Male sex, smoking history, and lower body mass index had no significant effect on the recurrence. Recurrence and length of hospital stay did not significantly differ between the patients in whom pleurectomy or pleural abrasion added to the procedure during the operation.

CONCLUSION

A longer interval between symptom onset and hospital admission and lower body mass index have no adverse effect on treatment outcomes and the recurrence in patients with primary spontaneous pneumothorax. Despite the fact that surgical treatment significantly decreases the recurrence rate, pleurectomy and pleural abrasion techniques have no significant difference on the clinical influence and recurrence of these patients.

Unexpected Histopathological Diagnosis of Placental Transmogrification of the Lung after Bullectomy for Recurrent Spontaneous Pneumothorax: A Case Report and Literature Review

We report a 33-year-old man who presented with recurrent right pneumothorax. Computed tomography (CT) showed the presence of a large bulla with a maximum diameter of 8 cm in the right middle lobe; he subsequently underwent bullectomy. Histopathology revealed that pulmonary parenchyma adjacent to the bulla represented nodular proliferation of clear cells characterized by a papillary structure resembling placental chorionic villi. Immunohistochemically, clear cells were positive for CD10, suggesting placental transmogrification of the lung (PTL). We reviewed 36 surgical cases of PTL, and only 2 cases (5.6%), including our case, were operated for spontaneous pneumothorax. Bullous lesions secondary to PTL tend to appear as unilateral large cystic masses in non-upper lobes, which is atypical for primary spontaneous pneumothorax (PSP). Although PTL is considered a very rare cause of secondary pneumothorax, we must carefully differentiate this condition.

Utility of thoracic computed tomography to predict need for early surgery and recurrence after first episode of primary spontaneous pneumothorax

INTRODUCTION

CT imaging is not advocated by British Thoracic Society guidelines after first episode of primary spontaneous pneumothorax (PSP). There is emerging evidence that emphysema-like changes and CT-based dystrophy severity score (DSS) can predict need for early surgery and recurrence.

OBJECTIVES

We aimed to assess the role of DSS during first episodes of PSP in predicting the need for early surgery and recurrence.

METHODS

We conducted a retrospective analysis of consecutive PSP episodes (n=197) admitted to our institution from 1 January 2012 to 31 December 2017. DSS was calculated based on type, number and distribution of blebs and bullae. Patients were categorised as low-grade (0-3) or high-grade (4-6) DSS assessed by a thoracic radiologist.

RESULTS

Forty-five PSP patients had CT at first presentation. Eight patients had low-grade DSS; all were managed non-surgically and none had recurrence over 12 months. Thirty-seven patients had high-grade DSS. Of these, 25 (67.5%) were managed surgically, with three having contralateral recurrence over 12 months; 12 (32.5%) were managed non-surgically, and of these two patients had ipsilateral recurrence over 12 months.

CONCLUSION

DSS seems to predict the need for early surgery and recurrence and CT can be used to risk-stratify patients after a first episode of PSP.

Management of Pneumothorax

Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.

A left lung with four lobes: a new discovery during the thoracotomy for recurrent primary spontaneous pneumothorax

Background

The right and left lung anatomy are similar but asymmetrical. The right lung consists of three lobes, and the left lung consists of two lobes. Our study is unique because of discovering a very rare morphological feature of the left lung which has not been reported yet. By the way, we compared two different available chemical agents for pleurodesis (talc and bleomycin) according to side effects, complications, and pneumothorax recurrence.

Case presentation

We reported a case of bilateral primary spontaneous pneumothorax, who underwent talc slurry and bleomycin pleurodesis at right and left side retrospectively, and then complicate with left-sided recurrent spontaneous pneumothorax, so underwent open thoracotomy and was surprisingly and accidentally found to have 4 lobes and 3 fissures in left lung.

Conclusion

In our case report, there were one main oblique fissure and two accessory fissures which divided the lung into 4 separated lobes, and this discovery in human’s and other animals’ lung anatomy has not been previously reported. In our case study, the talc slurry was more effective in preventing spontaneous pneumothorax recurrence, but with more side effects than bleomycin. We could hypothesize that the morphological variation of the lung might affect spontaneous pneumothorax development and recurrence.

Fate of contralateral asymptomatic bullae in patients with primary spontaneous pneumothorax

OBJECTIVES

This retrospective cohort study aimed to analyse the impact of asymptomatic blebs/bullae on the occurrence of primary spontaneous pneumothorax (PSP) by monitoring the natural course of contralateral blebs/bullae in patients with ipsilateral pneumothorax.

METHODS

From January 2003 to December 2017, 1055 patients [age 19.6 ± 3.98 years (mean ± standard deviation), 953 men] experiencing the first episode of unilateral PSP were enrolled in this study, excluding patients aged 30 years or more. The presence, number and maximal size of the blebs/bullae were investigated in contralateral asymptomatic lungs based on high-resolution computed tomography.

