Effectiveness of chemical pleurodesis in spontaneous pneumothorax recurrence prevention: a systematic review

The Role of Medical Thoracoscopy with Talc Poudrage in Spontaneous, Iatrogenic, and Traumatic Pneumothorax: A Prolonged Experience of a Tertiary Care Center

INTRODUCTION

Medical thoracoscopy is a minimally invasive and safe procedure mostly performed for unexplained exudative pleural effusions but may be considered for pneumothorax (PNX).

METHODS

This retrospective study included participants affected by PNX who underwent medical thoracoscopy with talc poudrage at a single academic hospital from 2008 to 2021. The primary endpoint was the observation of complete radiographical lung re-expansion and absence of air supply from the chest drain within 7 days of medical thoracoscopy. The secondary endpoint was achieving no recurrence of ipsilateral PNX at 24 months post-discharge.

RESULTS

A total of 95 patients affected by primary spontaneous PNX (PSP), secondary spontaneous PNX (SSP), iatrogenic, and traumatic PNX were enrolled. An additional procedure was required by 17.89% of patients, and only one patient with SSP required subsequent surgery. Recurrence of PNX occurred on the same side within 24 months after discharge in 9.47% of patients, with a median time to recurrence of 13.5 months. The PSP group was significantly more likely to achieve the primary endpoint. Pleural morphology was significantly associated with reaching the primary endpoint, while receiving a cumulative dose of talc greater than or equal to 4 g during hospitalization was associated with a lower risk of meeting it. Receiving a cumulative dose of talc greater than or equal to 4 g led in all cases to the achievement of the secondary endpoint. Patients with iatrogenic and traumatic PNX had an excellent prognosis in both the short- and long-term evaluation.

CONCLUSION

Medical thoracoscopy is an effective procedure for treating PNX in the acute setting in selected cases while preventing long-term relapses. Large prospective clinical studies are needed to support and better define the role of medical thoracoscopy in current clinical practice.

Management of spontaneous pneumothorax: a mini-review on its latest evidence

Spontaneous pneumothorax usually presents as a medical emergency and requires prompt attention and treatment. In patients with underlying lung diseases, it is often associated with prolonged hospitalization, persistent air leak and also a high rate of recurrence. It brings considerable clinical burden to patients and therefore advancement of spontaneous pneumothorax management is eagerly anticipated. In recent years, conservative approach with avoidance of invasive treatment has risen to be a main consideration for primary spontaneous pneumothorax (PSP) patients who are clinically stable with minimal symptoms. The body of evidence in secondary spontaneous pneumothorax (SSP) group is less robust compared with that in PSP group. Non-surgical treatment in SSP is becoming more common due to concerns about morbidity and mortality after surgical pleurodesis as patients are usually older with more underlying medical diseases. Until last year, there have been no updates on the international recommendation of pneumothorax management since the British Thoracic Society (BTS) guideline published in 2010. The latest 2023 BTS guideline on pleural diseases provides us a good opportunity to review the latest development and literature of the care for patients with spontaneous pneumothorax. This article will explore the goals of pneumothorax treatment including air evacuation, cessation of persistent air leak and prevention of recurrence.

Is there a change in the view of treatment for primary spontaneous pneumothorax?: The effect of thoracic CT and autologous blood pleurodesis: a retrospective cohort study

This study investigated recurrence rates and treatment efficacy based on tomographic findings during a long-term follow-up after primary spontaneous pneumothorax (PSP) treatment. We retrospectively analyzed patients with PSP treated at our hospital between 2003 and 2020. Patients were categorized into 2 groups based on computed tomography (CT) findings: group 1 (no bulla/bleb) and group 2 (bullae-bleb <3 cm). Data on demographics, recurrence, treatment methods, and outcomes were also collected and compared. A total of 251 PSP cases were evaluated, predominantly male (93.6%) with a mean age of 29.23 ± 1.14 years. Most cases (57%) occurred on the right side. Recurrence rates were highest within the first year (77.8%), with the first and second recurrences occurring at rates of 26% and 27.3%, respectively. In group 1 (n = 117), conservative treatment was applied in 15 cases, tube thoracostomy in 81, autologous blood pleurodesis (ABP) in 19, and surgery in 12. Recurrence rates were 46.6%, 21%, 5.3%, and 8.3%, respectively. In group 2 (n = 134), the recurrence rates were 50%, 32.7%, 20%, and 3.1%, respectively (P < .001). No mortality was observed for any patient. The treatment groups included conservative (n = 19), thoracostomy (n = 179), ABP (n = 34), and surgical (n = 44) groups. Recurrence rates were 47.3%, 27.4%, 11.8% (group 1: 5.3%, group 2: 20%, P = .035), and 4.5% (0% vs 6.3%), respectively. ABP effectively reduced recurrence in group 1 PSP patients without bullae or blebs on CT, potentially avoiding surgery. Video-assisted thoracoscopic surgery should be preferred in group 2 cases with bullae or blebs to minimize recurrence. These results underscore the importance of tailoring treatment strategies based on CT findings to optimize PSP management outcomes.

Treating Spontaneous Pneumothorax Using an Innovative Surgical Technique Called Capnodissection Pleurectomy: Case Report

Spontaneous pneumothorax is one of the most common conditions encountered in thoracic surgery. This condition can be treated conservatively or surgically based on indications and guidelines. Traditional surgical management includes pleurodesis (mechanical or chemical) in addition to bullectomy if the bullae can be identified. Mechanical pleurodesis is usually performed by surgical pleurectomy or pleural abrasion. In this case report, we present a case of a young patient with spontaneous pneumothorax who needed a surgical intervention. We performed a new, innovative surgical technique for surgical pleurectomy where we used carbon dioxide for dissection of the parietal pleura (capnodissection). This technique may provide similar efficiency to the traditional procedure but with less risk of bleeding and complications.

Intrapleural minocycline pleurodesis for bilateral pneumothorax due to septic pulmonary embolism: a case report

Background

Pneumothorax is a rare but serious complication of septic pulmonary embolism (SPE). SPE is a life-threatening disorder wherein infected thrombi bring infarction of the terminal and small caliber parts of the pulmonary vasculature and develop multiple nodular and cavitary lesions. Interventions other than conservative chest tube drainage for pneumothorax due to SPE have rarely been reported. Here, we present a case of bilateral pneumothorax due to SPE treated with intrapleural minocycline pleurodesis.

Case Description

A 72-year-old male patient previously diagnosed as esophageal carcinoma developed metachronous bilateral pneumothorax while treated for brain metastases. Based on blood cultures and chest computed tomography images, he was diagnosed with pneumothorax secondary to SPE due to methicillin-susceptible Staphylococcus aureus bacteremia. Bilateral chest tube drainage was instituted. Continuous air leakage was found bilaterally after chest tube placement. He was treated with broad-spectrum antibiotics based on the susceptibility profile and supportive treatment for sepsis. Approximately 3 weeks later, air leakage significantly reduced. We performed intrapleural minocycline pleurodesis bilaterally to prevent the recurrence of pneumothorax; the left side was firstly treated and the right side was treated 2 weeks later. Both chest tubes were successfully removed two days after procedures. Although the patient finally died of brain metastases 1 month after pleurodesis, he never recurred pneumothorax.

