Treatment of spontaneous pneumothorax: a more aggressive approach?

The Medical Management of Spontaneous Pneumothorax: A Concise Review

Spontaneous pneumothorax is an increasingly common clinical presentation, the management of which, until recent years, had remained unchanged for decades. A recent surge in pneumothorax research has produced the largest randomised controlled trials in the field yet and has revolutionised the management of spontaneous pneumothorax. The body of evidence supporting the introduction of conservative and ambulatory care in appropriate patients in recent guidelines now allows these patients, many of whom would otherwise have been admitted to hospital, to be managed in the outpatient setting and reduces their risk of complications compared to conventional chest drain insertion. In this review, we discuss recent advances in the management of pneumothorax and the evidence underpinning contemporary guidelines. We aim to equip physicians with the knowledge to engage their patients in the decision-making process regarding their pneumothorax, whilst keeping patient safety and patients' own preferences at the centre of their care.

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.

Spontaneous pneumothorax-When do we need to intervene?

BACKGROUND

Pneumothorax can be classified as traumatic, iatrogenic or spontaneous (SP), which can be subdivided into primary spontaneous pneumothorax (PSP), a condition without preexisting lung disease, or secondary spontaneous pneumothorax (SSP) a complication of a preexisting lung disease. Recurrence rate of PSP is 30% whereas for SSP rate is unknown. This article explores the experience of a tertiary center over 20 years.

METHODS

A retrospective case review of patients hospitalized with pneumothorax to investigate the natural history and treatment of SP in a young population in a single tertiary center was conducted. A search of the digital archive (going back to 01/01/1995) of Sheba Medical Center identified hospitalized patients below the age of 40.

RESULTS

The database was composed of the records of 750 patients (612 males, 138 females) who were hospitalized. The recurrence risk for SP after nonoperative treatment was significantly higher. Women were found to have an increased risk of SSP when having SP (OR 2.78). Asthma was the most prevalent disease causing SSP in young people.

CONCLUSIONS

In this large cohort, we found that operative procedure has clear protective effect from recurrence in SP, so surgery should be positively considered when treating SP in hospitalized patients. Among young people and particularly in pediatric patients, when females have a SP, we strongly recommend looking for primary lung disease. More studies are needed to determine the risk factors and produce clear guidelines regarding surgery as first treatment.

Recurrence of primary spontaneous pneumothorax following bullectomy with pleurodesis or pleurectomy: A retrospective analysis

Background

Primary spontaneous pneumothorax is managed initially with observation and chest tube placement, followed by surgical intervention in select cases. With little currently published evidence, the role of surgical pleurodesis or pleurectomy to reduce primary spontaneous pneumothorax recurrence is unclear. This study compares the recurrence rates of primary spontaneous pneumothorax following bullectomy alone versus bullectomy with pleurodesis or pleurectomy.

Methods

A retrospective review was performed at a quaternary hospital for all patients undergoing surgery for primary spontaneous pneumothorax between June 2006 and December 2018. Patient demographics, disease severity, operative technique, and time between initial surgery and recurrence were recorded. Standard statistical techniques were used for univariable and multivariable analyses.

Results

Of 222 total included patients, 28 required a second surgery: 4 (1.8%) for prolonged air leak and 24 (10.8%) for recurrent pneumothorax. The median time from first to second surgery was 363 days and 35.7% of recurrences did not present until after two years. Age, sex, smoking, year of initial surgery, disease severity, and surgical technique did not significantly affect recurrence rate on univariable analysis. On multivariable analysis, the odds ratios of recurrence for bullectomy with mechanical pleurodesis or pleurectomy were respectively 0.82 and 0.15 (P=0.218), compared to bullectomy alone. Combined bullectomy, pleurectomy, and pleurodesis was most effective (0/18, 0%).

Conclusions

Bullectomy with pleurectomy and pleurodesis demonstrated a 0% recurrence rate for the treatment of primary spontaneous pneumothorax in this study. Statistical significance was not achieved in univariable or multivariable analyses comparing recurrence rates for the surgical approaches. A multi-center randomized controlled trial with longer follow-up than previously performed is needed to confirm these preliminary findings and optimize surgical management of primary spontaneous pneumothorax.