RESULTS

Multiple and single blebs/bullae were noted in contralateral lungs in 425 (40.3%) and 88 (8.3%) patients, respectively. The median follow-up period was 44.0 (interquartile range 71.5) months. The 1-, 3- and 5-year cumulative occurrence rates of PSP in contralateral lungs were 7.9%, 13.7% and 16.7%, respectively. On multivariable analysis, younger age [hazard ratio (HR) 1.19, 95% confidence interval (CI) 1.12-1.27; P < 0.001) and multiple bullae (HR 4.42, 95% CI 3.06-6.38; P < 0.001) were independent risk factors for spontaneous pneumothorax in the contralateral lung. The 5-year cumulative occurrence rates of PSP were significantly higher in patients with multiple blebs/bullae than in those with no or a single bleb/bulla (28.2% vs 8.5%, respectively; P < 0.001).

CONCLUSIONS

Asymptomatic blebs/bullae often lead to PSP. If the patient is eligible for surgery for pneumothorax, preemptive surgery for contralateral bullae could be considered, especially in patients with multiple blebs/bullae.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

Recommendation for management of patients with their first episode of primary spontaneous pneumothorax, using video-assisted thoracoscopic surgery or conservative treatment

International guidelines do not recommend surgery for the first episode of primary spontaneous pneumothorax (PSP), except in cases of persistent air leak, hemopneumothorax, bilateral pneumothorax, or occupations at risk. However, these recommendations have been challenged because of a significant reduction in the recurrence rate in emerging studies. We evaluated the rationale of recommendations by systematically reviewing RCTs and observational studies by using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. We searched articles in PubMed, EMBASE, and Cochrane databases up to August 15, 2020. The primary outcomes were the recurrence rate and complication rate. The secondary outcomes were hospital stay and drainage duration. Nine eligible studies with 1121 patients were retrieved and analyzed. The recurrence rate was lower in the VATS than in conservative treatment with moderate evidence (OR 0.13, 95% CI 0.09 to 0.19, P < 0.001, I² = 0%). We did not find significant differences in complication rate (Peto OR 1.17, 95% CI 0.33 to 4.12, P = 0.80), hospital stay duration (MD − 0.48 days, 95% CI − 2.84 to 1.87, P = 0.69, very low evidence), and in drainage duration (MD − 3.99 days, 95% CI − 9.06 to 1.08, P = 0.12, very low evidence) between the two groups. Our results would suggest VATS treatment as a weak recommendation for patients with the first episode of PSP, based on our systematic review of the current evidence by using the GRADE system, indicating that different treatments will be appropriate for different patients and that patients’ values and preferences should be incorporated through shared decision making.

Trial REGISTRY: PROSPERO; No.: CRD42020162267.

[Pneumothorax]

A pneumothorax is defined by the presence of free air between the pleura visceralis and the pleura partietalis. The lung separates from the chest wall, which then, depending on several parameters, leads to a slight or clinically threatening impairment of lung function. Non-specific signs such as thoracic pain or coughing are common and do not correlate with the extent of the pneumothorax. Almost without exception, the cause of this accumulation of air is a leakage in the lung's surface, which then results in air escaping into the pleural space. Depending on the cause of the "lung leakage", a distinction is made between a primary (idiopathic) spontaneous pneumothorax (PSP) that can be triggered without direct cause, and a secondary spontaneous pneumothorax (SSP) in case of an underlying known lung disease. Further between an iatrogenic pneumothorax in connection with a lung injury caused by medical measures, and a traumatic pneumothorax in the case of an accident-related lung tear. The relevant therapeutic goals are the elimination of the acute symptoms, the reliable achievement of re-expansion of the lungs, and, after appropriate information gathering about the probability and clinical significance of a pneumothorax recurrence and depending on the patient's wish, avoiding a recurrence by means of surgical measures. The therapy options range from a "wait-and-see" procedure, that merely monitors the findings, to a primary video-assisted thoracoscopic surgical therapy with detection and resection of the superficial lung lesion, as well as a measurement to obliterate the pleural cavity that prevents relapse. Regarding "follow-up care" or even behavioral recommendations after a pneumothorax, there are no recommendations that reduce the risk of recurrence.

Recurrence of primary spontaneous pneumothorax: Associated factors

INTRODUCTION

Determining the risk of recurrence of primary spontaneous pneumothorax is challenging. The objective of this study was to develop a risk assessment model to predict the probability of recurrence in patients with spontaneous pneumothorax.

METHODS

A retrospective study was performed of all episodes of pneumothorax diagnosed in the last 12 years in a hospital, in patients not initially submitted to surgery. Logistic regression was used to estimate the probability of recurrence. Based on a set of variables, a predictive model was built with its corresponding ROC curve to determine its discrimination power and diagnostic precision.

RESULTS

Of the 253 patients included, 128 (50.6%) experienced recurrence (37% within the first year). Recurrence was detected within 110 days in 25% of patients. The median of time to recurrence for the whole population was 1120 days. The presence of blebs/bullae was found to be a risk factor of recurrence (OR: 5.34; 95% CI: 2.81-10.23; p=0.000), whereas chest drainage exerted protective effect (OR: 0.19; 95% CI: 0.08-0.40; p=0.000). The variables included in the regression model constructed were hemoglobin and leukocyte count in blood, treatment received, and presence of blebs/bullae, with a fair discriminative power to predict recurrence [AUC=0.778 (95% CI: 0.721-0.835)].

