New insights and improved strategies for the management of primary spontaneous pneumothorax

A retrospective comparison between digital to conventional drainage systems for secondary spontaneous pneumothorax related to diffuse interstitial lung disease

INTRODUCTION

Secondary spontaneous pneumothorax (SSP) occurs as one of the complications associated with interstitial pneumonia (IP). Chest drainage is performed when there is a large volume of air in the pleural space. Notably, SSP with IP (SSP-IP) is frequently not curable by chest drainage only. A digital drainage system (DDS) provides an objective evaluation of air leakage and maintains a pre-determined negative pressure, compared to an analog drainage system (ADS). Few studies have reported the effectiveness of DDS in the treatment of SSP-IP. This study aimed to assess the usefulness of DDS for SSP-IP.

METHODS

This retrospective study included patients with SSP-IP who had undergone chest drainage. We reviewed the included patients' medical records, laboratory data, computed tomography findings, and pulmonary function data.

RESULTS

DDS was used in 24 patients and ADS in 49 patients. The mean duration of chest drainage was 11.4 ± 1.9 days in the DDS group and 14.2 ± 1.3 days in the ADS group, which was not significantly different (p = 0.218). Surgery, pleurodesis, and/or factor XIII administration were performed in 40 patients. Additionally, five (20.8%) patients in the DDS group and nine (18.4%) in the ADS group had a recurrence of pneumothorax within 4 weeks (p = 1.000). One patient (14%) in the DDS group and six (12.2%) in the ADS group (p = 0.414) were cured of pneumothorax but later died.

CONCLUSION

DDS did not demonstrate a significant difference in the shortening of chest drainage duration. Further study is needed to validate the results of this study.

Early risk factors of operative management for hospitalization children with spontaneous pneumothorax

BACKGROUND

The optimal timing of operative management in children with primary spontaneous pneumothorax (PSP) remains controversial. This study sought to determine early risk factors for failure of chest tube nonoperative management during the initial hospitalization in adolescents with PSP.

METHODS

A retrospective review was conducted for children (aged ≤18 years) admitted to a single tertiary care referral center for their first presentation of a PSP managed with at least 48 h of chest tube decompression (CTD) alone. Patient outcomes and early risk factors for operative management were analyzed by multivariate regression.

RESULTS

Of the 39 patients who met inclusion criteria, 15 (38.5%) patients failed nonoperative treatment while 24 (61.5%) patients were managed with CTD therapy alone. Progression to thoracoscopic surgery was associated with longer CTD of 8 vs 3 days and hospital length of stay of 9 vs 4 days when compared to nonoperative management (p < 0.001, both). Air leak and increase in pneumothorax size at 24 h after CTD were independently associated with progression to surgery (p = 0.007, p = 0.002). Combined, these risk factors were associated with a significant increase in recurrence (OR 6.00, 95% CI 1.11-41.11, p = 0.048). There were no significant differences between PSP management strategies regarding cumulative radiation exposure or 2 year recurrence.

CONCLUSIONS

Air leak or increasing pneumothorax size within 24 h of CTD are highly correlated with failed nonoperative management during the initial hospitalization in pediatric patients with PSP. This data may be useful in the development of pediatric-specific treatment algorithms to optimally manage these patients.

LEVEL OF EVIDENCE

Treatment study, Level III.

Surgical Management of Pneumothorax and Pleural Space Disease

Pleural space diseases constitute a wide range of benign and malignant conditions, including pneumothorax, pleural effusion and empyema, chylothorax, pleural-based tumors, and mesothelioma. The focus of this article is the surgical management of the 2 most common pleural disorders seen in modern thoracic surgery practice: spontaneous pneumothorax and empyema.

Management of pneumothorax: an update

PURPOSE OF REVIEW

Pneumothorax is a global health problem. To date, there is still significant variation in the management of pneumothorax. For the past few years, there have been significant developments in the outpatient management of both primary and secondary spontaneous pneumothorax (SSP). We will review the latest evidence for the management of nontraumatic pneumothorax (spontaneous and iatrogenic) to include pneumothorax associated with COVID-19 infection.