Simultaneous bilateral thoracoscopic blebs excision reduces contralateral recurrence in patients undergoing operation for ipsilateral primary spontaneous pneumothorax

OBJECTIVE

Contralateral recurrence in patients with primary spontaneous pneumothorax is approximately 15%. If positive for blebs, the recurrence rate increases to 26%. This study seeks to determine whether simultaneous contralateral video-assisted thoracic surgery blebs excision would effectively lower the contralateral incidence of pneumothorax in patients undergoing surgery for ipsilateral primary spontaneous pneumothorax.

METHODS

Between January 2009 and December 2015, 335 patients with primary spontaneous pneumothorax, surgically treated in a single institution, were retrospectively studied. The median follow-up was 75 (50-99) months. All patients received video-assisted thoracic surgery blebectomy/bullectomy with pleural abrasions. They were classified into 3 groups: (1) ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae included 142 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs/bullae only receiving ipsilateral video-assisted thoracic surgery; (2) ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae included 123 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving only ipsilateral video-assisted thoracic surgery; and (3) bilateral video-assisted thoracic surgery with contralateral blebs/bullae included 70 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs/bullae receiving 1-stage bilateral video-assisted thoracic surgery. Demographic data, perioperative details, recurrence patterns, recurrence-free survivals, and risk factors were compared.

RESULTS

The percentage of contralateral recurrence for the ipsilateral video-assisted thoracic surgery without contralateral blebs/bullae, ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae, and bilateral video-assisted thoracic surgery with contralateral blebs/bullae groups differed significantly (0.7%, 14.6%, and 2.9%, respectively; P = .002). Multivariate analysis using the Cox proportional hazard model revealed that age less than 18 years (hazard ratio, 2.71; 95% confidence interval, 1.14-6.44; P = .024) and ipsilateral video-assisted thoracic surgery with contralateral blebs/bullae (hazard ratio, 22.13, 95% confidence interval, 2.96-165, P = .003) were predictors of contralateral recurrence, of which recurrence-free survival was notably different among groups as determined by Kaplan-Meier analysis (P < .0001).

CONCLUSIONS

Simultaneous contralateral blebectomy in patients with primary spontaneous pneumothorax receiving ipsilateral video-assisted thoracic surgery significantly lowered future contralateral recurrence.

Current Practice in the Management of Spontaneous Pneumothorax in Children

INTRODUCTION

There is a lack of pediatric-specific guidelines for the workup and management of primary spontaneous pneumothorax (PSP) in children. The aim of this study was to describe current practices among North American pediatric surgeons.

MATERIALS AND METHODS

An online survey comprising 18 questions was sent out through the American Pediatric Surgical Association Outcomes and Clinical Trials Committee to all members. Bivariate analysis was performed using Chi-square analysis.

RESULTS

A total of 287 surveys were completed (33% response rate). For a first episode of PSP, 57% of surgeons opt for chest tube drainage, 4% for upfront video-assisted thoracoscopic surgery (VATS), 3% for needle aspiration, and 29% for only oxygen administration. Eighty-one percent of surgeons report that the size of the pneumothorax influences management. However, neither practice setting (P = .87) nor years in practice (P = .11) correlated with initial management strategy. For patients with a persistent air leak after chest tube placement, there is wide variation in duration of observation before performing VATS, with 40% operating after 3 days, but 21% waiting at least 5 days. The use of chest computed tomography (CT) is also highly variable. Eighty-two percent of respondents perform surgery only after the second episode of PSP. Most perform a stapled apical blebectomy and mechanical pleurodesis for both initial and recurrent PSP.

CONCLUSION

There is significant variation among pediatric surgeons in the management of spontaneous pneumothorax, including the use of CT, timing of operation, and duration of observation for air leak before performing surgery. Prospective data are needed to better inform guidelines and standardize practice.