CONCLUSION

The overall recurrence rate was high and was associated with the presence of blebs/bullae, failure to perform an active intervention (chest drainage) and low levels of hemoglobin and leukocytes in blood. Recurrence rarely occurs later than three years after the first episode. Once validated, this precision model could be useful to guide therapeutic decisions.

[Recurrence score to predict the risk of recurrence after first episode of primary spontaneous pneumothorax]

Introduction

the relationship between computed tomography (CT) scan findings and the risk of recurrence of primary spontaneous pneumothorax (PSP) is controversial. The purpose of this study is to determine the relationship between the Dystrophy Severity Score (DSS) and PSP recurrence after an initial episode.

Methods

we conducted a retrospective study including patients admitted to the hospital with PSP (first episode) between 2005-2017. The study population was divided into 2 groups, G1: PSP recurrence, G2: No recurrence. We undertook univariate analysis including various variables such as the DSS score followed by multivariate analysis.

Results

eighty-six patients were included in this study. Forty-eight percent of cases had PSP recurrence. Although the DSS score was significantly associated with PSP recurrence (p=0.008), multivariate analysis showed that the presence of bubbles on chest CT scan was the independent risk factor associated with PSP recurrence after a first episode (risk report: 3.26, p < 0.008).

Conclusion

the risk of PSP recurrence is significantly associated with the presence of bubbles on chest CT scan. Further studies are needed for better assessment of the DSS score.

Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study

BACKGROUND

The notion that smoking cannabis may damage the respiratory tract has been introduced in recent years but there is still a paucity of studies on this subject. The aim of this study was to investigate the relationship between cannabis smoking, pneumothorax and bullous lung disease in a population of operated patients.

METHODS AND FINDINGS

We performed a retrospective study on patients operated on for spontaneous pneumothorax. Patients were divided into three groups according to their smoking habit: cannabis smokers, only-tobacco smokers and nonsmokers. Cannabis lifetime exposure was expressed in dose-years (1d/y = 1 gram of cannabis/week for one year). Clinical, radiological and perioperative variables were collected. The variables were analyzed to find associations with smoking habit. The impact of the amount of cannabis consumption was also investigated by ROC curves analysis. Of 112 patients, 39 smoked cannabis, 23 smoked only tobacco and 50 were nonsmokers. Median cannabis consumption was 28 dose/years, median tobacco consumption was 6 pack/years. Cannabis smokers presented with more severe chronic respiratory symptoms and bullous lung disease and with a higher incidence of tension pneumothorax than both tobacco smokers and nonsmokers. Cannabis smokers also developed a larger pneumothorax, experienced prolonged postoperative stay and demonstrated a higher incidence of pneumothorax recurrence after the operation than nonsmokers did. The risk of occurrence of chronic respiratory symptoms and bullous lung disease in cannabis smokers was dose-related.

CONCLUSIONS

Cannabis smoking seems to increase the risk of suffering from respiratory complaints and can have detrimental effects on lung parenchyma, in a dose-dependent manner. Cannabis smoking also negatively affected the outcome of patients operated for spontaneous pneumothorax. A history of cannabis abuse should always be taken in patients with pneumothorax. There may be need for a specific treatment for pneumothorax in cannabis smokers.

Simultaneous bilateral thoracoscopic blebs excision reduces contralateral recurrence in patients undergoing operation for ipsilateral primary spontaneous pneumothorax

OBJECTIVE

Contralateral recurrence in patients with primary spontaneous pneumothorax is approximately 15%. If positive for blebs, the recurrence rate increases to 26%. This study seeks to determine whether simultaneous contralateral video-assisted thoracic surgery blebs excision would effectively lower the contralateral incidence of pneumothorax in patients undergoing surgery for ipsilateral primary spontaneous pneumothorax.

METHODS

Between January 2009 and December 2015, 335 patients with primary spontaneous pneumothorax, surgically treated in a single institution, were retrospectively studied. The median follow-up was 75 (50-99) months. All patients received video-assisted thoracic surgery blebectomy/bullectomy with pleural abrasions. They were classified into 3 groups: (1) ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae included 142 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs/bullae only receiving ipsilateral video-assisted thoracic surgery; (2) ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae included 123 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving only ipsilateral video-assisted thoracic surgery; and (3) bilateral video-assisted thoracic surgery with contralateral blebs/bullae included 70 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving 1-stage bilateral video-assisted thoracic surgery. Demographic data, perioperative details, recurrence patterns, recurrence-free survivals, and risk factors were compared.

RESULTS

The percentage of contralateral recurrence for the ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae, ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae, and bilateral video-assisted thoracic surgery with contralateral blebs/bullae groups differed significantly (0.7%, 14.6%, and 2.9%, respectively; P = .002). Multivariate analysis using the Cox proportional hazard model revealed that age less than 18 years (hazard ratio, 2.71; 95% confidence interval, 1.14-6.44; P = .024) and ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae (hazard ratio, 22.13, 95% confidence interval, 2.96-165, P = .003) were predictors of contralateral recurrence, of which recurrence-free survival was notably different among groups as determined by Kaplan-Meier analysis (P < .0001).

