Management of primary spontaneous pneumothorax

Effectiveness of Video-Assisted Thoracoscopic Surgery with Bullectomy and Partial Pleurectomy in the Treatment of Primary Spontaneous Pneumothorax-A Retrospective Long-Term Single-Center Analysis

Background: Video-assisted thoracoscopic surgery (VATS) with bullectomy and partial pleurectomy (VBPP) is an increasingly used and well-established surgical treatment for primary spontaneous pneumothorax (PSP). However, reports on its effectiveness and long-term outcomes are limited. The aim of this study was to assess and compare long-term recurrence rates following VBPP and chest tube (CT) treatment and to identify potential risk factors for disease recurrence in patients with PSP. Methods: A total of 116 patients treated either by VBPP or CT were included in this study. Long-term recurrence rates and associations between clinical parameters and recurrence of pneumothorax were analyzed. Results: Sixty-two patients (53.4%) underwent VBPP, whereas 54 (46.6%) patients underwent CT treatment only. During a median follow-up period of 76.5 months, VBPP patients experienced a significantly lower recurrence rate compared to CT patients (6/62 vs. 35/54; p < 0.0001). CT treatment (VBPP vs. CT; p < 0.001) and a large initial pneumothorax size (Collins < 4 vs. Collins ≥ 4; p = 0.018) were independent risk factors for pneumothorax recurrence. Conclusion: VBPP is an effective and safe surgical treatment for PSP. Therefore, patients with a large pneumothorax size might benefit from VBPP, as they are at high risk for disease recurrence.

Two-port versus three-port video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: feasibility, postoperative outcome and long-term recurrence rates

Background

Two-port VATS (2-P-VATS) and three-port VATS (3-P-VATS) are well-established techniques for surgical therapy of primary spontaneous pneumothorax (PSP). However, comparisons of both techniques in terms of postoperative outcome and recurrence are limited.

Methods

From January 2010 to March 2020, we retrospectively reviewed data of 58 PSP patients who underwent VATS in our institution. For statistical analysis, categorical and continuous variables were compared by chi-square test or Fisher’s exact test and the Student´s t-test, respectively. Twenty-eight patients underwent 2-P-VATS and 30 were treated with 3-P-VATS. Operation time, length of hospital stay (LOS), total dose of analgesics per stay (opioids and non-opioids), duration of chest tube drainage, pleurectomy volume (PV), postoperative complications and recurrence rates were compared between both groups.

Results

Clinical and surgical characteristics including mean age, gender, Body-Mass-Index (BMI), pneumothorax size, smoking behaviour, history of contralateral pneumothorax, side of pneumothorax, pleurectomy volume and number of resected segments were similar in both groups. The mean operation time, LOS and total postoperative opioid and non-opioid dose was significantly higher in the 3-P-VATS group compared with the 2-P-VATS group. Despite not being statistically significant, duration of chest tube was longer in the 3-P-VATS group compared with the 2-P-VATS group. In terms of postoperative complications, the occurrence of hemothorax was significantly higher in the 3-P-VATS group (3-P-VATS vs. 2-P-VATS; p = 0.001). During a median follow-up period of 61.6 months, there was no significant statistical difference in recurrence rates in both groups (2/28 (16.7%) vs. 5/30 (7.1%); p = 0.274).

Conclusion

Our data demonstrate that 2-P-VATS is safer and effective. It is associated with reduced length of hospital stay and decreased postoperative pain resulting in less analgesic use.

Pneumothorax: Classification and Etiology

Pneumothorax is a common problem worldwide. Pneumothorax develops secondary to diverse aetiologies; in many cases, there may be no recognizable lung abnormality. The pathogenetic mechanism(s) causing spontaneous pneumothorax may be related to an interplay between lung-related abnormalities and environmental factors such as smoking. Tobacco smoking is a major risk factor for primary spontaneous pneumothorax; chronic obstructive pulmonary disease is most frequently associated with secondary spontaneous pneumothorax. This review article provides an overview of the historical perspective, epidemiology, classification, and aetiology of pneumothorax. It also aims to highlight current knowledge and understanding of underlying risks and pathophysiological mechanisms in pneumothorax development.

