Incidence of primary spontaneous pneumothorax: a validated, register-based nationwide study

Management of Sideline Medical Emergencies

Sideline medical care is typically provided by musculoskeletal specialists and orthopaedic surgeons with varying levels of training and experience. While the most common sports injuries are often benign, the potential for catastrophic injury is omnipresent. Prompt recognition of sideline emergencies and expeditious medical management are necessary to minimize the risk of calamitous events. Paramount to successful sideline coverage are both preseason and game-day preparations. Because the skillset needed for the sideline physician may involve management of injuries not commonly seen in everyday clinical practice, sideline providers should review basic life support protocols, spine boarding, and equipment removal related to their sport(s) before the season begins. Before every game, the medical bag should be adequately stocked, location of the automatic external defibrillator/emergency medical services identified, and introductions to the trainers, coaches, and referees made. In addition to musculoskeletal injuries, the sideline orthopaedic surgeon must also be acquainted with the full spectrum of nonmusculoskeletal emergencies spanning the cardiopulmonary, central nervous, and integumentary systems. Familiarity with anaphylaxis as well as abdominal and neck trauma is also critical. Prompt identification of potential life-threatening conditions, carefully orchestrated treatment, and the athlete's subsequent disposition are essential for the team physician to provide quality care.

Massive subcutaneous emphysema and bilateral tension pneumothorax following laparoscopic inguinal hernia repair under general anesthesia: A case report

The escalating adoption of laparoscopic surgical techniques has demonstrated their capacity to yield improved clinical outcomes. However, concomitant with the advantages of this minimally invasive approach, certain adverse complications have been reported. In this report, we present a noteworthy case involving a 72-year-old male patient who underwent laparoscopic inguinal hernia repair. The surgical procedure proceeded without noteworthy complications, and the patient maintained hemodynamic stability throughout. However, the post-anesthetic recovery was compromised by the onset of subcutaneous emphysema and bilateral tension pneumothorax. Immediate intervention was imperative, prompting the performance of an emergent needle thoracostomy, subsequently followed by the implementation of a closed drainage system within the thoracic cavity. These interventions proved efficacious in mitigating the patient's distressing symptoms. Although pneumothorax complications in the context of laparoscopic surgery are infrequent, it is imperative for anesthetists to remain vigilant regarding the potential occurrence of subcutaneous emphysema and pneumothorax in the perioperative period. This case underscores the significance of meticulous perioperative monitoring and rapid intervention, particularly in laparoscopic procedures, where the insufflation of carbon dioxide into the abdominal cavity can predispose patients to these rare yet potentially life-threatening complications. Heightened awareness among healthcare providers regarding the possibility of such events is pivotal in ensuring the safety and well-being of surgical patients.

Current situation of management of spontaneous pneumothorax in Japan: A cross-sectional cohort study

BACKGROUND

Limited epidemiological information is available on spontaneous pneumothorax. To address this gap, the Japan Society for Pneumothorax and Cystic Lung Disease (JSPCLD) conducted a nationwide retrospective survey to investigate the current epidemiology of spontaneous pneumothorax in Japan.

METHODS

In this study, we conducted a retrospective cross-sectional cohort study to demonstrate the clinical features of spontaneous pneumothorax in one year from April 2019 to March 2020, compare patient characteristics and treatment outcomes between primary (PSP) and secondary spontaneous pneumothorax (SSP), and investigate the risk factors associated with in-hospital mortality among patients with SSP.

RESULTS

A total of 1784 patients from 28 institutions were enrolled in the study, with PSP observed in 956 cases (53.6%) and SSP in 817 cases (45.8%). The age distribution showed a biphasic peak caused by the different peaks between PSP and SSP. In-hospital mortality occurred in 42 cases (2.4%) among all patients, with 0 cases (0%) in PSP and 42 cases (5.1%) in SSP. Multivariable analyses revealed that interstitial pneumonia as an underlying disease (odds ratio: 2.4700, 95% confidence interval: 1.1100 to 5.4800, p = 0.0269), performance status≧3 (odds ratio: 7.3900, 95% confidence interval: 3.1900 to 17.2000, p < 0.0001), and lower value of serum albumin on admission (odds ratio: 0.4060, 95% confidence interval: 0.2140 to 0.7690, p = 0.0057) were significantly associated with in-hospital mortality among patients with SSP.

CONCLUSIONS

SSP patients with poor baseline conditions are at a higher risk for in-hospital mortality. It is crucial to provide close and meticulous management for SSP patients with compromised conditions.