Conclusions

Intrapleural minocycline pleurodesis may be one of the useful and efficacious options in terms of treating intractable pneumothorax associated with SPE. Intrapleural minocycline pleurodesis could be a consideration for intractable pneumothorax related to SPE.

Beyond diagnosis: a narrative review of the evolving therapeutic role of medical thoracoscopy in the management of pleural diseases

Background and Objective

Medical thoracoscopy (MT) is an endoscopic technique performed by interventional pulmonologists with a favorable safety profile and few contraindications, providing diagnostic and therapeutic intervention in a single sitting. This narrative review was designed to summarize the therapeutic role of MT based on the latest results from the available literature.

Methods

Pertinent literature published in English, relative to human studies, between 2010-2022 was searched in Medline/PubMed and Cochrane databases. Publications regarded as relevant were considered for inclusion in this review; additional references were added based on the authors' knowledge and judgment. The review considered population studies, meta-analyses, case series, and case reports.

Key Content and Findings

MT has mostly been described and is currently used globally in the diagnostic approach to exudative pleural effusion of undetermined origin. Carefully evaluating the literature, it is clear that there is initial evidence to support the use of MT in the therapeutic approach of malignant pleural effusion, pneumothorax, empyema, and less frequently hemothorax and foreign body retrieval.

Conclusions

MT is an effective procedure for treating the clinical entities presented in this document; it must be carried out in selected patients, managed in centers with high procedural expertise. Further evidence is needed to assess the optimal indications and appropriate patients' profiles for therapeutic MT. The endpoints of length of hospital stay, surgical referral, complications and mortality will have to be considered in future studies to validate it as a therapeutic intervention to be applied globally.

Complications of lymphangioleiomyomatosis in pregnancy: a case report and review of the literature

Lymphangioleiomyomatosis is a rare cystic lung disease primarily affecting premenopausal females and may be exacerbated by pregnancy. We conducted a literature review of lymphangioleiomyomatosis during pregnancy with a specific focus on related maternal morbidity and obstetrical outcomes. We also report a case of lymphangioleiomyomatosis that presented as an acute spontaneous pneumothorax in the third trimester of pregnancy, followed by significant maternal morbidity. A 37-year-old primigravid woman who presented at 29 weeks 5 days gestation with chest pain was diagnosed with spontaneous pneumothorax. Further imaging demonstrated cystic lung lesions and renal angiomyolipomas. She developed severe abdominal pain concerning for placental abruption that led to an urgent cesarean delivery at 30 weeks 2 days gestation. Her course was complicated by recurrent pneumothorax, superimposed preeclampsia, and significant ileus and bowel dilation complicated by bowel perforation. For patients with a clinical suspicion of lymphangioleiomyomatosis in pregnancy, prompt recognition, diagnosis, and referral to appropriate multidisciplinary subspecialists is critical to mitigate complications and optimize outcomes both during and after pregnancy.

[Right upper lobe pulmonary sequestration as a rare cause of recurrent spontaneous pneumothorax]

A 19-year-old patient after previous wedge resection of the right upper pulmonary lobe a year ago urgently admitted with recurrent right-sided spontaneous pneumothorax. According to standard management of spontaneous pneumothorax, we performed diagnostic thoracoscopy and drainage of the right pleural cavity with regular X-ray examinations. However, these measures were ineffective. The patient was scheduled for surgery, and we intraoperatively observed an unusual cause of pneumothorax. Thus, we present spontaneous pneumothorax following right upper lobe pulmonary sequestration. The uniqueness of this case is associated with unusual manifestation and non-standard localization of rare lesion. A few cases of pneumothorax in similar patients are described in the world literature. The key limiting factor in diagnosis of such defects (identification of aberrant vessel supplying abnormal lung parenchyma) is the lack of routine CT angiography in patients diagnosed with pneumothorax. That is why CT changes were interpreted as postoperative ones, and the true cause was established only during redo surgery. A thorough inspection of the pleural cavity and alertness regarding unusual appearance of the right upper pulmonary lobe made it possible to suggest a non-standard diagnosis, avoid complications (bleeding from afferent vessel) and perform adequate lung resection.

Recurrent Spontaneous Pneumothorax in a Young Male With Duchenne Muscular Dystrophy Following COVID-19 Infection

Duchene muscular dystrophy (DMD) is a genetic disorder primarily affecting males. It is characterized by progressive muscle tissue degeneration. Patients with DMD are at an increased risk of respiratory infections, including coronavirus disease 20019 (COVID-19), due to weakened respiratory muscles. We present a case of a young male with DMD who experienced recurrent pneumothorax 10 months after recovering from a COVID-19 infection. The patient required prompt medical intervention, including a chest tube, multiple surgeries, and mechanical pleurodesis. This case highlights the importance of recognizing recurring pneumothorax as a potential complication of COVID-19, particularly in patients with underlying neuromuscular disorders, as it is a medical emergency requiring prompt treatment to prevent respiratory compromise.

The contemporary management of spontaneous pneumothorax in adults

Spontaneous pneumothorax is a common presentation, and there has been a recent surge of research into the condition. With the recent publication of the new British Thoracic Society guidelines and the upcoming European Respiratory Society guidelines, we provide a concise up-to-date summary of clinical learning points. In particular we focus on the role of conservative or ambulatory management, as well as treatment options for persistent air leak and guidance for when to refer to thoracic surgeons for the prevention of the recurrence of pneumothorax.

Educational aims

To give up-to-date guidance on the acute management of spontaneous pneumothorax, including the role of conservative or ambulatory managementTo discuss the different treatment options for persistent air leak.To guide physicians on when to refer patients to thoracic surgeons for the prevention of the recurrence of pneumothorax.

Long-term clinical outcomes after initial secondary pneumothorax surgery

Background

Given the heterogeneity of underlying lung disease and the higher morbidity and mortality associated with surgery for secondary pneumothorax (SP), treatment standardization and evidence-based early surgical management are challenging pursuits. Our aim was to document the clinical course of SP after initial surgical intervention and analyse related recurrence risk.

Methods

We conducted a retrospective review of 160 patients, each with SP, using clinical records housed in an institutional database. Clinical, imaging, and operative data were retrieved, and Cox proportional hazards (PH) analysis was undertaken to identify risk factors for recurrence.

Results

During a mean follow-up of 58.7 months, the overall recurrence rate in this cohort was 18.75% (ipsilateral, 14; contralateral, 16). A total of 24 patients had ≥3 ipsilateral episodes <6 months prior to surgery, marked by initial index episodes. In multivariate Cox PH analysis, the strongest risk factor for recurrence was underlying lung pathology other than chronic obstructive pulmonary disease [COPD: hazard ratio (HR) =5.3; P<0.001].

Conclusions

In this setting, underlying lung disease of a non-COPD nature is a proven risk factor for postsurgical recurrence. There is also a tendency in some patients for multiple episodes of pneumothorax within short periods of time, especially in the absence of COPD. Underlying disease processes may thus merit consideration in treatment planning.