Does Video-Assisted Thoracoscopic Surgery with Bullectomy and Partial Pleurectomy for Primary Spontaneous Pneumothorax Impair Health-Related Quality of Life and Pulmonary Function?

Background: Video-assisted thoracoscopic surgery (VATS) with partial pleurectomy is an established treatment for primary spontaneous pneumothorax (PSP). However, postoperative pulmonary function and health-related quality of life (HR-QoL) after VATS–bullectomy with partial pleurectomy (VBPP) have not been elucidated. Methods: Eligible patients were assessed for HR-QoL using the Short-Form 36 (SF-36) health survey. Pulmonary function (PF) was evaluated by spirometry. We compared the results of the VBPP cohort with the German national norms, and with a similar cohort of patients successfully treated by chest tube (CT) only. Results: A total of 25 VBPP patients completed the SF-36 health survey, of whom 15 presented for PF assessment. Between the VBPP and CT groups, the mean forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1/FVC ratio were not statistically significantly different. However, in both groups, FVC, FEV1, and FEV1/FVC were above the lower limit of normal (LLN), suggesting no restrictive or obstructive patterns. Compared with the sex- and age-matched normal German population, patients who underwent VBPP displayed a similar physical component summary score and a significantly decreased mental component summary score. Interestingly, comparison of the SF-36 domains between the VBPP and CT groups showed no statistical difference. Conclusion: VBPP is a suitable surgical treatment for PSP, with no apparent adverse impacts on pulmonary or physical function. However, psychological distress and measures to counteract its impact should be considered.

Socioeconomic Impact of Recurrent Primary Spontaneous Pneumothorax: Should Video-Assisted Thoracoscopic Surgery Be Considered at First Episode of Primary Spontaneous Pneumothorax?

BACKGROUND

Current guidelines recommend video-assisted thoracoscopic surgery (VATS) for recurrent primary spontaneous pneumothorax (PSP) and for cases with persistent air leak after chest tube treatment. The socioeconomic impact of recurrent PSP on the healthcare system is insufficiently reported.

METHODS

Ninety-six patients treated for PSP between 01/2010 and 01/2020 were included. Forty-eight patients underwent primary VATS, while the second group received chest tube (CT) treatment only. Length of hospital stay (LOS), duration of chest tube, prolonged air leak, postoperative complications, recurrences and treatment costs were analyzed.

RESULTS

Prolonged air leaks were evident in 12.5% and 22.9% patients of the VATS and CT group, respectively. Ten (20.8%) patients in the CT group underwent VATS for persistent air leakage. During follow-up, the VATS group recurred at 8.3% compared to 52.1% in the CT group. The total cost of treatment per patient, including treatment cost due to recurrence, was EUR 1.501 in the VATS group and EUR 2.233 in the CT group.

CONCLUSIONS

Primary treatment of PSP by CT is associated with an increased socioeconomic burden for patients and the healthcare system due to high recurrence rates. This burden may be reduced if VATS is considered at the first episode of PSP.

Overexpression of matrix metalloproteinases in lung tissue of patients with primary spontaneous pneumothorax

BACKGROUND

Although blebs and bullae are frequently found in the apexes of lungs of patients with primary spontaneous pneumothorax (PSP), its pathogens remain unclear.

OBJECTIVES

To examine the role of proteases [matrix metalloproteinase (MMP)-2, MMP-7 and MMP-9] and antiproteases [tissue inhibitors of metalloproteinase (TIMP)-1, TIMP-2, TIMP-3 and TIMP-4] in the pathogenesis of PSP.

METHOD

Fifty consecutive PSP patients who received standard surgical care were enrolled in the study. Lung tissues from 20 patients with stage I non-small cell lung cancer were used as a control. Immunohistochemistry (IHC), reverse transcription-polymerase chain reaction (RT-PCR) and gelatin zymography were used to evaluate the expression of MMP and TIMP in the lung tissue of patients with PSP.