CONCLUSIONS

Simultaneous contralateral blebectomy in patients with primary spontaneous pneumothorax receiving ipsilateral video-assisted thoracic surgery significantly lowered future contralateral recurrence.

Primary spontaneous pneumothorax in children: factors predicting recurrence and contralateral occurrence

BACKGROUND

The risk factors for recurrence in primary spontaneous pneumothorax (PSP) in children are not well known. We aimed to identify possible risk factors, and to evaluate the utility of computerised tomography (CT) scans in predicting future episodes.

METHODS

We reviewed children aged < 18 years admitted to our institution for PSP from 2008 to 2017, excluding those with malignancies. Basic demographic data were extracted. Clinical data collected include pneumothorax laterality, CT results, treatment protocols and recurrences.

RESULTS

63 patients were included, 19 (30.2%) of whom had CT scans. A total of 41 surgeries were performed. The median (interquartile range) age was 15.4 years (14.9-15.9), and body-mass index was 17.9 kg/m² (15.8-19.3). 56 (88.9%) patients were male. Median follow-up duration was 19.8 months (11.6-35.9). Multivariate logistic regression analyses identified surgery in the first episode as a predictor for a subsequent contralateral occurrence (odds ratio [95% confidence interval] 32.026 [1.685-608.518], p = 0.021). No predictors for ipsilateral recurrence were found. CT scans were 76.5% sensitive for bleb detection, and predicted poorly for occurrence (positive predictive value 14.3%, likelihood ratio 1.1).

CONCLUSION

This is the first study demonstrating that surgery at first presentation appears to predict for occurrence of PSP on the contralateral lung. CT appears to be ineffective in detecting blebs and predicting PSP occurrence.

Do Blebs or Bullae on High-Resolution Computed Tomography Predict Ipsilateral Recurrence in Young Patients at the First Episode of Primary Spontaneous Pneumothorax?

Background

The relationship between the size of bullae and pneumothorax recurrence is controversial. The aim of this study was to retrospectively evaluate the role of blebs or bullae in predicting ipsilateral recurrence in young patients experiencing their first episode of primary spontaneous pneumothorax (PSP) who underwent conservative treatment.

Methods

A total of 299 cases of first-episode PSP were analyzed. The status of blebs or bullae was reviewed on high-resolution computed tomography (HRCT). The dystrophic severity score (DSS; range, 0 to 6 points) was calculated based on HRCT.

Results

The 5-year recurrence rate was 38.2%. In univariate analysis, age (<20 years), body mass index (<20 kg/m²), a unilateral lesion, and intermediate risk (DSS 4 and 5) were associated with recurrence. Sex; smoking history; and the presence, number, and maximal size of blebs or bullae were not related to recurrence. In Cox regression, age and intermediate risk were independent risk factors for recurrence. High risk (DDS 6) was not an independent risk factor.

Conclusion

The presence, number, and size of blebs or bullae did not affect ipsilateral recurrence. DSS failed to show a positive correlation between severity and recurrence. The decision to perform surgery in patients experiencing their first episode of PSP should not be determined by the severity of blebs and bullae.

Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis

Primary spontaneous pneumothorax (PSP) recurrence rates vary widely in the published literature, with limited data describing the factors that influence recurrence. The aims of this systematic review were to determine an estimation of PSP recurrence rates and describe risk factors for recurrence.

A systematic review was conducted of all studies reporting PSP recurrence. Electronic searches were performed to identify English language publications of randomised trials and observational studies. The population was adults with PSP, who underwent conservative management, pleural aspiration or chest drainage. The outcome of interest was recurrence. Articles were screened and data extracted from eligible studies by two reviewers.

Of 3607 identified studies, 29 were eligible for inclusion, comprising 13 548 patients. Pooled 1-year and overall recurrence rates were 29.0% (95% CI 20.9–37.0%) and 32.1% (95% CI 27.0–37.2%), respectively. Female sex was associated with increased recurrence (OR 3.03, 95% CI 1.24–7.41), while smoking cessation was associated with a four-fold decrease in risk (OR 0.26, 95% CI 0.10–0.63). I2 for random effects meta-analysis was 94% (p<0.0001), reflecting high heterogeneity between studies.

This systematic review demonstrates a 32% PSP recurrence rate, with greatest risk in the first year. Female sex was associated with higher risk, suggesting possible sex-specific pathophysiology.