Spontaneous pneumothorax rates following video-assisted thoracoscopic talc pleurodesis with or without resection of macroscopic bullous disease

BACKGROUND

Recurrent primary spontaneous pneumothorax (PSP) is routinely treated by video-assisted thoracoscopic (VATS) talc pleurodesis (with or without localized resection of macroscopic bullous disease). There is a paucity of published data regarding durability of the procedure and the rate of recurrent pneumothorax after such surgery, and this has significant implications from a prognostic and employment limitation perspective.

METHODS

Patients who underwent a VATS talc pleurodesis (with or without localized resection of macroscopic bullous disease) for the treatment of their second or subsequent PSP or a PSP were followed for recurrent ipsilateral pneumothorax and new contralateral PSP. Follow up was by way of telephone interview and medical record verification out to 48 months.

RESULTS

New contralateral pneumothorax occurred in 7 patients (11.1%) in the talc pleurodesis plus wedge resection group and 2 (1.8%) in the talc pleurodesis only group. There was one case of recurrent ipsilateral pneumothorax in a patient who had no inflammatory response to talc insufflation.

CONCLUSION

Video-assisted thoracoscopic (VATS) talc pleurodesis (and lung resection for macroscopic bullous disease) is a durable treatment for recurrent PSP. Patients with macroscopic disease have a significant risk of subsequent contralateral PSP.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Study of the Relative Frequency of Spontaneous Pneumothorax Recurrence with Two Policy Therapies: A Clinical Trial

Background

Spontaneous pneumothorax is a potentially fatal condition with a high risk of recurrence. The purpose of this study is to compare two different approaches to SP management. In the first group, patients underwent only chemical pleurodesis; in the second group, CT-scan, VATS, and then chemical pleurodesis was performed.

Materials and Methods

This study is a non-randomized clinical trial conducted on 65 patients admitted to Al-Zahra Hospital in Isfahan with a primary complaint of sudden dyspnea and a definitive diagnosis of spontaneous pneumothorax. Two studies compared the main outcomes of recurrence within six months and the time until recurrence.

Results

Age, sex, and BMI were matched between the two study groups. The side of the pneumothorax, smoking history, and pulmonary disease history did not differ significantly (P > 0.05). Pneumothorax recurrence did not differ significantly between the two groups (P: 0.477).

Conclusion

This study demonstrated no distinction between VATS and chemical pleurodesis when using only chemical pleurodesis. However, because numerous studies have suggested that one of these techniques may be beneficial for patients with SP, it is recommended to conduct additional randomized controlled trials (RCTs) with a more detailed plan and more comparable procedures, although it appears that meta-analysis design may be effective given the abundance of available RCT studies.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Management of primary spontaneous pneumothorax in children: Current practices among Turkish pediatric surgeons

Background

This study aims to evaluate current practices in the management of primary spontaneous pneumothorax among Turkish pediatric surgeons.

Methods

Between October 2021 and November 2021, an online survey comprising 19 questions was delivered to all members of the Turkish Association of Pediatric Surgeons (TAPS). A total of 74 respondents (42 males, 32 females; mean age: 42.3±7.9 years; range, 29 to 61 years) were included.

Results

The response rate was 17.1% among all society members. The rate of utilization of computed tomography in the initial admission was 27.4%, and the rate of use in cases requiring surgical treatment was 78.4%. A total of 81% of surgeons reported that the size of the pneumothorax influenced management. For the first episode of primary spontaneous pneumothorax, 75.7% of surgeons opted for chest tube drainage, 14.9% for only oxygen administration, 4.1% for needle aspiration, and none of the surgeons preferred video-assisted thoracoscopic surgery. For patients with a persistent air leak after chest tube placement, there was a wide variation in the duration of observation before performing surgery. Video-assisted thoracoscopic surgery was the most preferred surgical intervention (75.3%) and the most preferred surgical method was stapled bullectomy (43.8%).

Conclusion

There are practice variations in the management of pediatric primary spontaneous pneumothorax among the society members. However, the majority of members seem to agree on the use of computed tomography, initial treatment, and surgical interventions.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

Autologous Blood Patch Pleurodesis for Secondary Spontaneous Pneumothorax: A Narrative Review, a Retrospective Case Series and State of Play in the UK

INTRODUCTION

Treatment of prolonged air leak due to secondary spontaneous pneumothorax is challenging. Autologous blood patch pleurodesis (ABPP) is a treatment option. Previous evidence is reliant on single-centre series and underpowered trials and is mostly described in air leaks post cardiothoracic intervention. There are no United Kingdom (UK) wide data.

METHODS

Members of the UK Pleural Society were surveyed for their practice and for patients who underwent blood patch. There were 16 respondents from 333 members. Twelve had performed the procedure, and six had kept records and could submit data. Basic demographics, intervention and clinical details of patients were then collected. The study was sponsored by the Audit Department of Northumbria Healthcare NHS Foundation Trust (reference 8124), and Caldicott Clearance for data sharing was provided by the Trust's Information Goverance Board (reference C4221). There was no requirement for informed consent.

RESULTS

Data for 12 patients that received ABPP between 2014 and 2022 in six respiratory centres were assessed. The aetiology of the secondary pneumothoraces was mostly due to chronic obstructive pulmonary disease and end-stage interstitial lung disease. The patients had a median age of 75 years. The median air leak time before ABPP was 17 days. A total of 50-100 ml of blood was used for ABPP. Five patients had two attempts at ABPP. Air leak resolved in six patients (50%). Four patients had pleural apposition prior to ABPP. Four patients were diagnosed with hospital-acquired pneumonia following ABPP.

CONCLUSION

This is the only UK-wide retrospective case series of ABPP of 'medical' patients with secondary pneumothorax. There is widespread variation in care. No formal conclusions can be drawn, and much larger robust datasets are required. An application has been made to the European Respiratory Society to incorporate ABPP within the International Collaborative Effusion database.

Platelet-Rich Plasma for Pleurodesis: An Experimental Study in Rabbits

Background and Objectives: This study was designed to evaluate platelet-rich plasma (PRP) as a method of pleurodesis in a rabbit model. Pleurodesis with PRP was compared against the gold-standard use of talc. The secondary evaluation assessed the ideal time for achieving pleurodesis. Materials and Methods: 25 healthy New Zealand white rabbits were assigned to three groups, as follows: 12 animals in the first and second groups, as well as one animal with no intervention in the final group, which was used as a control. The talc pleurodesis group (baseline) underwent pleurodesis with sterile talc, which is the gold-standard sclerosing agent used for pleurodesis. The PRP group underwent pleurodesis using autologous PRP. The last group had one rabbit with no intervention. A total of 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 3 days (72 h) after the intervention, and 12 rabbits (n = 6 for the talc pleurodesis group and n = 6 for the PRP group) were sacrificed 6 days (144 h) after the intervention. In both the talc and PRP group, FBC and CRP were measured before the intervention and in 3 or 6 days afterwards, respectively. The pleura and the lungs were evaluated histopathologically. Results: Macroscopically, there were no statistically significant differences between the two groups. In terms of microscopic findings, there were no statistically significant differences in inflammatory reactions provoked in the visceral and parietal pleura between the PRP and talc. In addition, with talc pleurodesis, a foreign-body reaction was observed in about 50% of the cases, which was not observed with PRP. In terms of inflammation between 3 and 6 days, there were no statistically significant differences with PRP, there was only a statistically significant difference between 3 and 6 days regarding the parietal pleura in the talc group. Conclusions: The instillation of autologous PRP in the pleural cavity shows promise in achieving pleurodesis. The efficacy of PRP as a pleurodesis agent should be examined further.

