Management of primary spontaneous pneumothorax: a review

Pleural abrasion versus apical pleurectomy for primary spontaneous pneumothorax: a systematic review and Meta-analysis

BACKGROUND

Surgical approach is the most effective treatment for primary spontaneous pneumothorax. The two most widely adopted surgical methods are mechanical abrasion and apical pleurectomy, in addition to bullectomy. We performed a systematic review and meta-analysis to examine which technique is superior in treating primary spontaneous pneumothorax.

METHODS

PubMed, MEDLINE and EMBASE databases were searched for studies published between January 2000 to September 2022 comparing mechanical abrasion and apical pleurectomy for treatment of primary spontaneous pneumothorax. The primary outcome was pneumothorax recurrence. Secondary outcomes included post-operative chest tube duration, hospital length of stay, operative time and intra-operative of blood loss.

RESULTS

Eight studies were eligible for inclusion involving 1,613 patients. There was no difference in the rate of pneumothorax recurrence between pleural abrasion and pleurectomy (RR: 1.34; 95% CI: 0.94 to 1.92). However, pleural abrasion led to shorter hospital length of stay (MD: -0.25; 95% CI: -0.51 to 0.00), post-operative chest tube duration (MD: -0.30; 95% CI: -0.56 to -0.03), operative time (MD: -13.00; 95% CI -15.07 to 10.92) and less surgical blood loss (MD: -17.77; 95% CI: -24.36 to -11.18).

CONCLUSION

Pleural abrasion leads to less perioperative patient burden and shorter hospital length of stay without compromising the rate of pneumothorax recurrence when compared to pleurectomy. Thus, pleural abrasion is a reasonable first choice surgical procedure for management of primary spontaneous pneumothorax.

A scoping review of clinical practice guidelines for the diagnosis of primary spontaneous pneumothorax

INTRODUCTION/BACKGROUND

Primary spontaneous pneumothorax (PSP) is characterised by the onset of pneumothorax with no evidence of trauma or associated co-morbidities. Several clinical practice guidelines (CPGs) have been published regarding the management of PSP. Inconsistency in imaging protocols across clinics globally may indicate variability in the recommendations within these guidelines. We aimed to support clinical decision making with an assessment of CPGs regarding PSP diagnosis.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was utilised. A systematic search of databases Medline, Embase, and Scopus was conducted. Manual searches of the grey literature and guideline-focused databases was undertaken Inclusion criteria included English-language CPGs pertaining to the management of PSP. Publications were independently extracted and critically appraised by two reviewers using the AGREE-II tool. Recommendations were assessed and tabulated.

RESULTS

Eight CPGs met the eligibility criteria. 16 recommendations were identified relating to assessment of medical history, physical examination, assessment of clinical stability, posterior-anterior chest X-ray (CXR) on held inspiration, computed tomography following inconclusive CXR, and ultrasound to complement other imaging modalities.

CONCLUSION

There is universal agreement on the exclusion of expiratory and lateral images in the conventional radiographic series, suggesting that these clinical behaviours may be influenced by local preferences or inhibitors to knowledge translation. This scoping review has summarised the key recommendations of CPGs regarding PSP diagnosis and assessed the methodological quality of the current evidence-base.

Suspected Primary Spontaneous Asymptomatic Pneumothorax in a Cat

Spontaneous pneumothorax (SPT) is a documented emergency of the respiratory tract condition classified as either primary or secondary based on the presence of underlying pulmonary conditions. All reported SPT in the feline literature are evaluated for respiratory clinical signs. Primary SPT without underlying pathology or without clinical signs is not reported in cats. This case report describes a 10-year-old domestic longhair cat that was referred for evaluation of chronic lethargy with severe azotemia and placement of a subcutaneous ureteral bypass (SUB) system. Prior to presentation, the cat was diagnosed with renal insufficiency and treated medically with no resolution. Clinical examination under sedation revealed right-sided renomegaly. Thoracic radiographs revealed gas in the caudodorsal pleural space and concurrent pulmonary atelectasis. No respiratory clinical signs were present. Thoracic CT showed two pulmonary bullae, one located in the right caudal lung lobe and one in the cranial segment of the left cranial lung lobe. Abdominal ultrasound showed a right-sided ureteral obstruction. Medical management was elected for the spontaneous pneumothorax. A SUB was placed to address the ureteral obstruction; no complications were noted during recovery. The cat was free of clinical signs of respiratory disease after a follow-up time of nine months. This is the first reported case of a cat diagnosed with a nonclinical suspected primary spontaneous pneumothorax with no concurrent predisposing pulmonary pathology.

Analysis of patients undergoing surgical treatment for primary spontaneous pneumothorax

Background

Primary spontaneous pneumothorax (psp) results from spontaneous rupture of bleb or bulla. Aims: We planned to discuss the etiologic factors, clinical and radiological findings, and treatment results of psp cases.

Materials and Methods

402 patients were evaluated. Patients were divided into two groups as patients receiving positive results with thoracostomy and patients who received positive results"> thoracotomy/video-assisted thoracoscopic surgery (vats). Groups were compared. Results were evaluated"> using Chi-square or Fishers' exact test. P < 0.05 was considered as significant.