High Nrf2 expression in alveolar type I pneumocytes is associated with low recurrences in primary spontaneous pneumothorax

Recurrent primary spontaneous pneumothorax (PSP) is a troublesome problem and a major concern for the patients. This study examined whether nuclear factor erythroid 2-related factor 2 (Nrf2) expression in alveolar type I pneumocytes was associated with the clinical manifestations of PSP patients including disease recurrence. Eighty-eight PSP patients who were managed with needlescopic video-assisted thoracoscopic surgery (NVATS) were included in this study. Immunohistochemistry (IHC) was assessed to determine Nrf2 expression in resected lung tissues and the results were correlated with clinicopathological characteristics by the chi-square or the Fisher's exact test. The prognostic value of Nrf2 for overall recurrence was evaluated by univariate and multivariable Cox regression model. The expression of Nrf2 was observed in type I pneumocytes of lung tissues from PSP patients by IHC. We found that low Nrf2 expression in PSP patients, especially in young (age ≤ 20, p = 0.033) and body mass index (BMI) ≥18 kg/m² (p = 0.019) groups, was significantly correlated with PSP recurrence. In the univariate and multivariate analyses, high Nrf2 expression was a significant protective factor for overall recurrence in PSP patients (univariate: p = 0.026; multivariate: p = 0.004). The expression level of Nrf2 in alveolar type I pneumocytes was a potential factor involved in PSP recurrence. Our findings suggest that elevated Nrf2 expression in PSP patients may be a promising way for reducing PSP recurrence.

Primary Spontaneous Pneumothorax Admitted in Emergency Unit: Does First Episode Differ from Recurrence? A Cross-Sectional Study

Introduction. Management of primary spontaneous pneumothorax (PSP) consists of immediate resolution of pleural air, or observation, and prevention of recurrence. The risk factors for recurrence remain debated. Objectives. We aimed to describe and compare the characteristics of patients presenting a first episode of PSP to those of patients presenting a recurrent PSP, in order to identify factors potentially related to recurrence. Methods. We conducted a cross-sectional study including all admissions for PSP in the EDs of fourteen French public hospitals from 2009 to 2013. PSP were classified as a first episode if the patient had no previous history of pneumothorax and as recurrence if a previous episode of spontaneous pneumothorax was documented in the patient's medical records or if a recurrence was identified during the inclusion period. To identify factors potentially associated with recurrence of PSP, multilevel logistic models were fitted. Results. During the study period, 918 (61,6%) first episodes and 573 (38,4%) episodes of recurrent PSP were identified. Clinical presentation, age, gender, smoking habits, and use of cannabis were similar in both groups. No clinical factor associated with recurrence was identified by multivariate analysis. Conclusion. In this large multicenter study, no clinical factor associated with recurrence was highlighted.

Association of MMP-2 and MMP-9 expression with recurrences in primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) is a common benign problem. However, PSP recurrence is still a troublesome complication for most patients. This study intended to determine the role of matrix metalloproteinase-2 (MMP-2) and MMP-9 in type II pneumocytes of patients with PSP and its relation with recurrence. Ninety-one patients who had undergone needlescopic video-assisted thoracoscopic surgery wedge resection of lung with identifiable blebs for PSP were included in this study. Immunohistochemical (IHC) staining was used to measure the expression of MMP-2 and MMP-9 in lung tissues of PSP patients. The results were further correlated with clinicopathological parameters and recurrence rates using chi-square or Fisher's exact test. The value of MMP-2 and MMP-9 for overall recurrence was analyzed by univariate and multivariable Cox regression model. IHC data revealed that MMP-2 and MMP-9 staining was predominantly observed in type II pneumocytes of patients with PSP. We found that MMP-2 and MMP-9 expression in PSP, especially male PSP patients, was significantly correlated with recurrence. In the univariate and multivariate analyses, MMP-2 and MMP-9 were statistically significant risk factors for overall recurrence in PSP patients. Therefore, high expression levels of MMP-2 and MMP-9 in type II pneumocytes show a positive correlation with PSP recurrence risk. Further studies are needed to validate whether reduction of MMP-2 and MMP-9 expression may be a promising way for decreasing the risk of PSP recurrence in the future.

First Episode of Spontaneous Pneumothorax: CT-based Scoring to Select Patients for Early Surgery

BACKGROUND

Although recurrence of primary spontaneous pneumothorax (PSP) is frequent, guidelines do not routinely recommend surgery after first presentation. A CT-based lung dystrophy severity score (DSS) has recently been proposed to predict recurrence following conservative therapy. This study compares the DSS in surgically and conservatively treated patients.

METHODS

This is a retrospective analysis of first episode PSP patients, comparing video-assisted thoracic surgery (VATS; group A) to conservative treatment with or without chest drainage (group B). CT scans were reviewed for blebs or bullae, and patients were assigned DSS values and stratified into risk groups (low and high-grade). Primary end point was ipsilateral or contralateral recurrence.

RESULTS

Fifty-six patients were included, 33 received VATS and 23 conservative treatment. In total, 37.5 % experienced recurrence, with a 5-year estimated recurrence rate of 40.7 % (group A: 13.3 %; group B: 73.9 %; p < 0.001). In group B, detection of any dystrophic lesions resulted in significantly higher 5-year recurrence rates (86.7 vs. 50.0 %; p = 0.03), there was no significant difference in group A (17.7 vs. 7.7 %; p = 0.50). Greater DSS values correlated with higher 5-year recurrence rates in group B (p = 0.02), but not in group A (p = 0.90). Comparing low- and high-grade patients in group B resulted in a significant 5-year recurrence rate of 53.8 versus 100 % (p = 0.023).