Diagnostic and Therapeutic Characteristics in Patients with Pneumotorax Associated with COVID-19 versus Non-COVID-19 Pneumotorax

Introduction: Pneumothorax is a condition that usually occurs in thin, young people, especially in smokers. It is an unusual complication of COVID-19 disease that can be associated with worse results. This disease can occur without pre-existing lung disease or without mechanical ventilation. Materials and Methods: We present a monocentric comparative retrospective study of diagnostic and treatment analysis of two groups of patients diagnosed with COVID-19 and non-COVID-19 pneumothorax. All patients included in this study underwent surgery in a thoracic surgery department. The study was conducted over a period of 18 months. It included 34 patients with COVID-19 pneumothorax and 42 patients with non-COVID-19 pneumothorax. Results: The clinical symptoms were more intense in patients with COVID-19 pneumothorax. We found that the patients with COVID-19 had significantly more respiratory comorbidities. Diagnostic procedures include chest CT exam for both groups. Laboratory findings showed that increasing values for the analyzed data were consistent with the deterioration of the general condition and the appearance of pneumothorax in the COVID-19 group. The therapeutic attitude regarding the non-COVID-19 group was to eliminate the air from the pleural cavity and surgical approach to the lesion that determined the occurrence of pneumothorax. The group of patients with COVID-19 pneumothorax received systemic treatment, and only minimal pleurotomy was performed. The surgical approach did not alter patients’ survival. Conclusions: Careful monitoring of the patient’s clinic and laboratory tests evaluating the degradation of the lung parenchyma, correlated with the imaging examination (chest CT) is mandatory and reduces COVID-19 complications. Early imaging examination starts an effective diagnosis and treatment management. In severe COVID-19 pneumothorax cases, the pneumothorax did not influence the evolution of COVID-19 disease. When we found that the general condition worsened with the rapid progression of dyspnea and the deterioration of the general condition, and we found that it represented the progression or recurrence of pneumothorax.

Indwelling pleural catheter for malignant pleural effusion with persistent air leak

Malignant pleural effusion with persistent air leak (PAL) is a rare manifestation of lung malignancy. We present a woman in her 50s with postpleuroscopy PAL. Pleural biopsy confirmed adenocarcinoma with detection of epidermal growth factor receptor mutation in exon 19. An indwelling pleural catheter (IPC) was inserted and connected to an Atrium Express Mini ambulatory drain. This procedure reduced the length of hospital stay. Autopleurodesis with resolution of PAL occurred at week 3 of IPC insertion.

Construction and validation of a nomogram for predicting prolonged air leak after minimally invasive pulmonary resection

Background

Prolonged air leak (PAL) remains one of the most frequent postoperative complications after pulmonary resection. This study aimed to develop a predictive nomogram to estimate the risk of PAL for individual patients after minimally invasive pulmonary resection.

Methods

Patients who underwent minimally invasive pulmonary resection for either benign or malignant lung tumors between January 2020 and December 2021 were included. All eligible patients were randomly assigned to the training cohort or validation cohort at a 3:1 ratio. Univariate and multivariate logistic regression were performed to identify independent risk factors. All independent risk factors were incorporated to establish a predictive model and nomogram, and a web-based dynamic nomogram was then built based on the logistic regression model. Nomogram discrimination was assessed using the receiver operating characteristic (ROC) curve. The calibration power was evaluated using the Hosmer-Lemeshow test and calibration curves. The nomogram was also evaluated for clinical utility by the decision curve analysis (DCA).

Results

A total of 2213 patients were finally enrolled in this study, among whom, 341 cases (15.4%) were confirmed to have PAL. The following eight independent risk factors were identified through logistic regression: age, body mass index (BMI), smoking history, percentage of the predicted value for forced expiratory volume in 1 second (FEV1% predicted), surgical procedure, surgical range, operation side, operation duration. The area under the ROC curve (AUC) was 0.7315 [95% confidence interval (CI): 0.6979–0.7651] for the training cohort and 0.7325 (95% CI: 0.6743–0.7906) for the validation cohort. The P values of the Hosmer-Lemeshow test were 0.388 and 0.577 for the training and validation cohorts, respectively, with well-fitted calibration curves. The DCA demonstrated that the nomogram was clinically useful. An operation interface on a web page (https://lirongyangql.shinyapps.io/PAL_DynNom/) was built to improve the clinical utility of the nomogram.

Conclusion

The nomogram achieved good predictive performance for PAL after minimally invasive pulmonary resection. Patients at high risk of PAL could be identified using this nomogram, and thus some preventive measures could be adopted in advance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02716-w.

Treating Recurrent Pleural Disease: A Review of Indications and Technique for Chemical Pleurodesis for the Interventional Radiologist

Pleural space diseases such as recurrent pleural effusion and pneumothorax inflict a significant symptomatic burden on patients. Guidelines and studies are available to guide best practices in the setting of refractory effusions, mostly in the setting of malignancy, and recurrent pneumothorax. Less data is available to guide management of refractory transudative effusions. Recurrent pleural effusions can be treated with tunneled pleural catheters or catheter-based pleurodesis. While refractory transudative effusions can benefit from tunneled pleural catheter, this is an area of ongoing research. Regarding recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) pleurodesis using mechanical or laser/argon beam coagulation is the most effective means of preventing recurrence. Catheter based pleurodesis, a less invasive means of administering chemical sclerosant via percutaneous thoracostomy tube, is only used when surgery is not an option. However, both approaches induce inflammation of the pleural space, resulting in adherence of the parietal and visceral pleura to prevent fluid or air re-accumulation. This article will discuss catheter based chemical pleurodesis geared toward the interventional radiologist, including a review of disease processes and indications, technique, and strategies to mitigate complications as well as a literature review comparing percutaneous chemical pleurodesis to other therapies.

Management of the Secondary Spontaneous Pneumothorax: Current Guidance, Controversies, and Recent Advances

Secondary spontaneous pneumothorax (SSP) is a medical emergency where the lung collapses in the presence of underlying chronic lung disease. It is the commonest cause of spontaneous pneumothorax and results in significant breathlessness, higher morbidity, mortality, and longer hospital admissions than with patients with pneumothoraces and no underlying lung disease. This article explores the current guidance, controversies, and recent advances in the management of this condition.