RESULTS

Overexpression of MMP-2, MMP-7 and MMP-9 was found in the afflicted lung by IHC, zymography and RT-PCR. By IHC, higher expression of MMP-2 and MMP-9 in PSP patients was identified in alveolar macrophages and type II pneumocytes (88 and 92% of patients in macrophages, and 72 and 70% of patients in type II pneumocytes, respectively). MMP-2, MMP-7 and MMP-9 expression in patients was higher in mesothelial cells (66, 76 and 76%). Overexpression of TIMP-2 was detected in the extracellular matrix around bullae and blebs. Expression levels of TIMP-1, TIMP-3 and TIMP-4 were negligible (<10% of cells) in both PSP patients and controls.

CONCLUSIONS

MMP-2, MMP-9, MMP-7 and TIMP-2 were upregulated in PSP lesions. These results suggest that an imbalance between the expression of proteases and antiproteases may be involved in the pathogeneses of PSP.

Approach to Lung Biopsies From Patients With Pneumothorax

Context.—Patients with pneumothorax occasionally require limited lung resections to control persistent air leaks. In some patients, especially smokers, histopathologic findings suggest that a ruptured bulla or bleb caused the pneumothorax. Other patients only exhibit histopathologic changes related to the physical trauma of acute, and likely occult recurrent, peripheral lung injury in the setting of “spontaneous,” or idiopathic, lung rupture. Sometimes, pneumothorax occurs secondary to an underlying localized or diffuse parenchymal lung disease. A comprehensive description of the morphologic findings that may be seen in these specimens will help the surgical pathologist distinguish patients with more common and indolent occurrences of pneumothorax from those requiring additional workup or treatment.

Objective.—To develop a diagnostic approach for surgical pathologists encountering lung specimens obtained in the context of pneumothorax repair.

Data Sources.—Literature review and consultation experience of the authors.

Conclusions.—Two general categories of histopathologic changes can be identified: (1) nonspecific changes, reflecting the lung's acute and chronic response to localized injury, and (2) changes suggesting an underlying lung disease that may have played an etiologic role in the development of pneumothorax. The latter changes are important to recognize because they may require additional workup or treatment of clinically occult lung disease. Difficulty arises when nonspecific histopathologic changes overlap with those of an underlying lung disease. Awareness of these diagnostic challenges and pitfalls, together with clinicoradiographic correlation, is essential in these situations and will help guide the surgical pathologist toward an accurate diagnosis and the appropriate management of clinically occult disease.

The utility of computed tomography in the management of patients with spontaneous pneumothorax

BACKGROUND

Spontaneous pneumothorax may result from rupture of subpleural blebs. Computed tomography (CT) has been used to identify blebs to serve as an indication for thoracoscopy. We reviewed our experience with spontaneous pneumothorax to assess the utility of CT in these patients.

METHODS

A retrospective review was conducted of all patients who underwent an operation for spontaneous pneumothorax from January 1999 to October 2009. All procedures were performed thoracoscopically.

RESULTS

We identified 39 pneumothoraces in 34 patients who underwent evaluation and a procedure for spontaneous pneumothorax. Mean age was 16.1 years (range, 10-23 years), with an average of 1.7 spontaneous pneumothoraces before operation (range, 1-4). Preoperative chest CT scans were obtained in 26 cases. Blebs were demonstrated on 8 CT scans. The presence of blebs was confirmed at operation in all 8 patients. Of the 18 negative scans, 14 (77.8%) were found to have blebs intraoperatively, 7 of these patients were initially managed nonoperatively and developed recurrence. The sensitivity of CT for identifying blebs was 36%.

CONCLUSIONS

Chest CT does not appear to be precise in the identification of pleural blebs and a negative examination does not predict freedom from recurrence. Operative decisions should be based on clinical judgment without the use of preoperative CT.

Resolution of experimental pneumothorax by room air

Observation alone is advised only for primary spontaneous pneumothoraces with less than 20 percent of the lungs collapsed. In such cases, it is the resorption capabilities of the visceral pleura that are solely relied upon. The AIM of the present experimental study was to demonstrate the capabilities of the pleura for pneumothorax resolution by room air.