A comparison of axillary thoracotomy versus video-assisted thoracoscopic surgery in the surgical treatment of primary spontaneous pneumothorax

Background

This study aims to compare the results of video-assisted thoracoscopic surgery and axillary thoracotomy in the surgical treatment of primary spontaneous pneumothorax.

Methods

Between January 2009 and December 2015, a total of 199 patients (178 males, 21 females; mean age 21.3±7.1 years; range 13 to 35 years) with primary spontaneous pneumothorax who were operated at Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Department of Thoracic Surgery and Kadikoy and Kozyatagi Acibadem hospitals were retrospectively analyzed. Of these patients, 48 underwent axillary thoracotomy, wedge resection, apical pleurectomy, and tissue adhesives, while 151 were administered videoassisted thoracoscopic surgery, wedge resection, apical pleurectomy, and tissue adhesives. Both groups were compared in terms of age, gender, the amount of long-term analgesic use, duration of surgery, length of hospitalization, recurrence, complication, and mortality rates.

Results

The patients were followed for one year. No mortality was observed in any patient. There was no significant difference in the age and gender distributions of the patients, postoperative length of hospital stay, recurrence rates, and complication rates according to the type of operation. However, the duration of operation was longer in the videoassisted thoracoscopic surgery patients.

Conclusion

Video-assisted thoracoscopic surgery is associated with less pain and higher patient satisfaction and allows returning to daily activities in a shorter time period. Based on our study results, we suggest that video-assisted thoracoscopic surgery is more suitable, compared to axillary thoracotomy, owing to its advantages, such as being less invasive and providing a better angle of view.

Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax: which is better?

Background

Needle aspiration and chest tube drainages are two main treatments for primary spontaneous pneumothorax (PSP). However, the application of needle aspiration or chest tube drainages has not reached a consensus. The aim of this study is to compare the needle aspiration with chest tube drainages in patients suffering with PSP and therefore help offer suggestions for clinical practice.

Methods

We searched literatures from PubMed, OVID and Web of Science from their inception to June 30, 2017. Continuous and dichotomous outcomes were expressed by weight mean difference (WMD) and risk ratio (RR) respectively, and each with 95% confidence intervals (CIs). We used the fixed effect or random effect model to perform quantitative synthesis.

Results

A total of 6 RCTs recruiting 458 participants were included in our analysis. On the basis of the six studies, our results indicated that compared with chest tube drainage applying needle aspiration shortened the hospital stay (WMD: ‒1.67 days; 95% CI: ‒2.25 to 1.08; P<0.001) and decreased hospitalization rate (RR: 0.40; 95% CI: 0.22-0.75; P=0.004). However, there was no difference regarding immediate success rate (RR: 1.01; 95% CI: 0.70-1.46; P=0.96) and one-year recurrence rate (RR: 0.89; 95% CI: 0.58-1.38; P=0.61).

Conclusions

In the light of this present research, it is necessary to apply needle aspiration into treating PSP to reduce hospitalization rate and shorten hospital stay. However, the two treatments have no significant difference with respect to immediate success rate, one-year recurrence rate, one-week success rate, three-month recurrence rate or complication rate.

Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults

BACKGROUND

For management of pneumothorax that occurs without underlying lung disease, also referred to as primary spontaneous pneumothorax, simple aspiration is technically easier to perform than intercostal tube drainage. In this systematic review, we seek to compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax. This review was first published in 2007 and was updated in 2017.

OBJECTIVES

To compare the clinical efficacy and safety of simple aspiration versus intercostal tube drainage for management of primary spontaneous pneumothorax.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1) in the Cochrane Library; MEDLINE (1966 to January 2017); and Embase (1980 to January 2017). We searched the World Health Organization (WHO) International Clinical Trials Registry for ongoing trials (January 2017). We checked the reference lists of included trials and contacted trial authors. We imposed no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of adults 18 years of age and older with primary spontaneous pneumothorax that compared simple aspiration versus intercostal tube drainage.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed trial quality, and extracted data. We combined studies using the random-effects model.