Analysis of factors predicting the application of chemical pleurodesis for pneumothorax: An observational study

Chemical pleurodesis is performed in pneumothorax patients to treat nonresolving air leakage or prevent recurrence. However, factors that might predict the need for chemical pleurodesis remain unknown. Therefore, this study investigated predictive factors for the application of chemical pleurodesis for pneumothorax.We retrospectively analyzed 401 adult pneumothorax patients who underwent chest tube drain insertion during hospitalization at Fukujuji Hospital from January 2016 to December 2020. The patients were divided into 3 groups: the pleurodesis group, comprising 89 patients treated with chemical pleurodesis; the nonpleurodesis group, comprising 206 patients treated without chemical pleurodesis; and the surgical group, comprising 106 patients treated surgically. Data for patients in the pleurodesis group were compared to those in the nonpleurodesis or surgical group, and a predictive score of the application of chemical pleurodesis for pneumothorax was developed.Compared with the nonpleurodesis group, in the pleurodesis group, patient age was higher (P < .001), emphysema (n = 33 (37.1%) vs 70 (34.0%), P = .045), and interstitial pneumonitis (n = 19 (21.3%) vs 19 (9.2%), P = .022) were more common causes, and chest tube suction was more common (n = 78 (87.96%) vs n = 123 (59.7%), P < .001). Similar results were found between the pleurodesis and surgical groups. We developed a score for predicting the application of chemical pleurodesis for pneumothorax, including the following factors: age ≥55 years; presence of emphysema and/or interstitial pneumonitis; and use of chest tube suction. The score for the pleurodesis group showed a high area under the receiver operating characteristic curve compared with that for the nonpleurodesis group (0.776 [95% confidence interval]: 0.725-0.827). With a score of 2 as the cutoff value, the sensitivity was 91.0% and the specificity was 52.4%. In a comparison between the pleurodesis and surgical groups, the predicting score showed the high AUC of 0.904 (95% confidence interval: 0.863-0.945).This study reveals predictive factors for the application of chemical pleurodesis and provides a predictive score including 3 factors.

Intrapleural Injection of Anti-PD1 Antibody: A Novel Management of Malignant Pleural Effusion

Background

Malignant tumors accompanied with malignant pleural effusion (MPE) often indicate poor prognosis. The therapeutic effect and mechanism of intrapleural injection of anti-programmed cell death protein 1 (PD1) on MPE need to be explored.

Methods

A preclinical MPE mouse model and a small clinical study were used to evaluate the effect of intrapleural injection of anti-PD1 antibody. The role of immune cells was observed via flow cytometry, RNA-sequencing, quantitative PCR, western blot, immunohistochemistry, and other experimental methods.

Results

Intrathoracic injection of anti-PD1 monoclonal antibody (mAb) has significantly prolonged the survival time of mice (P = 0.0098) and reduced the amount of effusion (P = 0.003) and the number of cancer nodules (P = 0.0043). Local CD8+ T cells participated in intrapleural administration of anti-PD1 mAb. The proportion of CD69+, IFN-γ+, and granzyme B+ CD8+ T cells in the pleural cavity was increased, and the expression of TNF-α and IL-1β in MPE also developed significantly after injection. Local injection promoted activation of the CCL20/CCR6 pathway in the tumor microenvironment and further elevated the expression of several molecules related to lymphocyte activation. Clinically, the control rate of intrathoracic injection of sintilimab (a human anti-PD1 mAb) for 10 weeks in NSCLC patients with MPE was 66.7%. Local injection improved the activity and function of patients' local cytotoxic T cells (CTLs).

Conclusions

Intrapleural injection of anti-PD1 mAb could control malignant pleural effusion and the growth of cancer, which may be achieved by enhancing local CTL activity and cytotoxicity.

Utility of thoracic computed tomography to predict need for early surgery and recurrence after first episode of primary spontaneous pneumothorax

INTRODUCTION

CT imaging is not advocated by British Thoracic Society guidelines after first episode of primary spontaneous pneumothorax (PSP). There is emerging evidence that emphysema-like changes and CT-based dystrophy severity score (DSS) can predict need for early surgery and recurrence.

OBJECTIVES

We aimed to assess the role of DSS during first episodes of PSP in predicting the need for early surgery and recurrence.

METHODS

We conducted a retrospective analysis of consecutive PSP episodes (n=197) admitted to our institution from 1 January 2012 to 31 December 2017. DSS was calculated based on type, number and distribution of blebs and bullae. Patients were categorised as low-grade (0-3) or high-grade (4-6) DSS assessed by a thoracic radiologist.

RESULTS

Forty-five PSP patients had CT at first presentation. Eight patients had low-grade DSS; all were managed non-surgically and none had recurrence over 12 months. Thirty-seven patients had high-grade DSS. Of these, 25 (67.5%) were managed surgically, with three having contralateral recurrence over 12 months; 12 (32.5%) were managed non-surgically, and of these two patients had ipsilateral recurrence over 12 months.

CONCLUSION

DSS seems to predict the need for early surgery and recurrence and CT can be used to risk-stratify patients after a first episode of PSP.

Pleurodesis After Bronchial Occlusion for Inoperable Secondary Spontaneous Pneumothorax

BACKGROUND

In many cases of secondary spontaneous pneumothorax (SSP), surgery is not feasible. Furthermore, in cases with a collapsed lung or numerous air leaks, pleurodesis is ineffective, and treatment options are severely limited. For these cases, bronchial occlusion might be the only effective treatment, despite the low success rate. If, however, bronchial occlusion can expand the lung and reduce air leakage, it can positively amplify later effects on pleurodesis, resulting in a powerful treatment. We reviewed the clinical data of patients who underwent bronchial occlusion with endobronchial Watanabe spigot (BO-EWS) and pleurodesis to investigate the usefulness of bronchial occlusion therapy in inoperable SSP patients.

MATERIALS AND METHODS

This single-center, retrospective study reviewed 36 cases of inoperable SSP patients who underwent pleurodesis after BO-EWS from April 2007 to October 2018. Twenty cases were allocated to the air leak analysis group, and 16 cases were included in the pneumothorax volume analysis group. The Robert David Cerfolio classification and the Collins method were used to evaluate air leak and pneumothorax volume, respectively.

RESULTS

Pneumothorax volumes decreased significantly after BO-EWS from 29.1%±17.3% to 12.1%±8.8%, while the air leak score decreased from 2.9±1.4 to 1.2±1.0. The success rate for chest tube removals in cases that underwent pleurodesis after BO-EWS was 85.0% (17/20).

CONCLUSIONS

This study demonstrated the synergistic effectiveness of BO-EWS and the usefulness of pleurodesis treatment in inoperable SSP patients with lung collapse or numerous air leaks. We believe that this treatment will benefit patients with inoperable SSP which, until now, has had few treatment options.