MATERIAL AND METHODS

The study was conducted with six laboratory animals (New Zealand white rabbits, weighing 2.5-3.5 kg), in which right total pneumothorax was induced. Conventional chest X-rays at intervals of 2 days were used to monitor the changes in the size of the pneumothorax until its final resolution. The size of the pneumothorax was estimated by the Light index.

RESULTS

Total resolution of the pneumothorax occurred within 12 days after it was induced. The average rate of pneumothorax resolution was 6.63% (SEM +/- 0.20)/daily.

CONCLUSION

The study imitates initial clinical observation in pneumothorax. Despite the fact that the study demonstrates resolution of total pneumothorax (100%), observation only is inappropriate as a treatment modality in patients with more than 20% collapse of the lung.

Single-incision thoracoscopic surgery for primary spontaneous pneumothorax

OBJECTIVE

Single-incision laparoscopic surgery had been proven effective for appendectomy, cholecystectomy, and inguinal hernia repair. However, single-incision thoracoscopic surgery (SITS) in primary spontaneous pneumothorax (PSP) has not been reported.

METHODS

We prospectively enrolled 30 PSP patients who received thoracoscopic surgery in the division of Thoracic Surgery of China Medical University Hospital. Ten patients received SITS and 20 patients received traditional three-port thoracoscopic surgery. The operative time, blood loss, wound size, visual analog scale (VAS) pain score, and patient satisfaction score were compared.

RESULTS

There was no significant difference in the operative time and blood loss between the two groups. However, the VAS pain scores were significantly better in the SITS group in first 24 hours after surgery. Patient satisfaction scores in the SITS group were also significantly better in the first 24 and 48 hours after operation.

CONCLUSION

Although three-port thoracoscopic surgery for PSP is well established, SITS results in better patient satisfaction and decreased postoperative pain in the treatment of PSP.

The Prevalence of Blebs or Bullae Among Young Healthy Adults

BACKGROUND

To determine the prevalence of blebs or bullae using thoracoscopy in young healthy adults, and to compare patient characteristics among those with and without blebs.

METHODS

Bilateral thoracoscopic evaluation of the lungs was performed in healthy individuals who were referred for thoracoscopic thoracic sympathectomy for essential hyperhidrosis. Participants were enrolled into a registry and followed for up to 9 years.

RESULTS

Analysis was performed on 250 consecutive cases. Blebs were observed in 15 of 250 individuals (6%; male, n = 6; female, n = 9; mean age, 25.3 years; range, 15 to 51 years). Individuals with blebs had a significantly lower body mass index (BMI) [mean +/- SD, 20.7 +/- 2.4 kg/m(2) vs 22.7 +/- 3.4 kg/m(2); p = 0.027] when compared to individuals without blebs, whereas all other parameters were similar. Blebs were most prevalent among slim individuals (BMI < 22 kg/m(2)) who smoked (odds ratio, 5.9; 95% confidence interval, 1.19 to 29.20).

CONCLUSION

Blebs were identified thoracoscopically in 6% of young healthy adults with no underlying lung disease. Low BMI in combination with smoking may have an important role in the development of pleural blebs in healthy young adults; however, these changes may not be responsible for future spontaneous pneumothoraces.

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

OBJECTIVE

To assess the association between primary spontaneous pneumothorax (PSP) recurrence and pulmonary CT scan findings, and other variables pertaining to clinical presentation and management.

METHODS

Consecutive patients hospitalized for the first episode of PSP and treated by various strategies including chest tube or pleurocatheter drainage and, in persistent pneumothorax, by chemical or surgical pleurodesis. All patients had a pulmonary CT scan examination in the week following hospital discharge in order to calculate a score combining distribution, number and size of dystrophic pulmonary abnormalities. This score as well as other pertinent clinical and therapeutic parameters were compared between patients who ultimately experienced PSP recurrence and those who did not.