CONCLUSIONS

The DSS is useful to indicate VATS after the first episode. For routine application, assigning patients to low- and high-grade groups seems most practical. We recommend CT-evaluation for every PSP patient and early surgery for those with lesions exceeding one bleb. After VATS, the preoperative DSS is not beneficial in predicting recurrence.

Correlation of matrix metalloproteinase-2 and -9 expression with recurrences in primary spontaneous pneumothorax patients

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common benign disorder. However, unpredictable recurrence is a major concern for most patients. The aim of the present study was to assess the role of matrix metalloproteinase-2 (MMP-2) and MMP-9 in alveolar macrophages of patients with PSP and its relationship with recurrence.

METHODS

Ninety-two patients who received needlescopic video-assisted thoracoscopic surgery (NVATS) wedge resection of lung with identifiable blebs for PSP were enrolled for the study. Immunohistochemistry was performed to evaluate the expression of MMP-2 and MMP-9 in lung tissues of patients with PSP. The result was correlated with clinicopathological variables and recurrence rates by the chi-square test. The value of MMP-2 and MMP-9 for overall recurrence was evaluated by univariate and multivariable Cox regression analyses.

RESULTS

The MMP-2 and MMP-9 staining was predominantly observed in alveolar macrophages of patients with PSP. We found that MMP-2 (recurrence: P<0.001; smoking status: P=0.029) and MMP-9 (recurrence: P=0.001; smoking status: P=0.045) expression in PSP, especially male patients, was significantly correlated with recurrence and smoking status. In the multivariate analyses, MMP-2 [hazard ratio (HR) =2.83; 95% confidence interval (CI): 1.37-5.85, P=0.005) and MMP-9 (HR =2.25; 95% CI: 1.19-4.24, P=0.013) were statistically significant risk factors for overall recurrence in PSP patients.

CONCLUSIONS

High expression levels of MMP-2 and MMP-9 showed a positive correlation with recurrence in PSP patients. Further studies are required to test whether inhibition of MMP-2 and MMP-9 expression renders a promising approach for reducing the risk of PSP recurrence in the future.

Postoperative predictors of ipsilateral and contralateral recurrence in patients with primary spontaneous pneumothorax

BACKGROUND

Preventive surgery for contralateral recurrence of primary spontaneous pneumothorax (PSP) remains controversial and few studies discussed both ipsilateral and contralateral recurrences simultaneously. Thus, we aimed to identify the predictors of ipsilateral and contralateral PSP recurrence and to review literatures on the association of blebs/bullae on HRCT with PSP recurrence.

METHODS

We retrospectively reviewed consecutive patients who were treated at our hospital for first recurrence of PSP between January 2001 and December 2005.

RESULTS

This study included 553 patients who were followed-up for a mean period of 124 months. Ipsilateral and contralateral recurrence of PSP developed in 19.35% and 15.19% of patients, respectively. In the Cox regression analysis, the only significant predictors were no video-assisted thoracoscopic surgery (VATS) bullectomy (OR: 16.629, P<0.001) for ipsilateral recurrence, and the presence of blebs/bullae on HRCT (OR: 3.215, P=0.024) and low BMI (<18.5 kg/m²) (OR: 1.560, P=0.045) for contralateral recurrence.

CONCLUSIONS

VATS bullectomy was a strong independent predictor for prevention of ipsilateral PSP recurrence. Patients with contralateral blebs or bullae on chest HRCT or those with low BMI may be candidates for preventive VATS bullectomy to avoid recurrences and possible complications.

Abnormal bone mineral density and bone turnover marker expression profiles in patients with primary spontaneous pneumothorax

BACKGROUND

To examine the bone mineral density (BMD) and the role of bone biomarkers, including bone formation marker procollagen type I aminoterminal propeptide (PINP) and N-terminal midmolecule fragment osteocalcin (N-MID), bone resorption marker b-C-telopeptides of type I collagen (b-CTX) and tartrate-resistant acid phosphatase 5b (TRACP5b) in the pathogenesis of PSP.

METHODS

Eighty-three consecutive primary spontaneous pneumothorax (PSP) patients (PSP group) and 87 healthy individuals (control group) were enrolled in this study. General data, including gender, age, height, weight, and body mass index (BMI), were recorded. Dual-energy X-ray absorptiometry, electrochemiluminescence immunoassay (ECLIA), and ELISA were used to evaluate bone mineral density and expression levels of bone metabolism markers, including PINP, b-CTX, TRACP5b, N-MID, and 25-hydroxyvitamin D (25-OH VD).

RESULTS

Mean height was significantly greater in the PSP group compared with the control group, whereas weight and BMI were lower. Patients in the PSP group had significantly lower average bone mineral density, which mainly manifested as osteopenia (11/12, 91.7%); however, only one patient (8.3%) developed osteoporosis. Serum overexpression of PINP, b-CTX, TRACP5b, and N-MID were found in PSP patients. Expression of 25-OH VD was low in PSP patients. Bone resorption markers showed positive linear relationships with bone formation markers in all participants; whereas only TRACP5b expression negatively correlated with 25-OH VD. Expression levels of all bone turnover markers negatively correlated with BMI. Regression analysis identified risk factors of PSP as age, height, weight, and TRACP5b and 25-OH VD expression levels; whereas gender and PINP, b-CTX, and N-MID expression levels were not significantly associated with the onset of PSP.