RECENT FINDINGS

Outpatient management of both primary and SSP may be safe and feasible.

SUMMARY

Outpatient management of both primary and SSP should be included in treatment options discussion with patients.

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.

Conservative management of a complete primary spontaneous pneumothorax

Large primary spontaneous pneumothorax (PSP) has traditionally been managed with needle aspiration, chest tube drainage and, in refractory cases, thoracic surgery. A recent randomized trial, however, provided evidence that a conservative observational approach was safe and 85% of patients recovered without requiring pleural drainage interventions. A conservative approach provided similar re-expansion rates at 8 weeks compared with chest tube drainage and offered the advantages of early hospital discharge, fewer days off work and avoidance of procedural risks. Nonetheless, clinicians are understandably anxious with conservative (non-drainage) management for patients with very large pneumothorax. Here, we report a patient with a right-sided PSP and total lung collapse that was managed successfully without intervention with minimal time in hospital or off work.

Bilateral primary spontaneous pneumothorax with multiple bleb performed by VATS and wedge resection: A rare case in Indonesian adult and review article

Background

Bilateral primary spontaneous pneumothorax (PSP) is a rare case of lung disease.

Case presentation

A 20-year-old man with a complaint of shortness of breath is suspected of having PSP and tuberculosis. The patient underwent water seal drainage installation in both lung cavities, but showed no improvement. Multiple blebs were found after a few days. A wedge resection with VATS became an option. The patient had improved lung function after the procedure.

Discussion

The WSD installation showed lungs improvement. However, when trained for lung expansion, the lung condition became bad. After wedge resection with the help of VATS on multiple blebs, the lung had a significant improvement.

Conclusion

Wedge resection could be considered in PSP patients with multiple blebs.

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The prevalence of bilateral primary spontaneous pneumothorax (PSP) is very low, around 1–2%.

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Multiple blebs in bilateral PSP patients indicate the need for surgery.

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PSP is often found in young adults.

A novel finding related to bulla and bleb formation in patients with primary spontaneous pneumothorax

BACKGROUND

Spontaneous pneumothorax is a common problem globally. Bullas and blebs have been implicated in this problem, but the etiology of their formation is unknown. We aim to show the relation between a novel clinical finding, the pulmonary delayed inflation (PDI) sign, and the etiology of bulla and bleb formation in young patients.

METHODS

We retrospectively analyzed data from 111 patients with pneumothorax and a control group of 27 patients. We evaluated the relation between the PDI sign and other clinical factors.

RESULTS

The PDI sign was observed in 78 patients. Of these, 75 exhibited the PDI sign in only the upper lobe. Regardless of smoking status, patients 34 years of age or younger had a significantly higher incidence of the PDI sign than, patients 55 years of age or older and control patients. The inflation time in patients 34 years of age or younger, regardless of smoking status, was significantly longer than in patients 55 years of age or older and patients in the control group. There was no significant association between inflation time and the presence of asthma.

CONCLUSIONS

The novel PDI sign is seen in patients 34 years of age or younger. Because this sign may indicate a peripheral bronchial abnormality and may be related to the formation of blebs and bullae in young patients with spontaneous pneumothorax, it is possible that it can be used to develop effective treatments for pneumothorax in young patients.

Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial

BACKGROUND

Patients with a primary spontaneous pneumothorax (PSP) who are treated with chest tube drainage are traditionally connected to an analogue chest drainage system, containing a water seal and using a visual method of monitoring air leakage. Electronic systems with continuous digital monitoring of air leakage provide better insight into actual air leakage and changes in leakage over time, which may lead to a shorter length of hospital stay.

METHODS

We performed a randomized controlled trial comparing the digital with analogue system, with the aim of demonstrating that use of a digital drainage system in PSP leads to a shorter hospital stay.