MAIN RESULTS

Of 2332 publications obtained through the search strategy, seven studies met the inclusion criteria; one study was ongoing and six studies of 435 participants were eligible for inclusion in the updated review. Data show a significant difference in immediate success rates of procedures favouring tube drainage over simple aspiration for management of primary spontaneous pneumothorax (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.69 to 0.89; 435 participants, 6 studies; moderate-quality evidence). Duration of hospitalization however was significantly less for patients treated by simple aspiration (mean difference (MD) -1.66, 95% CI -2.28 to -1.04; 387 participants, 5 studies; moderate-quality evidence). A narrative synthesis of evidence revealed that simple aspiration led to fewer adverse events (245 participants, 3 studies; low-quality evidence), but data suggest no differences between groups in terms of one-year success rate (RR 1.07, 95% CI 0.96 to 1.18; 318 participants, 4 studies; moderate-quality evidence), hospitalization rate (RR 0.60, 95% CI 0.25 to 1.47; 245 participants, 3 studies; very low-quality evidence), and patient satisfaction (median between-group difference of 0.5 on a scale from 1 to 10; 48 participants, 1 study; low-quality evidence). No studies provided data on cost-effectiveness.

AUTHORS' CONCLUSIONS

Available trials showed low to moderate-quality evidence that intercostal tube drainage produced higher rates of immediate success, while simple aspiration resulted in a shorter duration of hospitalization. Although adverse events were reported more commonly for patients treated with tube drainage, the low quality of the evidence warrants caution in interpreting these findings. Similarly, although this review observed no differences between groups when early failure rate, one-year success rate, or hospital admission rate was evaluated, this too needs to be put into the perspective of the quality of evidence, specifically, for evidence of very low and low quality for hospitalization rate and patient satisfaction, respectively. Future adequately powered research is needed to strengthen the evidence presented in this review.

Chest Tubes: Generalities

Insertion, management, and withdrawal of chest tubes is part of the routine activity of thoracic surgeons. The selection of the chest tube and the strategy for each of these steps is usually built on knowledge, practice, experience, and judgment. The indication to insert a chest tube into the pleural cavity is the presence of air or fluid within it. Various types and sizes of chest tubes are now commercially available.

Optimal surgical technique in spontaneous pneumothorax: a systematic review and meta-analysis

BACKGROUND

Numerous thoracoscopic techniques have been used in the management of primary spontaneous pneumothorax (PSP), including wedge resection, pleurectomy, pleural abrasion, chemical pleurodesis, and staple line covering. The purpose of this systematic review was to compare outcomes for the most commonly reported techniques.

MATERIALS AND METHODS

A systematic literature search looking at pneumothorax recurrence rate, length of stay, and chest tube duration after surgery was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database.

RESULTS

Fifty-one unique studies comprised of 6907 patients published between January 1988 and June 2015 were identified. Heterogeneity among effect sizes was significant for all outcomes. The lowest recurrence rates were observed in the wedge resection + chemical pleurodesis (1.7%; 95% confidence interval [CI], 1.0%-2.7%) and the wedge resection + pleural abrasion + chemical pleurodesis (2.8%; 95% CI, 1.7%-4.7%) groups. The shortest chest tube duration and length of stay were observed in the wedge resection + staple line covering ± other group (2.1 d; 95% CI, 1.4-2.9 and 3.3 d; 95% CI, 2.6-4.0, respectively).

CONCLUSIONS

The variability in reported outcomes and the lack of published multicenter randomized controlled trials highlights a need for more robust investigations into the optimal surgical technique in the management of PSP. Based on the limited quality studies available, this systematic review favors wedge resection + chemical pleurodesis and wedge resection + pleural abrasion + chemical pleurodesis in terms of recurrence rate after surgery for PSP.