Population-based study on surgical care for primary spontaneous pneumothorax

OBJECTIVES

The optimal surgical strategy for primary spontaneous pneumothorax remains a matter of debate and variation in surgical practice is expected. This variation may influence clinical outcomes, such as postoperative complications and length of stay. This national population-based registry study provides an overview and extent of variability of current surgical practice and outcomes in the Netherlands.

METHODS

To identify national patterns of care and between-hospital variability in the treatment of primary spontaneous pneumothorax, patients who underwent surgical pleurodesis and/or bullectomy between 2014 and 2021, were identified from the Dutch Lung Cancer Audit-Surgery database. The type of surgical intervention, postoperative complications, length of stay and ipsilateral recurrences were recorded.

RESULTS AND CONCLUSIONS

Out of 4338 patients, 1851 patients were identified to have primary spontaneous pneumothorax. The median age was 25 years (interquartile range 20-31) and 82% was male. The most performed surgical procedure was bullectomy with pleurodesis (83%). The overall complication rate was 12% (Clavien-Dindo grade ≥III 6%), with the highest recorded incidence for persistent air leak >5 days (5%). Median postoperative length of stay was 4 days (interquartile range 3-6) and 0.7% underwent a repeat pleurodesis for ipsilateral recurrence. Complication rate and length of stay differed considerably between hospitals. There were no differences between the surgical procedures. In the Netherlands, surgical patients with primary spontaneous pneumothorax are preferably treated with bullectomy plus pleurodesis. Postoperative complications and length of stay vary widely and are considerable in this young patient group. This may be reduced by optimization of surgical care.

Can the generalizability issue of artificial intelligence be overcome? Pneumothorax detection algorithm

The generalizability of artificial intelligence (AI) models is a major issue in the field of AI applications. Therefore, we aimed to overcome the generalizability problem of an AI model developed for a particular center for pneumothorax detection using a small dataset for external validation. Chest radiographs of patients diagnosed with pneumothorax (n = 648) and those without pneumothorax (n = 650) who visited the Ankara University Faculty of Medicine (AUFM; center 1) were obtained. A deep learning-based pneumothorax detection algorithm (PDA-Alpha) was developed using the AUFM dataset. For implementation at the Health Sciences University (HSU; center 2), PDA-Beta was developed through external validation of PDA-Alpha using 50 radiographs with pneumothorax obtained from HSU. Both PDA algorithms were assessed using the HSU test dataset (n = 200) containing 50 pneumothorax and 150 non-pneumothorax radiographs. We compared the results generated by the algorithms with those of physicians to demonstrate the reliability of the results. The areas under the curve for PDA-Alpha and PDA-Beta were 0.993 (95% confidence interval (CI): 0.985-1.000) and 0.986 (95% CI: 0.962-1.000), respectively. Both algorithms successfully detected the presence of pneumothorax on 49/50 radiographs; however, PDA-Alpha had seven false-positive predictions, whereas PDA-Beta had one. The positive predictive value increased from 0.525 to 0.886 after external validation (p = 0.041). The physicians' sensitivity and specificity for detecting pneumothorax were 0.585 and 0.988, respectively. The performance scores of the algorithms were increased with a small dataset; however, further studies are required to determine the optimal amount of external validation data to fully address the generalizability issue.

Deep Learning-based Diagnosis and Localization of Pneumothorax on Portable Supine Chest X-ray in Intensive and Emergency Medicine: A Retrospective Study

PURPOSE

To develop two deep learning-based systems for diagnosing and localizing pneumothorax on portable supine chest X-rays (SCXRs).

METHODS

For this retrospective study, images meeting the following inclusion criteria were included: (1) patient age ≥ 20 years; (2) portable SCXR; (3) imaging obtained in the emergency department or intensive care unit. Included images were temporally split into training (1571 images, between January 2015 and December 2019) and testing (1071 images, between January 2020 to December 2020) datasets. All images were annotated using pixel-level labels. Object detection and image segmentation were adopted to develop separate systems. For the detection-based system, EfficientNet-B2, DneseNet-121, and Inception-v3 were the architecture for the classification model; Deformable DETR, TOOD, and VFNet were the architecture for the localization model. Both classification and localization models of the segmentation-based system shared the UNet architecture.

