Talc poudrage in the treatment of spontaneous pneumothoraces in patients with cystic fibrosis

Management of Primary Spontaneous Pneumothorax in a Third-Level Pediatric Surgical Center: A Retrospective Study

INTRODUCTION

The management of primary spontaneous pneumothorax (PSP) in pediatrics remains controversial. The aim of this study was to investigate the risk of recurrence after non-surgical treatment vs. surgery, the difference in the length of stay (LOS) between various treatment options, and the role of computed tomography (CT) in the management of PSP.

MATERIALS AND METHODS

We retrospectively reviewed patients admitted to our Pediatric Surgery Unit for an episode of PSP between June 2009 and July 2020. Medical records including clinical presentation at admission, diagnostics, treatments, complications, and LOS were collected.

RESULTS

Twenty-three patients (22 males and 1 female) were included in this study. Median age was 15.65 (range 9-18). Chest X-rays were performed in all patients and showed 5 small (22%) and 18 large (78%) PSP. Chest drain was used for large PSP (≥2 cm) if the patient was clinically unstable. Eleven patients (48%) were managed non-operatively with observation alone and a recurrence rate of 18%, chest drain was used in 11 patients with a recurrence rate of 36%, and surgery was deemed necessary as a first treatment choice in one case. Six patients (27%) had an episode of relapse after non-operative management or chest drain placement. Following surgery, a relapse occurred in 2 of the 6 patients. Chest drain insertion was associated with a longer LOS than observation alone (6.36 vs. 2.4 days), and surgery resulted in a longer LOS than other types of treatment (P = 0.001).

CONCLUSION

According to our experience, small PSP or clinically stable larger PSP can be treated conservatively with observation alone. Operative management should be taken into consideration in children with large symptomatic PSP, persistent air leak, and/or relapse after chest drain insertion.

Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency)

First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.

Pneumothorax in cystic fibrosis

Pneumothorax is recognized as a common and life-threatening complication in cystic fibrosis (CF) patients, especially in those who are infected with P. aeruginosa, B. cepacia or Aspergillus, need enteral feeding, are diagnosed as suffering from allergic bronchopulmonary aspergillosis (ABPA), developed massive hemoptysis, and their respiratory function is seriously compromised. Structural impairment and altered airflow dynamics in the lungs of CF patients are considered as the main predisposing factors, but also inhaled medications and non-invasive positive pressure ventilation (NIPPV) could increase the risk of pneumothorax. Clinical presentation could range from dramatic to very mild. Management of spontaneous pneumothorax occurring to patients with CF is essentially similar to that for non-CF patients. Therapeutic options include intercostal tube drainage, video-assisted thoracoscopic surgery (VATS), and medical or surgical pleurodesis. Pneumothorax increases both short- and long-term morbidity and mortality in CF patients and causes significant deterioration of their quality of life.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Video-assisted thoracic surgery for primary spontaneous pneumothorax in children: is there an optimal technique?

OBJECTIVE

Video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax refractory to nonoperative management was first reported in children by Rodgers in 1986 (Ann Surg. 1986; 204:677-680). Small series have shown success with apical blebectomy, mechanical or chemical (talc) pleurodesis, or combination techniques. We report the largest pediatric series of VATS for primary spontaneous pneumothorax (PSP) to date, to assess outcomes and compare techniques.

METHODS

Retrospective review of all children undergoing VATS for PSP between 1999 and 2007 at 2 university-affiliated hospitals by the same group of surgeons. Mann-Whitney U tests and chi(2) used (P < .05 = significant).

RESULTS

Thirty-two patients underwent 41 VATS procedures (32 initial-30 unilateral, 2 bilateral; 9 subsequent-7 contralateral, 2 ipsilateral recurrences). Mean age at presentation was 16.5 years (range, 13-20 years). Blebs were identified at the time of VATS in 95% of patients, but in 12.5%, they were on lower lobes. Mean duration of postoperative air leak was 2.7 days, postoperative hospital length of stay was 5.0 days, and postoperative chest tube duration was 5.1 days; 2 patients required Heimlich valves, which were managed at home. Five different surgical techniques were used as follows: blebectomy plus mechanical pleurodesis had the shortest length of stay (4.3 days) and need for chest tube drainage (4.1 days) but had a higher recurrence risk (6% major, 16% minor) than blebectomy plus chemical pleurodesis. The risk of requiring an additional VATS procedure (ipsilateral or contralateral) was 28%. Mean follow-up was 46 months.