Results

Gender difference (P: 1.00) and localization of disease (P: 0.45)were not significant for psp. Smoking and being subtotal or total compared to partial had a substantial effect on the implementation of thoracotomy/vats (P < 0.05). Furthermore, psp was most frequently seen in August and September.

Discussion

Risk factors of psp are described as genetic predisposition, being tall, smoking, and autosomal dominant heredity. The main determinant factor in the treatment of psp is the degree of pneumothorax.

Conclusion

Psp was frequently observed in smokers. The preferred method for overall psp is tube thoracostomy. Thoracotomy/vats is more commonly performed for subtotal or total psp compared to partial psp.

Vaping associated spontaneous pneumothorax - A case series of an enigmatic entity!

The use of electronic nicotine delivery devices (ENDDs) has risen to an epidemic level among high schoolers and people aged 18–34. To our knowledge there are only 7 reported cases of spontaneous pneumothorax (SP-PTX) associated with vaping, and herein we describe 4 additional cases. We propose identifying this disease process as a novel entity, Vaping-Associated Spontaneous Pneumothorax (VASP). VASP requires early interventional treatment and has a high recurrence rate, and we suggest that vaping cessation and early interventional treatment including tube thoracostomy and surgical treatment is necessary in most cases to prevent recurrences.

Management of Apatinib-Related Adverse Events in Patients With Advanced Osteosarcoma From Four Prospective Trials: Chinese Sarcoma Study Group Experience

Four prospective trials have reported apatinib-related efficacy in osteosarcoma, with a high response rate of 43.2%. Currently, Adverse Events (AEs) have increasingly gained attention, as treatment with multiple tyrosine kinase inhibitors (TKIs) is potentially lifelong. For this reason, a consensus meeting of the Chinese Sarcoma Study Group (CSSG), which is a multidisciplinary panel composed of pediatric, medical and surgical oncologists specializing in sarcoma, nurse specialists, oncological senior pharmacists and gastroenterologists, was held to develop comprehensive guidelines on AEs emerging due to apatinib treatment to better assist in the prevention, management, and understanding of AE development. We summarized all AEs that arose in ≥10% of the participants as well as rare AEs that required extra caution to prevent that were observed in these four published prospective trials and arranged these AEs into 14 disorder systems according to CTCAE 5.0. In this review, we discuss strategies for the management of AEs in patients with advanced osteosarcoma, with the aim of maximizing treatment benefits and minimizing the need for apatinib treatment discontinuation. We also focus on providing recommendations for the prophylaxis and treatment of advanced osteosarcoma using apatinib to achieve optimal outcomes.

Detection of the location of pneumothorax in chest X-rays using small artificial neural networks and a simple training process

The purpose of this study was to evaluate the diagnostic performance achieved by using fully-connected small artificial neural networks (ANNs) and a simple training process, the Kim-Monte Carlo algorithm, to detect the location of pneumothorax in chest X-rays. A total of 1,000 chest X-ray images with pneumothorax were taken randomly from NIH (the National Institutes of Health) public image database and used as the training and test sets. Each X-ray image with pneumothorax was divided into 49 boxes for pneumothorax localization. For each of the boxes in the chest X-ray images contained in the test set, the area under the receiver operating characteristic (ROC) curve (AUC) was 0.882, and the sensitivity and specificity were 80.6% and 83.0%, respectively. In addition, a common currently used deep-learning method for image recognition, the convolution neural network (CNN), was also applied to the same dataset for comparison purposes. The performance of the fully-connected small ANN was better than that of the CNN. Regarding the diagnostic performances of the CNN with different activation functions, the CNN with a sigmoid activation function for fully-connected hidden nodes was better than the CNN with the rectified linear unit (RELU) activation function. This study showed that our approach can accurately detect the location of pneumothorax in chest X-rays, significantly reduce the time delay incurred when diagnosing urgent diseases such as pneumothorax, and increase the effectiveness of clinical practice and patient care.

High-Resolution CT Following Primary Spontaneous Pneumothorax in Adolescents: Useful Tool or Wasted Radiation?

Background The current trend in management of first-time primary spontaneous pneumothorax (PSP) in children is to obtain a high-resolution chest computerized tomography (HRCT) scan to look for bleb/bullae disease or other forms of structural lung disease. We aimed to evaluate the significance of HRCT findings in relation to initial management strategies, and we hypothesized that these findings do not guide management.  Methods We evaluated patients with first-time PSP in a single-institution, retrospective, longitudinal study. Data were obtained through direct chart review. The primary endpoint was the percentage of patients who underwent surgical intervention after HRCT. Results We identified 10 children from 10 to 17 years old from January 2013 to November 2019 who met criteria for the study. Seven out of 10 patients (70%) had HRCT after the first-time PSP during the same hospital stay. Blebs/bullae were discovered in five out of seven (71%) of those patients. Two of those five patients had subsequent surgical intervention (40%) before a recurrence. Of the three patients with blebs/bullae identified on HRCT treated without initial surgery, two had a recurrence of PSP and subsequently underwent VATS with blebectomy and pleurodesis. Among the patients without initial HRCT, there were no recurrent cases of PSP noted. Conclusions Our study suggests there is value in obtaining HRCT after the first time PSP, as these results can be used to guide management strategies. Further studies in pediatric PSP are needed to validate the sensitivity of HRCT in bleb detection, the predictive value of bleb disease and recurrence, and the benefits and risks of early surgical intervention.