RESULTS

In diagnosing pneumothorax, performance was excellent for both detection-based (Area under receiver operating characteristics curve [AUC]: 0.940, 95% confidence interval [CI]: 0.907-0.967) and segmentation-based (AUC: 0.979, 95% CI: 0.963-0.991) systems. For images with both predicted and ground-truth pneumothorax, lesion localization was highly accurate (detection-based Dice coefficient: 0.758, 95% CI: 0.707-0.806; segmentation-based Dice coefficient: 0.681, 95% CI: 0.642-0.721). The performance of the two deep learning-based systems declined as pneumothorax size diminished. Nonetheless, both systems were similar or better than human readers in diagnosis or localization performance across all sizes of pneumothorax.

CONCLUSIONS

Both deep learning-based systems excelled when tested in a temporally different dataset with differing patient or image characteristics, showing favourable potential for external generalizability.

Cannabis-Associated Pneumothorax: A Case Report

The use of cannabis for therapeutic and recreational purposes has been on the rise in recent years. This has increased the prevalence of cannabis use disorder across various demographic subgroups. A recent medical literature review describes a few cases demonstrating the association of spontaneous pneumothorax and bullous lung disease in cannabis users without concomitant tobacco use. We herein present a case report of a young male with chronic cannabis use who presented with right-sided spontaneous pneumothorax and bilateral apical blebs.

Outcomes of Non-intubated Versus Intubated Thoracoscopic Surgery for Primary Spontaneous Pneumothorax

BACKGROUND

This study aimed to compare the outcomes of non-intubated video-assisted thoracic surgery (N-VATS) and intubated video-assisted thoracic surgery (I-VATS) for primary spontaneous pneumothorax (PSP).

MATERIALS AND METHODS

We retrospectively analyzed 120 consecutive patients who underwent VATS for PSP. The patients were divided into N-VATS and I-VATS groups. Demographics, clinical characteristics, postoperative results, pain scores, follow-up results, and management were evaluated and compared between the groups. Local anesthesia and deep sedation (ketamine 2 mg/kg IV and propofol 2 mg/kg IV slow infusion) were administered under spontaneous ventilation in the N-VATS group.

RESULTS

The groups did not differ significantly in terms of age, sex, American Society of Anesthesiology score, pneumothorax side, or smoking history ( P >0.05). The mean operation time, anesthesia time, oral intake opening time, and mobilization time were significantly shorter in the N-VATS group (26.04±4.61 vs. 48.26±7.82 min, 42.14±6.40 vs. 98.16±12.4 min, 2.1±0.4 vs. 8.4±1.2 h, and 4.2±0.9 vs. 2.6±1.4 between N-VATS and I-VATS, respectively; P <0.05). The surgical outcomes did not differ in terms of minor complications (12%-13%) and recurrence rates (5.1%-6.4%) during a mean follow-up period of 88.4±10.2 mo. No cases of conversion to open surgery or mortality were observed. General anesthesia and intubation were not required for any patient in the N-VATS group.

CONCLUSIONS

Our results revealed no differences in minor complications or recurrence rates between groups. However, the N-VATS group had significantly shorter operation, anesthesia, oral intake opening, and mobilization times. The most important advantage of N-VATS for PSP is its fast recovery while avoiding the risks of general anesthesia and intubation. Further prospective studies with larger sample sizes are warranted.

Probability of sporadic lymphangioleiomyomatosis in women presenting with spontaneous pneumothorax

BACKGROUND

Sporadic lymphangioleiomyomatosis (S-LAM) is a rare low-grade neoplasm of young women characterized by multiple pulmonary cysts leading to progressive dyspnea and recurrent spontaneous pneumothorax (SP). The diagnosis of S-LAM may be delayed by several years. To reduce this delay, chest computed tomography (CT) screening has been proposed to uncover cystic lung disease in women presenting with SP. However, the probability to discover S-LAM in this population has not been determined precisely. The aim of this study was to calculate the probability of finding S-LAM in women presenting with (a) SP, and (b) apparent primary SP (PSP) as first manifestation of S-LAM.

METHODS

Calculations were made by applying the Bayes theorem to published epidemiological data on S-LAM, SP and PSP. Each term of the Bayes equation was determined by meta-analysis, and included: (1) the prevalence of S-LAM in the general female population, (2) the incidence rate of SP and PSP in the general female population, and (3) the incidence rate of SP and apparent PSP in women with S-LAM.