Clinical Pathway for the Treatment of Primary Spontaneous Pneumothorax in a General Surgery Department

Primary spontaneous pneumothorax is a common abnormality for which there is a variety of treatments. This study presents the results of a year's evaluation of a clinical pathway (CP). A series of 34 patients treated during 1 year before CP development was analyzed to identify the weak points. To address these weak points, the CP includes associated protocols. In the CP, 31 patients were evaluated during 1 year; the results were compared with those of the pre-CP series. The mean length of stay of the pre-CP patients and the CP patients was 7.3 days and 5.0 days, respectively. The number of radiographs fell from 4.3 to 3.2. The rate of complications and readmissions is similar in both groups. The mean cost per process dropped from 1863 [UNKNOWN] to 1168 [UNKNOWN]. The CP for pneumothorax successfully manages to reduce both the variability in care patterns and hospital costs, justifying the work involved in its development and implementation.

Covering the staple line with a polyglycolic acid sheet after bullectomy for primary spontaneous pneumothorax prevents postoperative recurrent pneumothorax

BACKGROUND

Postoperative recurrent pneumothorax (PORP) can arise after surgery for primary spontaneous pneumothorax (PSP) that is recurrent or involves prolonged air leakage. In this study, which included 265 patients (279 cases) with PSP who underwent surgery at our department, the percentage of patients that did not experience PORP was compared between a group that underwent bullectomy alone (group A) and a group in which the staple line and the surrounding visceral pleura were covered with a PGA sheet after bullectomy (group B) in order to study the utility of PGA sheets for preventing PORP.

METHODS

Among the patients with PSP who underwent surgery, the cases of 92 patients (98 cases) from Group A and 173 patients (181 cases) from Group B were reviewed retrospectively. The incidence rates of PORP in these two groups were statistically analyzed in addition to the associations between PORP and age, gender, the affected side, height, body weight, height/weight ratio, smoking habits, or the surgical procedure.

RESULTS

In total, 96.7% of the patients in group B did not suffer PORP, which was significantly higher than the equivalent figure for group A (83.7%, log-rank test: P=0.0003). Moreover, among the examined parameters, only covering the staple line with a PGA sheet was found to be an independent prognostic factor (Cox regression: P=0.0003; HR =0.212; 95% CI, 0.082-0.547).

CONCLUSIONS

It was revealed that when bullectomy is performed in patients with PSP, wide coverage of the staple line and the surrounding visceral pleura with a PGA sheet significantly reduces the risk of PORP.

ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.

Pleural Disorders

This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments. Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.

Detection of blebs and bullae in patients with primary spontaneous pneumothorax by multi-detector CT reconstruction using different slice thicknesses

INTRODUCTION

The aim of this study was to compare the diagnostic performances of multi-detector computed tomography (MDCT) reconstruction at two different slice thicknesses (1 mm, 'high resolution' vs. 5 mm, 'routine') with respect to the detection of blebs and bullae (BBs) in patients with primary spontaneous pneumothorax (PSP).

METHODS

Thirty-one patients underwent wedge resection of BBs (29 unilateral and 2 bilateral) for PSP from January 2010 to January 2013. Two observers assessed the presence and locations of BBs independently using high-resolution CT (HRCT) and routine CT reconstruction, and compared the sensitivities of each reconstruction method for BB detection using operative findings as a standard reference. In addition, the number of BBs in each CT image set was recorded and inter-observer agreements were evaluated.

RESULTS

Sensitivity for the detection of BBs was significantly better for HRCT than routine CT (97.0% vs. 63.6% for observer 1 and 94.0% vs. 57.6% for observer 2, respectively, both P-values < 0.001). On a per-bleb and a per-bulla basis, inter-observer agreements regarding BBs by HRCT were good and very good (k = 0.66 and 0.94, respectively) and superior to those determined by routine CT (k = 0.59 and 0.60, respectively).

CONCLUSION

Different slice thickness reconstructions influence the diagnostic efficacy of MDCT for the detection of BBs in patients with PSP. High-resolution thin slice CT reconstruction was found to have a significantly greater sensitivity than routine thicker slice thickness reconstruction for the detection of BBs.

