Spontaneous hemopneumothorax: an overlooked life-threatening condition

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

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

Unusual case of primary spontaneous hemopneumothorax in a young man with atypical tension pneumothorax: a case report

BACKGROUND

Spontaneous life-threatening hemopneumothorax is an atypical but treatable entity of unexpected circulatory collapse in young patients, affecting 0.5-11.6% of patients with primary spontaneous pneumothorax. Spontaneous pneumothorax is a well-documented disorder with a classic clinical presentation of acute onset chest pain and shortness of breath. This disorder might be complicated by the development of hemopneumothorax or tension pneumothorax.

CASE PRESENTATION

A 23-year-old Asian man was referred to the emergency room of Xiamen Chang Gung Memorial Hospital with a 1-day history of right-sided chest pain that had been aggravated for 1 hour. A physical examination revealed a young man who was awake and alert but in mild to moderate painful distress. His vital parameters were relatively stable at first. The examining physician noted slight tenderness along the right posterolateral chest wall along the eighth and tenth ribs. Primary spontaneous pneumothorax was considered, and a standing chest X-ray confirmed the diagnosis. A right thoracostomy tube was immediately placed under sterile conditions, and he was referred to the respiratory service. While in the respiratory department, approximately 420 mL of blood was drained from the thoracostomy tube over 15 minutes. Our patient developed obvious hemodynamic instability with hypovolemic shock and was subsequently admitted to the cardiothoracic surgical ward after fluid resuscitation. During the ensuing 4 hours after admission, 750 mL of blood was drained through the thoracostomy tube. A bedside chest X-ray was requested after he was temporarily hemodynamically stabilized. Primary spontaneous hemopneumothorax associated with right tension pneumothorax was considered based on the radiological impression and clinical signs. An emergency limited posterolateral thoracotomy was performed. A standing chest X-ray performed on day 6 of admission after the removal of the thoracostomy tube showed a complete re-expansion of his right lung. He remained stable and was discharged within 1 week.

CONCLUSIONS

The successful treatment of a large spontaneous hemopneumothorax depends on early recognition, proactive intervention, and early consideration by a cardiothoracic surgeon. Once the diagnosis is confirmed, early thoracotomy should be considered. Such an aggressive surgery not only leads to shorter hospitalization but also confers better long-term outcomes.

Assessment of spontaneous hemopneumothorax: Indications for surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Non-traumatic and spontaneous hemothorax in the setting of forensic medical examination: a systematic literature survey

Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax.

Early Surgeryfor Treatment of Spontaneous Hemopneumothorax

Purpose:

Spontaneous hemopneumothorax (SHP) is a rare life threatening disorder. We retrospectively investigated patients with SHP who were treated with video- assisted thoracic surgery (VATS), and report our results.

Methods:

From January 1993 to July 2006, 239 patients with spontaneous pneumothorax were treated, among whom 11 (4.6%) were diagnosed with SHP.

Results:

All 11 patients had a collapsed lung condition worse than moderate and a chest tube inserted, of whom 10 underwent an emergency operation. The points of hemorrhaging, each of which were in the apical portion of the lung, were easily revealed during VATS, and we were able to distinguish between brisk flow and seepage. Hemostasis was acquired using VATS in all surgery cases, while the other was treated with tube drainage. The single patient who did not undergo surgical treatment had recurrent spontaneous pneumothorax 3 months later.

Conclusion:

It is important to perform surgery for SHP at the appropriate time. VATS was found to be an easily performed and safe procedure for initial treatment in patients with active hemorrhaging and massive blood clotting in the thorax. The long-term outcome of our patients with early surgical indication was excellent and we recommend early surgical treatment for SHP.

Video-assisted thoracic surgery for spontaneous haemopneumothorax

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early Video-Assisted Thoracic Surgery for Primary Spontaneous Hemopneumothorax

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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