RESULTS

The prevalence of S-LAM in the general female population was 3.03 per million (95% confidence interval 2.48, 3.62). The incidence rate of SP in the general female population was 9.54 (8.15, 11.17) per 100,000 person-years (p-y). The incidence rate of SP in women with S-LAM was 0.13 (0.08, 0.20). By combining these data in the Bayes theorem, the probability of finding S-LAM in women presenting with SP was 0.0036 (0.0025, 0.0051). For PSP, the incidence rate in the general female population was 2.70 (1.95, 3.74) per 100,000 p-y. The incidence rate of apparent PSP in women with S-LAM was 0.041 (0.030, 0.055). With the Bayes theorem, the probability of finding S-LAM in women presenting with apparent PSP as first disease manifestation was 0.0030 (0.0020, 0.0046). The number of CT scans to perform in women to find one case of S-LAM was 279 for SP and 331 for PSP.

CONCLUSION

The probability of discovering S-LAM at chest CT in women presenting with apparent PSP as first disease manifestation was low (0.3%). Recommending chest CT screening in this population should be reconsidered.

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.

The role of telomerase in the etiology of primary spontaneous pneumothorax

Background

This study aims to investigate the role of telomerase activity in the risk of primary spontaneous pneumothorax, which is most frequently encountered in the practice of thoracic surgery.

Methods

A total of 61 patients (56 males, 5 females; median age: 29.4 years; range, 17 to 43 years) who underwent treatment for primary spontaneous pneumothorax and 19 age- and sex-matched healthy controls (10 males, 9 females; median age: 29.1 years; range, 23 to 43 years) were included in this prospective study between January 2018 - August 2018. Telomerase activity was evaluated with enzyme-linked immunosorbent assay. The correlation between telomerase activity and clinical and demographic parameters was examined.

Results

The mean serum telomerase level was 3.4±0.6 ng/mL in the primary spontaneous pneumothorax group and 1.9±0.5 ng/mL in the control group, indicating significantly higher levels in the patient group (p<0.001). There was no significant association between the telomerase levels and presence of blebs and/or bullae on thoracic computed tomography, extent of pneumothorax, laterality (right, left, or bilateral), and pack years of cigarette smoking.

Conclusion

Telomerase levels of patients with primary spontaneous pneumothorax are significantly higher than healthy individuals. Future genetic studies may ultimately clarify a potential relationship between primary spontaneous pneumothorax and short telomere syndrome.

[Update on primary spontaneous pneumothorax - conservative or primarily surgical therapy?]

Spontaneous pneumothorax is a potentially life-threatening situation. Therefore, it is mandatory to treat it safely. The incidence is approximately 10 out of 100 000 residents per year. It occurs through an immediate disruption of the visceral pleura that results in an accumulation of air in the pleural space. According to its etiology, spontaneous pneumothorax is divided into 2 groups. Whereas primary spontaneous pneumothorax occurs in healthy individuals without any detectable lung disease, secondary spontaneous pneumothorax occurs in patients with preexisting. Diagnosis of pneumothorax is typically made by chest x-ray. After diagnosis pneumothorax is traditionally treated by an insertion of a thoracic tube.Recently, thoracic ultrasound gained influence in diagnosis of pneumothorax and primarily conservative treatment strategies have been shown to be safe and equally effective in particular groups of patients. This article aims to present and discuss these upcoming strategies.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

Prevalence of Birt-Hogg-Dubé Syndrome Determined Through Epidemiological Data on Spontaneous Pneumothorax and Bayes Theorem

Background: Birt-Hogg-Dubé syndrome (BHD) is a rare inherited disorder characterized by cutaneous fibrofolliculomas, multiple pulmonary cysts, recurrent spontaneous pneumothorax (SP), and renal tumors. More than 40 years after its description, the prevalence of BHD in the general population remains unknown. This study aimed at determining the prevalence of BHD by applying the Bayes theorem of conditional probability to epidemiological data on SP. Methods: We performed a meta-analysis of published data on: (1) the probability of having BHD among patients with apparent primary SP (4 studies), (2) the incidence rate of primary SP in the general population (9 studies), and (3) the probability of experiencing a SP in BHD (16 studies). Results were corrected for SP relapses, stratified by gender and year of study publication (before and after 2000), and computed with the Bayes equation. Results: The probability of having BHD among patients with apparent primary SP was 0.09 (95% confidence interval: 0.07, 0.11) or 9%. It was 0.20 (0.14, 0.27) in women and 0.05 (0.04, 0.07) in men. The incidence rate of primary SP in the general population was 8.69 (6.58, 11.46) per 100,000 person-years (p-y). It was 3.44 (2.36, 4.99) per 100,000 p-y in women and 13.96 (10.72, 18.18) per 100,000 p-y in men, and was about 2 times higher in studies published after 2000 than in those published before 2000. The probability of experiencing at least one SP among patients with BHD was 0.43 (0.31, 0.54) or 43%, without gender difference. By combining these data in the Bayes equation, we found a prevalence of BHD in the general population of 1.86 (1.16, 3.00) per million, with values of 1.86 (1.02, 3.39) per million in men, and 1.88 (0.97, 3.63) per million in women. Conclusion: The prevalence of BHD in the general population is about 2 cases per million, without difference between genders.