Thoracoscopy for Spontaneous Pneumothorax

Video-assisted thoracic surgery (VATS) is the treatment of choice for recurrence prevention in patients with spontaneous pneumothorax (SP). Although the optimal surgical technique is uncertain, bullous resection using staplers in combination with mechanical pleurodesis, chemical pleurodesis and/or staple line coverage is usually undertaken. Currently, patient satisfaction, postoperative pain and other perioperative parameters have significantly improved with advancements in thoracoscopic technology, which include uniportal, needlescopic and nonintubated VATS variants. Ipsilateral recurrences after VATS occur in less than 5% of patients, in which case a redo-VATS is a feasible therapeutical option. Randomized controlled trials are urgently needed to shed light on the best definitive management of SP.

Mechanical or chemical and mechanical pleurodesis for spontaneous pneumothorax: what is the most effective approach in preventing recurrence? A systematic review and meta-analysis

OBJECTIVES

Surgical management of spontaneous pneumothorax typically involves wedge resection and mechanical pleurodesis. It is unclear whether combining mechanical and chemical pleurodesis can further reduce the recurrence rate. We have performed a meta-analysis of studies comparing the combined approach with mechanical pleurodesis alone.

METHODS

A comprehensive search of the existing literature was performed using PubMed, EMBASE and Web of Science for all types of studies that compared combined pleurodesis to a single approach. We used the Cochrane Risk of Bias Tool and Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) to assess the quality of the studies. Relative risk of pneumothorax recurrence was calculated, and the differences between the studies were examined. The primary outcome was the recurrence of pneumothorax.

RESULTS

Of 2301 eligible studies, 5 studies were included. Five hundred sixty-one patients who received combined pleurodesis were compared to 286 patients who received mechanical pleurodesis only. Patients treated with combined intervention had a 63% lower risk of developing a recurrent pneumothorax compared to single intervention [relative risk 0.37, 95% confidence interval (CI) 0.18-0.76; P = 0.006]. There were no statistically significant differences in the length of stay (standardized mean difference -0.17, 95% CI -0.39 to 0.05, P = 0.138), the duration of postoperative air leak (standardized mean difference 0.17, 95% CI -1.14 to 1.47, P = 0.804) or the duration of postoperative chest tube drainage (standardized mean difference -0.07, 95% CI -0.27 to 0.12, P = 0.471).

CONCLUSIONS

This meta-analysis demonstrated that combined intervention with mechanical and chemical pleurodesis for spontaneous pneumothorax may be more effective in preventing recurrence than mechanical pleurodesis alone. These findings will provide some guidance to surgeons in the decision-making process.

Autologous blood patch pleurodesis treatment for persistent pneumothorax: A case series of five dogs (2016-2020)

Background

Autologous blood patch pleurodesis (ABP) has been described as a treatment for persistent pneumothorax in the dogs and among humans. Although the treatment of persistent or recurring spontaneous pneumothorax is classically surgical, it cannot always be performed due to medical or financial constraints. This case series describes the clinical course, etiology, and outcome of five dogs with persistent pneumothorax treated with ABP.

Case Description

Five client-owned dogs with persistent pneumothorax are presented. Two dogs had pneumothorax due to congenital pulmonary bullae, one due to thoracic trauma, another due to lungworm infection, and a fifth with unknown cause in the context of a relapsing subcutaneous haemangiosarcoma. Around 5 ml/kg of non-coagulated blood was aseptically collected from the jugular vein and injected via a thoracotomy tube immediately into the pleural cavity of dogs with persistent pneumothorax. The procedure was successful in four out of five dogs after one procedure, therefore a success rate of 80%. A repeat of the pleurodesis was attempted in the fifth dog, 12 hours after the first injection due to the recollection of the pneumothorax. Still, the dog died during anesthesia in preparation for the procedure. No complications that could be directly linked to ABP occurred.

Conclusion

ABP is a simple, rapid, inexpensive, effective, and safe procedure that can be useful for treating persistent pneumothorax that does not respond to conservative treatment and where surgical exploration cannot be carried out. Pneumothorax secondary due to trauma and congenital pulmonary bullae seem to respond well to ABP.

Risk factors for recurrent spontaneous pneumothorax: A population level analysis

BACKGROUND

We sought to determine the rate and risk factors of recurrent spontaneous pneumothorax in a diverse population.

METHODS

Cohort study using the California Public Discharge Data file (1995-2010). We identified patients with first-time spontaneous pneumothorax. The primary outcome was recurrent pneumothorax. Associations with clinical, patient, and hospital characteristics were assessed using Cox regression analysis.

RESULTS

Among 14,609 patients with a first-time episode of spontaneous pneumothorax, 26.2% developed a recurrence. Risk factors included age <35 (Hazard Ratio [HR] 1.24 95%-Confidence Interval [CI] 1.14-1.36), Asian race (HR 1.24, CI 1.13-1.37), and tube thoracostomy (HR 1.2, CI 1.15-1.31). Mechancial pleurodesis (HR 0.37 CI 0.31-0.45) was superior to chemical pleurodesis (HR 0.71 CI 0.58-0.86) in reducing recurrence risk.

CONCLUSIONS

The risk of recurrent pneumothorax is greatest in patients age <35, Asians, and those requiring a tube thoracostomy. The risks of operative intervention should be balanced against patient risk for recurrence.

Usefulness of the Electrocardiogram in a Patient Presenting with Right-Sided Pneumothorax and Presyncope

We present the case of a 71-year-old man with history of smoking, pulmonary emphysema, hypertension, multivessel coronary artery disease and prior coronary artery bypass graft surgery who presented with spontaneous right-sided pneumothorax associated with phasic changes of the QRS amplitude on the electrocardiogram. While several case reports have described QRS amplitude changes associated with left-sided pneumothorax, reports of phasic ECG changes in right-sided pneumothorax are exceedingly rare. Such changes, when present in a patient with sudden onset chest pain and dyspnea, should prompt a diagnostic workup for possible pneumothorax.

Efficacy of an autologous blood patch for prolonged air leak, a systematic review

BACKGROUND

Prolonged air leak (PAL) following pulmonary surgery remains a clinical challenge and sometimes needs surgical reintervention. An autologous blood patch (ABP) may provide a noninvasive method to cease air leak. Its value, however, is debatable. The aim of this systematic review is to synthesize evidence regarding the efficacy of ABP in patients with PAL.

METHODS

A comprehensive search for published studies was performed in the Medline database, Embase and the Cochrane library. Randomized controlled trials, case-control studies and case series in which a postoperative ABP was performed were included. Findings from these studies were tabulated and data was synthesized graphically. PROSPERO registration number CRD42020157591.

RESULTS

A total of 8 studies was included in the analysis, comprising 151 patients. Studies demonstrated heterogeneity in ABP timing and practice and an intermediate to high risk of bias was scored. The majority of studies demonstrated a beneficial effect of the ABP, with a high rate of success of over 89%. One randomized trial did not find a difference in time to cease of air leak following ABP compared with conservative tube thoracostomy. The overall complication rate was 10%.

CONCLUSIONS

Quality of included studies is limited due to lack of comparison groups. Synthesized data in this review demonstrates a high rate of successful procedures and acceptable complication rates, which seems to be encouraging to justify a large randomized clinical trial on the use of ABP for patients who suffer from PAL following thoracic surgery.