CONCLUSIONS

Blebectomy plus either mechanical or chemical pleurodesis were both associated with acceptable outcomes. Blebectomy plus chemical pleurodesis appears to have less risk of ipsilateral recurrence but longer postoperative stay and chest tube drainage.

Pulmonary surgery in cystic fibrosis

Cystic fibrosis (CF) has a variety of pulmonary manifestations that include pneumonia, pulmonary abscess, bronchiectasis, hemoptysis, and pneumothorax. Although newer therapies have greatly improved survival of patients with CF, surgical interventions for definitive treatment of these sequelae are often required. Several reports have illustrated that, with the current advances in the perioperative treatment and care of CF patients, surgical interventions for these pulmonary manifestations may be performed safely, resulting in a greatly improved quality of life. Also, although improvements in lung transplantation offer new hope for definitive treatment of those patients with cystic fibrosis, special considerations regarding other surgical issues, such as the prevalence of gastroesophageal reflux, need to be addressed.

Surgical management of pulmonary and gastrointestinal complications in children with cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis is a common disorder, affecting as many as 1:2500 Caucasian live births. Despite improved medical management, disease-specific complications are common and are responsible for substantial morbidity and ultimately mortality. Both pulmonary and gastrointestinal complications of cystic fibrosis are well known; however, the complications requiring surgical intervention in the pediatric population are infrequent. We provide a detailed review of the cystic fibrosis-associated pulmonary and gastrointestinal complications and potential surgical options for management in children with cystic fibrosis.

RECENT FINDINGS

Recent operative approaches are described that include application of minimally invasive surgical techniques primarily for intrathoracic disease. Novel medical therapies are also presented. Finally an attempt is made to put in perspective those surgical care advances that have had a benefit on disease outcomes.

SUMMARY

This report will provide the physician caring for the child with cystic fibrosis an understanding of those disease complications that will require surgical consultation and potential operative intervention.

Thoracoscopic treatment of spontaneous pneumothorax in children

BACKGROUND/PURPOSE

This study describes the authors experience and results with thoracoscopic treatment of spontaneous pneumotrorax (SP) in 22 children.

METHODS

A total of 32 thoracoscopic procedures were performed in 22 children. The patients ranged in age from 9 to 21 years at the time of their first thoracoscopy. SP was primary in 9 and secondary in 13 patients. Pleurodesis was performed in all thoracoscopies using talc in 28 and pleural abrasion in 4 procedures. In 2 of these, apical pleurectomy was added to abrasion. Blebectomy was the additional surgical procedure associated with pleurodesis in 4 patients.

RESULTS

Thoracoscopy usually was performed with the patient under general anesthesia. In children with severe respiratory insufficiency, regional anesthesia was used. The mean operative time was 42.6 minutes (range, 8 to 114 minutes). The mean time of postoperative chest tube drainage was 4.6 days (range, 2 to 12 days). Three patients with cystic fibrosis had prolonged air leak lasting longer than 7 days after thoracoscopy. None of them required an additional surgical intervention, and the air leak ceased in 8, 8, and 12 days with continuous suction. One patient required a repeat thoracoscopy for bleeding from an intercostal artery on postoperative day one. The mean follow-up was 4 years (range, 2.5 months to 14 years). There have been 2 partial recurrences (6.25%), both in patients with secondary SP, which were treated by a repeat thoracoscopy and talc pleurodesis.

CONCLUSIONS

Thoracoscopic treatment of SP is safe and effective in children. It can be performed under regional anesthesia also in children with severe respiratory insufficiency. Because the complications and recurrences are encountered more frequently in children with an underlying lung disease, special care in surgical manipulation is required in this subgroup of patients with SP.

Pneumothorax in cystic fibrosis

Spontaneous pneumothorax is a common complication in patients with cystic fibrosis (CF). It is thought to occur more frequently in patients with more advanced disease. Recommendations on the management of pneumothorax in CF are based on retrospective analyses and reports from CF centers. The following is a review of what has been published regarding the incidence and management of pneumothorax in this population, with some comment on the pathogenesis of the complication.