CONCLUSIONS

It had lower bone mineral density in PSP patients. Bone formation marker PINP, N-MID and bone resorption marker b-CTX, TRACP5b were upregulated in PSP patients. 25-OH VD expression was relatively low in this population of PSP patients. Age, height, weight, and expression levels of TRACP5b and 25-OH VD may be risk factors for PSP.

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.

Spontaneous pneumothorax as indicator for Birt-Hogg-Dubé syndrome in paediatric patients

Background

Birt-Hogg-Dubé syndrome (BHD) is a rare autosomal dominantly inherited disorder caused by germline mutations in the folliculin (FLCN) gene. Clinical manifestations of BHD include skin fibrofolliculomas, renal cell cancer, lung cysts and (recurrent) spontaneous pneumothorax (SP). All clinical manifestations usually present in adults > 20 years of age.

Case presentations

Two non-related patients with (recurrent) pneumothorax starting at age 14 accompanied by multiple basal lung cysts on thoracic CT underwent FLCN germline mutation analysis. A pathogenic FLCN mutation was found in both patients confirming suspected BHD. The family history was negative for spontaneous pneumothorax in both families.

Conclusion

Although childhood occurrence of SP in BHD is rare, these two cases illustrate that BHD should be considered as cause of SP in children.

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.

Can preoperative imaging studies accurately predict the occurrence of bullae or blebs? Correlation between preoperative radiological and intraoperative findings

BACKGROUND

Radiological findings of patients with primary spontaneous pneumothorax (PSP) undergoing surgery have not been well analyzed. The aim of this study was to evaluate the accuracy of imaging studies for predicting the presence of emphysema-like changes (ELCs) detectable during surgery.

METHODS

Ninety-three PSP patients who underwent surgery from September 2005 to October 2009 were included in the study. We analyzed preoperative chest radiographic and computed tomographic (CT) findings, and compared the findings with intraoperative detection of ELCs. Chest radiographic findings were analyzed by classifying the PSP size into three categories: small, moderate, and complete.

RESULTS

Seventy-six of the 93 patients (82%) had ELCs detected during surgery. The size of the PSP on a radiograph was significantly correlated with the presence of ELCs (p=0.0121). Preoperative CT revealed 64 of the 76 ELCs (sensitivity, 84%; specificity, 100%; accuracy, 87%). Twenty-nine patients without ELCs detected by preoperative CT were analyzed separately. In this group, a larger PSP size also increased the likelihood of ELCs being present (p=0.0049). Seven patients (8%) experienced a recurrence after surgery. No factor could significantly predict recurrence.

CONCLUSIONS

Chest CT analysis alone was associated with a false-negative rate of about 15% for ELCs. Combining the analysis of chest radiographic and CT findings could improve sensitivity.

What factors predict recurrence after an initial episode of primary spontaneous pneumothorax in children?

PURPOSE

Recurrence is the most common complication after an initial episode of primary spontaneous pneumothorax (PSP). However, preventive surgery in children remains a controversial issue. The purpose of this study was to determine predictive factors of recurrence to better inform early surgical referrals.

METHODS

We retrospectively reviewed all consecutive patients under 18 years of age who conservatively treated for an initial episode of PSP between March 2005 and September 2011.

RESULTS

One hundred fourteen patients were included in this study. The mean follow-up period was 43.1 months. Ipsilateral and contralateral recurrence developed in 47.3% and 14.0% of patients. The risk of ipsilateral recurrence for patients with or without air-containing lesions according to high-resolution computed tomography (HRCT) was 60.3% and 31.4%. In the multivariate analysis, the presence of air-containing lesions on HRCT scans and bullae on chest X-rays were independent risk factors for ipsilateral recurrence.

CONCLUSION

The presence of bleb or bullae on HRCT scans or chest X-rays after an initial episode of PSP was significantly related to the ipsilateral recurrence in children. If the risk factors are clarified in further studies, hospital stays and the recurrence of PSP after the first episode could be reduced with early video-assisted thoracoscopic surgery.

Spontaneous contralateral pneumothorax in a patient with low Body Mass Index

Spontaneous pneumothorax is most common in adolescents and young adults. Some of them develop contralateral pneumothorax. In this paper, we report the case of a patient with spontaneous contralateral pneumothorax, whose body mass index (BMI) was 18.8 kg/m2. For either chest physicians or thoracic surgeons, follow up with recognition of increased risk of the contralateral pneumothorax is important especially in patients with contralateral bullous lesions and low BMI.

Role of blebs and bullae detected by high-resolution computed tomography and recurrent spontaneous pneumothorax

BACKGROUND

The prevention of recurrence after a first episode of primary spontaneous pneumothorax (PSP) remains a debated issue. The likelihood of recurrence based on the presence of blebs and bullae detected on high-resolution computed tomography (HRCT) imaging is controversial.