Non-traumatic complications of a solitary rib osteochondroma; an unusual cause of hemoptysis and pneumothorax

Osteochondromas are a very common and usually asymptomatic entity which may originate anywhere in the appendicular and axial skeleton. However, the ribs are a rare site of origin and here they may prove symptomatic for mechanical reasons. In this case report, we describe an unusual case of a symptomatic osteochondroma of the rib secondary to its location and unique shape, ultimately requiring surgical intervention.

Etiology and prognosis of spontaneous pneumothorax in the elderly

AIM

Spontaneous pneumothorax shows a bimodal age distribution, with the secondary peak including patients aged ≥50 years. The purpose of this study was to clarify the etiology and prognosis of spontaneous pneumothorax in the elderly.

METHODS

Patients aged ≥50 years who were admitted to a tertiary university hospital between 2006 and 2016 due to spontaneous pneumothorax were retrospectively investigated.

RESULTS

Among 136 consecutive patients aged ≥50 years with spontaneous pneumothorax (mean age, 70 years; 114 men), 124 (91%) had underlying lung diseases, including pulmonary emphysema (42%) and interstitial pneumonia (27%). The median period of thoracic drainage was longer (14 days) in the cases with interstitial pneumonia than in the cases of primary pneumothorax (4 days; P < 0.001) and emphysema (9 days; P < 0.005). Eighteen patients (13%) died within 180 days after the onset of pneumothorax. The mortality rate was highest in the cases with interstitial pneumonia (27%) and was mostly associated with infectious complications. Death or worsened respiratory failure within 180 days from admission was associated with older age, systemic corticosteroid use and interstitial pneumonia in multivariate logistic regression analysis.

CONCLUSIONS

Pulmonary emphysema is the most common underlying disease associated with spontaneous pneumothorax in the elderly population. Pneumothorax associated with interstitial pneumonia is less frequent, but it requires prolonged tube thoracostomy and demonstrates higher mortality and morbidity, particularly in those receiving systemic corticosteroids. Different treatment strategies are warranted for patients with interstitial pneumonia-related pneumothorax. Geriatr Gerontol Int 2020; 20: 878-884.

Does a gender have something to do with clinical pictures of primary spontaneous pneumothorax?

OBJECTIVE

Primary spontaneous pneumothorax is relatively rarer in women than in men. In addition, women develop secondary spontaneous pneumothorax, such as lymphangioleiomyomatosis, which is rare and difficult to diagnose. Therefore, the clinical characteristics of primary spontaneous pneumothorax in women remain unknown presently. We compared the clinical characteristics of primary spontaneous pneumothorax between the two sexes at two pneumothorax centers.

METHODS

Between January 2015 and July 2019, we retrospectively evaluated 627 cases (106 women and 521 men) who underwent first video-assisted thoracoscopic surgery for primary spontaneous pneumothorax and extracted the medical backgrounds and postoperative recurrence between the sexes. Univariate and multivariate analysis was used to examine the effect of sexual specificity on postoperative recurrence.

RESULTS

Among women and men with PSP, the mean ages were 27.8 ± 10.7 and 24.3 ± 10.0 years, respectively; their mean heights were 162.0 ± 5.9 and 173.3 ± 6.1 cm, respectively. These differences were statistically significant. Three women (2.8%) and 54 men (10.4%) developed postoperative recurrence, which showed significant difference on Kaplan-Meier analysis (p = 0.027). Univariate and multivariate analysis showed the factors; women (p = 0.045, hazard ratio: 0.289 [95% confidence interval 0.086-0.973]) and smoker (p = 0.035, hazard ratio: 0.269 [95% confidence interval 0.079-0.909]) had the preventing factor for postoperative recurrence, respectively.

CONCLUSIONS

Women with PSP had lower postoperative recurrence rate than men. Although we could not reveal why women had lower postoperative recurrence rates than men in this study, the sexual difference such as hormonal cycle, development of body structure possibly affects the clinical characteristics of women with primary spontaneous pneumothorax.