[Ambulatory management of bilateral secondary spontaneous pneumothorax in palliative care]

INTRODUCTION

Secondary spontaneous pneumothoraces account for 35% of all pneumothoraces after the age of 50. Their management is still debated and can be challenging due to the underlying respiratory condition. In our observation, the use of small-bore chest tubes allowed prolonged ambulatory care in a palliative setting.

CASE REPORT

We report the case of a 54-year-old woman suffering from a leiomyosarcoma with multiple pulmonary metastases who had repeated episodes of pneumothorax, one of which was bilateral. Treatment involved the bilateral insertion of 8.5F pigtail catheters connected to Heimlich valves that allowed management as an outpatient. Recurrences were treated similarly, in association with oncological management, providing great additional benefits for patient comfort in this palliative context.

CONCLUSION

Altogether, this case report confirms the applicability of outpatient management for drained spontaneous secondary pneumothoraces, even bilateral, especially in a palliative-care setting.

Pleurography (thoracography) for pleural fistulas: A case series

Background

Pleurography (PG) has been described previously but has not gained popularity. PG can determine the exact air leak points in the lung, which is important for treating pneumothorax and pleural fistulas. We believe that the usefulness of PG should be reassessed, and here we describe the method, air leak detection rate, and common complications.

Methods

From the 1210 cases of pleural fistulas that were treated at our institution between March 2015 and October 2018, 275 patients with recurrent primary pneumothorax or secondary spontaneous pneumothorax were selected for this study. PG was performed in 127 patients with persistent air leakage during exhalation. In addition, 35 patients with postoperative complications of air leakage persisting for 7 days or longer were included.

Results

Air leak points were detected in 119 patients (73%), in the apex of the lung in 65 cases, in the basal segment in 13 cases, and in the middle lobe or lingular segment in 9 cases. There were 8 cases of hilar lesions, 12 cases of S6 lesions, 8 cases of upper lobe lesions other than apex, and 4 cases of upper mediastinal lesions. Complications within 30 days were observed in 10 cases (6.2%), with 8 grade 2 cases involving fever, 1 grade 3 case involving infection, and one grade 1 case with abdominal distension.

Conclusions

The incidence of grade ≥3 adverse events after PG was 0.6%, which is considered acceptable. Our findings suggest that PG is a safe examination method to identify air leaks before surgery for pleural fistulas.

Allogenic blood patch pleurodesis for continuous pneumothorax in three cats

Case series summary

Following diaphragmatic herniorrhaphy, three cats developed a continuous pneumothorax. All three cats required continuous suction to evacuate air from the thoracic cavity. Despite continuous suction, the pneumothorax persisted for all cats and blood patch pleurodesis (BPP) was performed using blood donor cats. All three cats had resolution of their pneumothorax within 24 h of BPP.

Relevance and novel information

This is the first report of BPP used in feline patients. More recently autologous BPP has been reported for use in dogs and humans, with a reportedly high success rate. BPP may allow timely resolution of continuous pneumothorax in cats and provide an alternative treatment option to prolonged medical management or surgical intervention. Allogenic blood from a donor cat may be necessitated in feline BPP when cardiovascular instability is appreciated in these small patients.

Recurrent Spontaneous Pneumothorax in a 47-Year-Old Woman

Pneumothorax is a condition where air exists in the chest cavity, outside the lung. The causes of pneumothorax are numerous and determining the etiology can aid in treatment and prevent recurrence. We describe a 47-year-old female patient with past medical history of endometriosis who presented to the emergency room with recurrent right sided pneumothorax, its onset correlating with onset of menses. She underwent video assisted thorascopic surgery for a suspected catamenial pneumothorax whereby nodular "chocolate" appearing areas were noted on the middle lobe and multiple similar appearing lesions and fenestrations were noted on the diaphragm. A biologic mesh was affixed to the diaphragm after which mechanical and chemical pleurodesis were performed. She tolerated the procedure well and has been symptom free since. Herein, we review the pathophysiology, diagnosis, and treatment strategies for catamenial pneumothorax in the hopes of increasing awareness and understanding of this rare cause of spontaneous pneumothorax.

Recurrence Prophylaxis in Secondary Spontaneous Pneumothorax: A Nationwide Readmission Database Analysis

BACKGROUND

Secondary spontaneous pneumothorax (SSP) is defined as a pneumothorax presenting as a complication of underlying lung disease. Due to the high recurrence rate and the possibility of life-threatening complications, same-admission recurrence prophylaxis (SARP) following the first occurrence of SSP is recommended by many experts. The rate of SARP in SSP admissions has not been reported.

RESEARCH QUESTION

How often were SARP procedures performed in SSP admissions in the United States? How did outcomes differ between SSP admissions with SARP vs those without SARP?

STUDY DESIGN AND METHODS

This study used the Nationwide Readmission Database to analyze 71,451,419 inpatient admissions in the United States in 2016 and 2017. SSP admissions with patients aged ≥ 18 years were included, and admissions with documented traumatic or iatrogenic causes of pneumothorax were excluded. Outcomes were compared between SSP admissions with and without SARP. Multivariate logistic analysis was used to model binary-dependent variables.

RESULTS

There were 21,838 SSP admissions in 2016 and 2017 (30.56 per 100,000 admissions per year), among which 7,366 (33.73%) received SARP. SARP was associated with lower odds of in-hospital mortality (adjusted OR [aOR], 0.48; 95% CI, 0.34-0.70), 30-day mortality (aOR, 0.52; 95% CI, 0.35-0.77), 90-day mortality (aOR, 0.56; 95% CI, 0.40-0.79), and 1-year mortality (aOR, 0.28; 95% CI, 0.10-0.74). SARP was also associated with lower all-cause readmission at 30 days (aOR, 0.40; 95% CI, 0.40-0.49), 90 days (aOR, 0.47; 95% CI, 0.40-0.55), and 1 year (aOR, 0.46; 95% CI, 0.30-0.68), as well as lower rates of postdischarge pneumothorax recurrence in 30 days (aOR, 0.22; 95% CI, 0.11-0.44), 90 days (aOR, 0.26; 95% CI, 0.20-0.33), and 1 year (aOR, 0.22; 95% CI, 0.11-0.44).

INTERPRETATION

The rate of SARP in SSP admissions was 33.73% in the United States in 2016 and 2017. SARP was associated with lower mortality, all-cause readmission, and pneumothorax recurrence in SSP admissions.

Thoracoscopic surgery under local anesthesia for high-risk intractable secondary spontaneous pneumothorax

OBJECTIVES

To evaluate the outcomes of thoracoscopic surgery for intractable secondary spontaneous pneumothorax (SSP) under local anesthesia in high-risk patients and report intraoperative findings useful for identifying air leakage points.

METHODS

We analyzed outcomes of 14 consecutive thoracoscopic operations under local anesthesia for high-risk SSP from 2015 to 2019. Suspicious lesions were determined based on intraoperative direct or indirect detections. Direct detection involved identifying pleural fistulas or air bubbles. Indirect detection involved finding thin and transparent bullae without any other suspicious lesions. Identifications of culprit lesions were confirmed by arrest or significant decrease in air leakage after surgical repair. All surgical repairs were followed by immediate single pleurodesis for a definitive cure and prevention of recurrence. Success was defined as the removal of the thoracic tube by surgical repair combined with immediate postoperative single pleurodesis.