RESULTS

Eighty patients (mean age: 27+/-7 yr) were admitted for PSP and had a chest drainage with either a drain or pleurocatheter. Chest drainage and hospitalization durations were 4.7+/-3.2 and 6.2+/-3.5 days, respectively. Sixteen patients required chemical pleurodesis. Dystrophic bullae were present in CT scans in 72.5% patients. After a mean follow up of 34+/-20 months, 15 out of the 80 patients (19%) had a PSP recurrence. Multivariate statistical analysis disclosed the use of pleurocatheter (OR=5; 95% CI: 1.4-20; P=0.02) and of chemical pleurodesis (OR=8; 95% CI: 1.5-47; P=0.015) as independent predictors of PSP recurrence. The severity of dystrophic lesions inferred from the dystrophic score was not statistically associated with the risk of recurrence.

CONCLUSION

Dystrophic lesions are frequently present in PSP. They are not associated with an increased risk of recurrence.

Management of spontaneous pneumothorax

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

SCUBA diving for individuals with disabilities

Self-contained underwater breathing apparatus (SCUBA) diving has become an increasingly popular recreational activity, enjoyed by millions of individuals. There has also been a growing interest in SCUBA diving in the disabled population for rehabilitation and recreation. This review discusses medical issues relevant to individuals with disabilities who wish to participate in SCUBA diving. In addition, specialized equipment, adaptations in techniques, and additional precautions will be presented. SCUBA diving can be an enriching experience, potentially helping to improve self-image and quality of life. Knowledgeable healthcare professionals can help to guide their patients who are interested in SCUBA diving.

Pneumothorax

Spontaneous pneumothoraces can occur without obvious underlying lung disease (primary) or in patients with known underlying lung disease (secondary). Management guidelines for spontaneous pneumothorax have been published by major professional organizations, but awareness and application among clinicians seems poor. First episodes of primary spontaneous pneumothorax can be managed with observation if the pneumothorax is small. If the pneumothorax is large or if the patient is symptomatic, manual aspiration via a small catheter or insertion of a small-bore catheter coupled to a Heimlich valve or water-seal device, should be performed. In general, definitive measures to prevent recurrence are recommended after the first recurrence of the pneumothorax, and can be achieved by medical (e.g. talc) or surgical (video-assisted thoracic surgery) pleurodesis. Secondary pneumothoraces should be treated with chest tube drainage followed by pleurodesis after the first episode to minimize any risk of recurrence. Traumatic pneumothoraces may be occult (not seen on an initial CXR) or non-occult. The majority are treated by placement of a chest tube. Selected patients may be treated conservatively, with approximately 10% of these patients eventually requiring chest tube placement. Iatrogenic pneumothoraces have a myriad of causes with transthoracic lung needle biopsy being most common. Transthoracic needle biopsy-related pneumothoraces have CT findings that can predict their occurrence and the need for chest tube placement. Iatrogenic pneumothoraces, regardless of cause, may be managed by observation or small bore chest tube placement, depending upon patient stability and the size of the pneumothorax.

Pneumothorax in dairy cattle: 30 cases (1990-2003)

OBJECTIVE

To evaluate the features, underlying causes, results of diagnostic testing, and treatment of pneumothorax in dairy cattle.

DESIGN

Retrospective study.

ANIMALS

30 dairy cattle.

PROCEDURE

Medical records of all cattle with a diagnosis of pneumonia were reviewed. For cattle with pneumothorax, information was obtained pertaining to signalment, anamnesis, diagnosis, treatment, and outcome. Survival data were compared between cattle with pneumonia with or without pneumothorax.

RESULTS

Pneumothorax was associated with bronchopneumonia in 18 cattle, interstitial pneumonia in 7 cattle, pharyngeal or laryngeal trauma in 3 cattle, and neonatal respiratory distress in 2 calves. Bovine respiratory syncytial virus was the most commonly detected infectious agent. Eighteen of 30 (60%) cattle survived; 8 were euthanatized and 4 died. Survival rate was 81% for cattle with pneumonia without pneumothorax during the same time period. Pneumothorax was a significant risk factor for failure to survive to discharge from the hospital for cattle with underlying chronic bronchopneumonia.

CONCLUSIONS AND CLINICAL RELEVANCE

Pneumothorax in dairy cattle appears to occur most commonly in association with chronic bronchopneumonia. Cattle of both sexes and all ages can be affected.