Pneumothorax

Pneumothorax-either spontaneous or iatrogenic-is commonly encountered in pulmonary medicine. While secondary pneumothorax is caused by an underlying pulmonary disease, the spontaneous type occurs in healthy individuals without obvious cause. The British Thoracic Society (BTS, 2010) and the American College of Chest Physicians (ACCP, 2001) published the guidelines for pneumothorax management. This review compares the diagnostic and management recommendations between the two societies. Patients diagnosed with primary spontaneous pneumothorax (PSP) may be observed without intervention if the pneumothorax is small and there are no symptoms. Oxygen therapy is only discussed in the BTS guidelines. If intervention is needed, BTS recommends a simple aspiration in all spontaneous and some secondary pneumothorax cases, whereas ACCP suggests a chest tube insertion rather than a simple aspiration. BTS and ACCP both recommend surgery for patients with a recurrent pneumothorax and persistent air leak. For patients who decline surgery or are poor surgical candidates, pleurodesis is an alternative recommended by both BTS and ACCP guidelines. Treatment strategies of iatrogenic pneumothorax are very similar to PSP. However, recurrence is not a consideration in iatrogenic pneumothorax.

Thoracic emergencies

This article discusses thoracic emergencies, including the anatomy, pathophysiology, clinical presentation, examination, diagnosis, technique, management, and treatment of acute upper airway obstruction, massive hemoptysis, spontaneous pneumothorax, and pulmonary empyema.

The Effect of Additional Pleural Procedures onto Recurrence Rates on the Spontaneous Pneumothorax Surgery

Background

Spontaneous pneumothoraxes constituted 1/1000 hospital admissions. They are particularly one of life threatening health issues in combination with bilateral pneumothorax, tension pneumothorax, repertory failure or COPD.

Objectives

The cases of spontaneous pneumothorax represent a significant portion of the patients profile within the chest surgery clinics. The risk of recurrent pneumothorax in post thoracoscopy is between 2% and 14%, thus the subject of cure treatment and approach is still controversial. The cases were retrospectively treated due to spontaneous pneumothorax and their reasons, treatment approaches and results were comparatively examined with the literature.

Patients and Methods

The years between 2007 and 2010, according to our hospital clinic, outpatients and accident &amp; emergency admission records, 79 patients were admitted with a diagnosis of spontaneous pneumothorax; and the patients’ age, gender, symptoms, types of pneumothorax, surgical intervention and recurrence, average length of stay, mortality and complications were retrospectively evaluated.

Results

Seventy of all the patients (88.6%) were male and 9 of those (13.7%) were female. The mean age was calculated as 45.50 ± 21.07 (0-85). The patients were comprised of 41 (51.9%) with primary spontaneous pneumothorax and 38 (48.1%) with secondary spontaneous pneumothorax. 55 of the patients (69.6%) with the first attack, and 24 patients (30.4%) with post tube thoracotomy’s 2nd or 3rd pneumothorax attack were admitted. Those who were accepted with post tube thoracostomy’s 2nd or 3rd attack made up 2/3 of the secondary spontaneous pneumothorax patients. 57 of the patients (68.4%) were treated with the tube thoracostomy. The tube thoracostomy related complication was 6.3%, hemorrhage due to parenchymal damage and massive air leak were observed. An open surgical method to 22 of those patients and apical resection and apical pleurectomy + tetracycline pleurodesis to 16 of whom and bullae ligation and mechanical abrasion to 6 patients were applied. The recurrence of pneumothorax in post-surgery was not observed for 1-3 year period Complication was not detected .Mortality, one patient (1.3%) died in post tube thoracotomy, which was a stage 4 lung cancer patient.

Conclusions

Most cases for pneumothorax were consisted of the patients with the primary spontaneous pneumothorax; the patients with recurrent pneumothorax were comprised of secondary spontaneous pneumothorax patients and those of majority secondary spontaneous pneumothorax patients were observed with bullous emphysema profile. By looking at the pertinent literature, there are publications showing VATS with the recurrence rate ranging from 2% to 14% and post thoracotomy recurrence rate from 0% to 7%. We think that applying pleurectomy, mechanical abrasion and chemical pleurodesis additional to bullae ligation or apical resection in pneumothorax surgery will significantly reduce the recurrence rate.