RESULTS

In 102 patients enrolled with PSP we found no differences in total duration of chest tube drainage and hospital stay between the groups. However, in a post-hoc analysis, excluding 19 patients needing surgery due to prolonged air leakage, hospital stay was significantly shorter in the digital group (median 1 days, IQR 1-5 days) compared to the analogue group (median 3 days, IQR 2-5 days) (p 0.014). Treatment failure occurred in 3 patients in both groups; the rate of recurrence within 12 weeks was not significantly different between groups (16% in the digital group versus 8% in the analogue group, p 0.339).

CONCLUSION

Length of hospital stay was not shorter in patients with PSP when applying a digital drainage system compared to an analogue drainage system. However, in the large subgroup of uncomplicated PSP, a significant reduction in duration of drainage and hospital stay was demonstrated with digital drainage. These findings suggest that digital drainage may be a practical alternative to manual aspiration in the management of PSP.

TRIAL REGISTRATION

Registered 22 September 2013 - Retrospectively registered, Trial NL4022 (NTR4195).

Genetic Risk Factors for Spontaneous Pneumothorax in Birt-Hogg-Dubé Syndrome

BACKGROUND

Birt-Hogg-Dubé syndrome (BHDS) is a genetic tumor syndrome characterized by lung cysts, spontaneous pneumothorax, fibrofolliculomas, and renal cell cancer. Because of its rarity and clinical heterogeneity, much is still unknown regarding the course of the disease and individual risk assessment. Therefore, we studied nonenvironmental risk factors for pneumothorax in a large sample of patients with BHDS.

METHODS

Clinical data were available from 197 patients with BHDS (male patients, 103; female patients, 94) belonging to 63 unrelated families. The FLCN coding region including adjacent intronic sequences was analyzed by PCR and subsequent Sanger sequencing as well as by multiplex ligation-dependent probe amplification. Statistical analyses were performed, using adequate methods to account for familial clustering.

RESULTS

Patients who had only a single spontaneous pneumothorax were significantly older at the time of occurrence than those with multiple pneumothoraces (mean, 38.93 vs 29.74 years; P value, .010). The risk for three or more pneumothoraces drastically increased after the second event. Significantly increased pneumothorax risks were found for mutations c.1300G>C (59%) and c.250-2A>G (77%), compared with FLCN hotspot mutation c.1285dup (37% risk) (P value, .02).

CONCLUSIONS

We observed significant differences for the spontaneous pneumothorax risk regarding both age and sex in patients with BHDS. Furthermore, two FLCN mutations were identified that are associated with significantly increased pneumothorax risk. Thus, formerly unknown individual predictors have been identified that provide improved risk stratification for patients with BHDS.

Characteristics of 30-day readmission in spontaneous pneumothorax in the United States: a nationwide retrospective study

Objective: Our study aimed to determine the national estimates of the 30-day all-cause readmission rate among patients with spontaneous pneumothorax and to investigate the burden of these readmissions in terms of mortality, length of stay and hospitalization costs in the USA.

Methods: We utilized the Nationwide Readmission Database for 2013–2014 and identified adults with a primary diagnosis of spontaneous pneumothorax. We analyzed and reported patient- and hospital-level variables of the study cohort. Our primary outcome was 30-day readmission rate, including the reasons for readmission. Our secondary outcomes included all-cause mortality, resources utilization and predictors of readmissions.

Results: We identified 47,108 index admissions with spontaneous pneumothorax. The 30-day readmission rate was 13.6%. The most common reason for admission was recurrent pneumothorax. In index admissions, the in-hospital mortality rate was 3.1%; whereas, in readmissions, the mortality was higher (4.6%, p < 0.001). Both age group 45–64 (HR: 1.31, 95% CI: [1.15–1.49], p < 0.001) and history of cancer (HR: 1.34, 95% CI: [1.17–1.53], p < 0.001) were found to predict the risk of 30-day readmission.

Conclusion: The 30-day readmission rate in patients with spontaneous pneumothorax was 13.6%, and a recurrent event was the most likely cause. The 30-day readmissions were associated with higher mortality and hospitalization charges. Middle age and history of cancer increase likelihood of 30-day readmission.