RESULTS

The main underlying pulmonary diseases were emphysema (n = 7), carcinoma (n = 3), interstitial pneumonia (IP) (n = 3), and nontuberculous mycobacterial infection (n = 1). A leakage point was identified in 13 cases (six on direct and seven on indirect detections). Success was achieved in nine cases (four on direct and five on indirect detections). Adverse events included one case of acute exacerbation of IP and one case of carbon dioxide narcosis.

CONCLUSION

Thoracoscopic surgery under local anesthesia can be the worthwhile definitive modality, among few remaining treatments, for highly fragile patients with SSP. Detecting air leakage directly and the presence of thin and transparent bullae without any other suspicious lesions can be clues for identifying culprit lesions.

A Case of Persistent Air Leak Managed by Selective Left Main Bronchus Intubation in an Infant with Pulmonary Tuberculosis

BACKGROUND Persistent air leak, or persistent pneumothorax, is defined as a pneumothorax that persists beyond the first week, or air leak through a chest drain for more than 48 hours. The most common findings in pediatric pulmonary tuberculosis are parenchymal disease and mediastinal lymphadenopathy, but airway obstruction can cause emphysema and pneumothorax. A case is presented of persistent air leak in a 3-month-old infant with pulmonary tuberculosis that was managed by selective left main bronchus intubation. CASE REPORT A 3-month-old boy presented with respiratory distress and fever. Imaging findings suggested pulmonary tuberculosis, and first-line anti-tuberculous treatment was initiated with isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE). He was discharged home after eight days, but was admitted four days later with respiratory distress. Chest X-rays showed a tension pneumothorax that required drainage and chest computed tomography (CT) showed right lung emphysema. Bronchoscopy found extrinsic obstruction of both main bronchi. Chest drains continued to leak air leak after 48 h. Right middle and lower lobectomy and drainage of multiple lymph nodes resulted in significant improvement. He developed pneumonia and acute respiratory distress syndrome, which prevented mechanical ventilation. The left main bronchus was selectively intubated to allow the air leak to heal and to ventilate the lung. He was extubated 10 days later and recovered completely. CONCLUSIONS This case highlights that when medical management of persistent air leak associated with tuberculosis is not effective, surgery, active ventilation, and selective main bronchus intubation should be considered.

Video-Assisted Thoracic Surgery (VATS) Talc Pleurodesis Versus Pleurectomy for Primary Spontaneous Pneumothorax: A Large Single-Centre Study with No Conversion

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively common clinical entity with high incidence in the young population. Video-Assisted Thoracic Surgery (VATS) bullectomy and chemical or mechanical pleurodesis are two primary modalities of treatment. There has been much debate on the ideal mode of pleurodesis, but the literature on surgical outcomes comparing VATS pleurectomy with talc pleurodesis has been inconclusive.

METHODS

We performed a single-centre 5-year observational retrospective study of 202 patients who underwent VATS bullectomy with talc pleurodesis or parietal pleurectomy.

RESULTS

There were no significant differences in the demographics, pre-operative and intra-operative characteristics in both groups. Recurrence of pneumothorax, chest tube duration and hospital stay were similar in both groups. However, talc pleurodesis had a shorter operative time compared to pleurectomy.

CONCLUSION

Our study demonstrated comparable outcomes between talc pleurodesis and pleurectomy following VATS bullectomy for patients with PSP.

Management of air leaks post-surgical lung resection

Airleaks are one of the most common complications associated with elective lung resection. There have been many techniques and modern advancements in thoracic surgery, however airleaks persist. This review article will discuss several interventions ranging from conservative noninvasive to surgical management of the persistent airleak. These techniques include stopping of suction on the plueravac, fibrin patches, pleurodesis, use of endobronchial valves (EBVs), return to OR for operative intervention, and lastly to send patients home with mini pleuravacs.

Comparison of several methods for pain management after video-assisted thoracic surgery for pneumothorax: an observational study

BACKGROUND

There is no defined gold standard for pain management after video-assisted thoracic surgery (VATS) for pneumothorax. In addition to systemic analgesia, various loco-regional analgesic techniques have been proposed but remain poorly evaluated in this context. We aimed to assess the analgesic efficacy of several of these techniques for the management of postoperative pain.

METHODS

We conducted a monocentric prospective observational cohort study from February 2017 to April 2018 in patients suffering from spontaneous pneumothorax and scheduled for VATS (n = 59). Patients received systemic analgesia (i) alone (n = 15); (ii) combined with a continuous paravertebral block (n = 9); (iii) combined with a continuous serratus plane block (n = 19); or (iv) single-shot serratus plane block (n = 16) as decided by the attending physician. Pain scores and analgesic-related side effects were prospectively collected by an independent observer during the first postoperative 72 h. The primary endpoint criterion was the cumulative oral morphine consumption at the end of the third postoperative day. Statistical analysis used univariate and multivariate step-by-step forward logistic regression models to determine risk factors associated with the main criteria.

RESULTS

Mean pain scores and morphine consumption were not significantly different between the 4 groups. In the multivariate analysis, the use of a continuous serratus plane block through a catheter was the only technique associated with a reduced incidence of high-dose oral morphine consumption (OR 0.09-95%CI [0.01-0.79], p = 0.03).

CONCLUSION

This study suggests that serratus plane block combined with continuous infusion through a catheter may have some benefits, although further studies are needed to confirm these results and determine the true place of the serratus plane block in pain management after VATS for pneumothorax.

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

The pathophysiology and management of primary spontaneous pneumothorax (PSP) are a subject of debate. Despite advances in the understanding of its etiopathogenesis and improvements in its management, implementation in clinical practice is suboptimal. In this manuscript, we review the recent literature with a focus on PSP pathophysiology and management. Blebs and emphysema-like changes (ELC) are thought to contribute to the pathophysiology of PSP but cannot explain all cases. Recent studies emphasize the role of a diffuse porosity of the visceral pleura. Others found a relationship between smoking, occurrence of a PSP and bronchiolitis, which could be the initial pathological process leading to ELC development. Recent or ongoing studies challenge the need to systematically remove air from the pleural cavity of stable patients, introducing conservative management as a valuable therapeutic option. Evidence is growing in favour of needle aspiration instead of chest tube insertion, when air evacuation is needed. In addition, ambulatory management is considered as a successful approach in meta-analyses and is under exploration in a large randomized study. Because of a high recurrence rate of PSP, the benefit of performing a pleurodesis at first occurrence is under evaluation with interesting but not generalizable results. Better identification of 'at risk patients' is needed to improve the investigation strategy. Finally, recent publications confirm the efficacy, security and cost-effectiveness of graded talc poudrage pleurodesis to prevent PSP recurrence. In conclusion, PSP pathophysiology and management are still under investigation. The results of recently published and ongoing studies should be more widely implemented in clinical practice.