METHODS

We evaluated patients conservatively treated for PSP who underwent chest HRCT scan in a single-institution retrospective longitudinal study. Absolute risk values and positive and negative predictive values of recurrence based on HRCT findings were the primary end points.

RESULTS

We analyzed 176 patients. Ipsilateral and contralateral recurrence developed in 44.8% and 12% of patients, respectively. The risk of recurrence was significantly related to the presence of blebs or bullae, or both, at HRCT. The risk of ipsilateral recurrence for patients with or without blebs and bullae was 68.1% and 6.1%, respectively (positive predictive value, 68.1%; negative predictive value, 93.9%). The risk of contralateral pneumothorax for patients with or without blebs and bullae was 19% and 0%, respectively (positive predictive value, 19%; negative predictive value, 100%). The risk of ipsilateral recurrence was directly related to the dystrophic severity score: recurrence risk increased by up to 75% in patients with bilateral multiple lesions. Multivariate analysis showed that a positive HRCT was significantly related to ipsilateral recurrence.

CONCLUSIONS

The presence of blebs and bullae at HRCT after a first episode of PSP is significantly related to the development of an ipsilateral recurrence or a contralateral episode of pneumothorax. Further studies are needed to validate the dystrophic severity score in the selection of patients for early surgical referral.

Pediatric spontaneous pneumothorax

Spontaneous pneumothorax (SP) occurs when air enters the pleural space in the absence of a traumatic or iatrogenic etiology and is an uncommon phenomenon in the pediatric population. Although the typical presentation has been well described in the literature, much debate still surrounds the epidemiology, pathophysiology, diagnosis, and management of this condition in the pediatric population. To date, much of the emphasis in the pediatric literature has been on surgical options. Questions still remain regarding the true incidence of this disease in children, appropriate diagnostic imaging, and treatment recommendations for practitioners in the emergency department setting. This review of the evidence seeks to elaborate on current knowledge and clinical practice, as well as the applicability of adult recommendations to the pediatric population.

Primary spontaneous pneumothorax: a diffuse disease of the pleura

Primary spontaneous pneumothorax (PSP) is by definition not associated with any underlying lung disease. However, this does not mean that there is no underlying pathological process. It has become increasingly apparent over recent years that PSP is associated with diffuse and often bilateral abnormalities within the pleura and is not simply a disease caused by ruptured blebs/bullae. The pathological process includes emphysema-like changes, pleural porosity and inflammation. In this review, we summarise the recent advances in our understanding of the pathogenesis of PSP and discuss how this relates to management strategies for patients with PSP.

Management of primary spontaneous pneumothorax in children

OBJECTIVE

To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP).

METHODS

Retrospective cohort study.

RESULTS

The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage.

CONCLUSIONS

Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP.

Pleural controversy: aetiology of pneumothorax

Pneumothoraces are classified as spontaneous, traumatic and iatrogenic. Spontaneous pneumothoraces that occur without recognized lung disease are termed primary spontaneous pneumothoraces (PSP), whereas those that occur due to an underlying lung disease are termed secondary spontaneous pneumothoraces. The aetiology of secondary, traumatic or iatrogenic pneumothoraces is not usually debated. However, the aetiology of PSP is potentially controversial and often debated. Therefore, PSP is the focus of this article. There are several purported causes, which include blebs, bullae, emphysema-like changes (ELC) and pleural porosity. The controversy is valid because of the importance of recurrence prevention. This article reviews the current available evidence for the causes of PSP. The causes of PSP are likely a combination ELC, pleural porosity and other potential factors.

Review: Diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men. Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is reviewed concerning mechanisms and personal clinical experience with PSP. The chest computed tomography (CT) has been more commonly used than before to help understand the pathogenesis of PSP and plan further management strategies. The development of video-assisted thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to its minimal invasiveness and high effectiveness for patients with these diseases.

Radiological predictors of recurrent primary spontaneous pneumothorax following non-surgical management

BACKGROUND

Studies to date have not identified any reliable predictors for recurrence of primary spontaneous pneumothorax (PSP) on plain chest radiograph (CXR). The aim of this study was to assess whether abnormalities on CXR at first presentation of PSP can be used to predict recurrence of PSP.

METHOD

The study included all patients admitted to The Canberra Hospital between 1998 and 2004. CXRs taken at initial presentation were reviewed retrospectively by an independent radiologist. Radiological abnormalities on CXR included: pleural thickening: blebs/bullae; pleural irregularities and pleural adhesions.

RESULTS

One hundred patients were followed up for a mean duration of 57 months. The total rate of recurrence was 54%. Multivariate analysis found that the presence of an abnormality (irrespective of the type) increased the likelihood of recurrence and the risk of recurrence increased with each additional abnormality. Patients having one, two and three or more abnormalities were 3.0 (95% CI=2.09, 3.91, p=0.018), 5.3 (95% CI=4.47, 6.13, p<0.001) and 12.6 (95% CI=11.57, 13.63, p<0.001) times more likely to develop recurrence respectively.

CONCLUSION

In view of these results we now offer surgical treatment at first presentation PSP in patients in whom we identify two or more radiological abnormalities on CXR.