Intrapleural talc for the prevention of recurrent pneumothorax

The ipsilateral recurrence rate after the first spontaneous pneumothorax treated with tube thoracostomy is reported to be between 23 percent and 52 percent. The incidence of recurrence after the first recurrence is substantially higher. Chemical pleurodesis has been attempted to decrease the recurrence rate. Tetracycline has been widely utilized, but parenteral tetracycline is no longer available. Therefore, alternative sclerosing agents have been used. Talc has been demonstrated to be effective in preventing recurrences and it has minimal long-term effects. This prospective study was designed to determine the efficacy of talc pleurodesis in patients with recurrent spontaneous pneumothorax. Eighteen patients admitted between May 1985 and March 1993 to the Department of Thoracic Surgery underwent thoracoscopy and were treated by tube thoracostomy with chemical pleurodesis. All the patients had had at least two pneumothoraces and six had had at least six pneumothoraces. Sterile asbestos-free talc, 2g, was aerosolized throughout the pleural surface. One or two chest tubes were inserted, left clamped for 2 h, and unclamped after this time. The tubes were removed when no air had escaped for 24 h. Only one (5.6 percent) patient had recurrence of the pneumothorax, and a second insufflation of talc resulted in no new recurrence after a follow-up of 10 months. The remaining 94.4 percent did not have recurrence of pneumothorax within an observation period of 38.5 +/- 28.1 months. The follow-up was more than 2 years for 66.7 percent with no recurrence and was more than 5 years for 33.3 percent. We conclude from these observations that the insufflation of 2 g of talc into the pleural space is a safe effective treatment for control of recurrent spontaneous pneumothorax.

Pediatric thoracoscopy: where have we come and what have we learned?

The procedure of thoracoscopy was employed in adult patients for more than half a century before the first report evaluating its use in children was published in 1976. Initially thoracoscopy was proposed as a technique for obtaining pulmonary biopsy specimens in immunocompromised children when interstitial pneumonia developed, but, as more experience with the technique was gained, new indications for its use in children have arisen. A review of the published reports on the use of thoracoscopy in children has brought to light areas in which the procedure has been particularly useful as well as several limitations of the procedure. In properly selected patients, thoracoscopy is an extremely accurate method of tissue diagnosis for diffuse and localized pulmonary infiltrates. This technique may be the procedure of choice in the diagnosis of mediastinal lesions in children and in the surgical treatment of empyema and pneumothorax. Most of the morbidity and mortality reported for the procedure have been in patients with diffuse interstitial pneumonias. Such patients, who are on high-pressure ventilator support, are best managed by a standard open lung biopsy. Maintenance of a sufficient pneumothorax has proved difficult in very small infants and children, and the procedure may not be applicable in children who weigh under 8 kg. Refinements in thoracoscopy instrumentation will allow the performance of more complicated surgical dissections as pediatric surgeons acquire more familiarity with this technique.

Thoracoscopic surgery for diseases of the lung and pleura. Effectiveness, changing indications, and limitations

OBJECTIVE

This study compared the results of video-assisted thoracic surgery (VATS) with thoracoscopic surgery (TS) for diseases of the lung and pleura.

SUMMARY BACKGROUND DATA

No studies exist that compare the capabilities of VATS with advanced video systems and instrumentation to that of TS which has been done for 80 years.

METHODS

A retrospective study was done comparing the effectiveness, indications, complications, and limitations of TS and VATS done for four categories of pleural disease: 1) pleural fluid problems, 2) diffuse lung disease, 3) lung masses, and 4) pneumothorax. The TS period was 1981-1990. The VATS period was 1991-1992.

RESULTS

Eighty-nine consecutive TS cases and 64 consecutive VATS cases were reviewed. TS for resolution of pleural fluid problem was successful in 29 of 34 patients (85%), and VATS was successful in 18 of 20 (90%). Diffuse lung disease was diagnosed by TS using a cup biopsy on end-stage patients in respiratory failure. Since 1991 the diagnosis has been made with VATS using stapled wedge excisions on ambulatory patients. Surgical mortality decreased from 33% (10 of 30) to 9% (1 of 11) and the postoperative stay from 16.6 +/- 2.4 days to 8.2 +/- 2.2 days. Lung masses were diagnosed entirely by incisional biopsies using TS. Diagnosis was made in 83% and postoperative stay was 5.3 +/- 1.0 day. VATS allowed excisional biopsies permitting diagnosis in 100% with a postoperative stay of 3.0 +/- 0.2 days (p = 0.05). However, 20% required conversion to thoracotomy to locate the subpleural mass. TS was performed for spontaneous pneumothorax in only 26% (5 of 19) of the total pneumothorax cases, whereas, VATS was used for spontaneous pneumothorax in 67% (12 of 18).

CONCLUSION

VATS has continued the effectiveness of TS for treating pleural fluid problems, has resulted in earlier surgical diagnostic intervention in diffuse lung disease and earlier therapeutic intervention in primary pneumothorax states, and has markedly expanded the safety, efficacy and indications for lung mass biopsy.

The effects of talc pleurodesis on growing swine

Talc pleurodesis is an effective means of preventing recurrent pneumothorax. We have successfully applied talc pleurodesis with thoracoscopy in children with cystic fibrosis presenting with pneumothorax. However, little is known about the effects of talc pleurodesis on lung compliance in growing children. Therefore, six young pigs (10 weeks old, weighing 15 +/- 1 kg) were prepared for study. In each pig, one hemithorax underwent thoracoscopy and talc pleurodesis (TALC). The other hemithorax underwent either thoracoscopy alone or no procedure (CONTROL). Dynamic and static respiratory mechanics were studied 5 and 10 weeks later. Air flow and airway pressure were measured to calculate dynamic transpulmonary and transrespiratory compliance, and static transpulmonary compliance. At 5 weeks, dynamic transpulmonary and transrespiratory compliance were less in the TALC lungs when compared with CONTROL lungs. At 10 weeks, the differences in dynamic transpulmonary and transrespiratory compliance between the TALC and CONTROL lungs had resolved. Static compliance was lower in the TALC lungs than in the CONTROL lungs at both 5 and 10 weeks, but this was significant only at 10 weeks. There was an improvement in static compliance in the TALC lungs between 5 and 10 weeks, but this only approached significance. At autopsy, there were marked adhesions and pleural thickening in the talc lungs. Histological examination demonstrated no differences in lung parenchyma between the TALC lungs and the CONTROL lungs. Talc pleurodesis causes a temporary impairment in dynamic transpulmonary and transrespiratory compliance that resolves with time and growth. Static compliance is more persistently compromised, but a trend toward improvement with time and growth exists.(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracoscopy and talc poudrage for pneumothoraces and effusions

The indications, technique, and results of thoracoscopic talc poudrage in the two clinical settings of pneumothorax and recurrent pleural effusion in chronically ill patients are reported. Forty patients underwent this treatment between May 1982 and September 1989. The patients ranged in age from 10 months to 78 years. Of the 20 patients who underwent treatment of pneumothorax, 9 had cystic fibrosis, 7 had severe chronic obstructive pulmonary disease, 2 had spontaneous pneumothoraces, and 2 had postoperative parenchymal bronchopleural fistulas. Nineteen patients (95%) had successful treatment. Of the 20 patients who underwent treatment of chronic effusions, 14 had malignant etiologies, 3 had chylothoraces, and 3 had other miscellaneous effusions. Eighteen patients (90%) in this group had successful treatment. There were two hospital deaths related to the underlying disease processes after the pleural space problems were successfully treated. This study suggests that proper selection of patients and full exploitation of the capabilities of thoracoscopy and talc poudrage will result in effective treatment with low morbidity and mortality.

Pneumothorax in cystic fibrosis: a 26-year experience

We reviewed the records of all patients with cystic fibrosis and radiologically demonstrated pneumothorax at Rainbow Babies and Childrens Hospital between 1959 and 1987. There occurred 144 pneumothoraces, 71 right and 73 left, in 99 patients, 48 female and 51 male. The median survival from the date of the first pneumothorax was 29.9 months. Primary therapy included the following: observation; tube thoracostomy; tube thoracostomy with instillation of quinacrine hydrochloride, tetracycline, silver nitrate, or talc; or partial pleurectomy. Complications were minimal in each group. The surgical group did significantly better than all other groups except the group given talc. We conclude that pneumothorax is a late and ominous complication of cystic fibrosis. The primary treatment of pneumothorax should be partial pleurectomy. Talc instillation should be reserved for patients in respiratory failure who are too ill to undergo operation and for the occasional patient in whom surgical intervention fails.