Spontaneous contralateral pneumothorax in a patient with low Body Mass Index

Spontaneous pneumothorax is most common in adolescents and young adults. Some of them develop contralateral pneumothorax. In this paper, we report the case of a patient with spontaneous contralateral pneumothorax, whose body mass index (BMI) was 18.8 kg/m2. For either chest physicians or thoracic surgeons, follow up with recognition of increased risk of the contralateral pneumothorax is important especially in patients with contralateral bullous lesions and low BMI.

Three-step management of pneumothorax: time for a re-think on initial management

Pneumothorax is a common disease worldwide, but surprisingly, its initial management remains controversial. There are some published guidelines for the management of spontaneous pneumothorax. However, they differ in some respects, particularly in initial management. In published trials, the objective of treatment has not been clarified and it is not possible to compare the treatment strategies between different trials because of inappropriate evaluations of the air leak. Therefore, there is a need to outline the optimal management strategy for pneumothorax. In this report, we systematically review published randomized controlled trials of the different treatments of primary spontaneous pneumothorax, point out controversial issues and finally propose a three-step strategy for the management of pneumothorax. There are three important characteristics of pneumothorax: potentially lethal respiratory dysfunction; air leak, which is the obvious cause of the disease; frequent recurrence. These three characteristics correspond to the three steps. The central idea of the strategy is that the lung should not be expanded rapidly, unless absolutely necessary. The primary objective of both simple aspiration and chest drainage should be the recovery of acute respiratory dysfunction or the avoidance of respiratory dysfunction and subsequent complications. We believe that this management strategy is simple and clinically relevant and not dependent on the classification of pneumothorax.

Pediatric bilateral spontaneous pneumothoraces in monozygotic twins

Primary spontaneous pneumothorax from subpleural bleb disease is an uncommon occurrence in pediatric patients. This is a rare case of monozygotic twins presenting at alternating intervals with a single-sided spontaneous pneumothorax, only to have it surgically corrected, and to present later with a subsequent contralateral pneumothorax. A review of familial spontaneous pneumothoraces occurring in children was queried for congenital or genetic syndromes. We concluded that a vast majority of pneumothoraces in children, like adults, are not spontaneous and not familial linked. While they are rare, some congenital syndromes have been identified. The HLA haplotype A2 B40, the gene encoding folliculin, Alph-1-antitrypsin, Marfan's syndrome, Ehlers-Danlos syndrome and Birt-Hogg-Dube syndrome have all been associated with familial spontaneous pneumothoraces. Physicians need to counsel family members to ensure appropriate observation and expedited treatment is not delayed.

Pleural controversy: aetiology of pneumothorax

Pneumothoraces are classified as spontaneous, traumatic and iatrogenic. Spontaneous pneumothoraces that occur without recognized lung disease are termed primary spontaneous pneumothoraces (PSP), whereas those that occur due to an underlying lung disease are termed secondary spontaneous pneumothoraces. The aetiology of secondary, traumatic or iatrogenic pneumothoraces is not usually debated. However, the aetiology of PSP is potentially controversial and often debated. Therefore, PSP is the focus of this article. There are several purported causes, which include blebs, bullae, emphysema-like changes (ELC) and pleural porosity. The controversy is valid because of the importance of recurrence prevention. This article reviews the current available evidence for the causes of PSP. The causes of PSP are likely a combination ELC, pleural porosity and other potential factors.

Review: Diagnosis and treatment of primary spontaneous pneumothorax

Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men. Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is reviewed concerning mechanisms and personal clinical experience with PSP. The chest computed tomography (CT) has been more commonly used than before to help understand the pathogenesis of PSP and plan further management strategies. The development of video-assisted thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to its minimal invasiveness and high effectiveness for patients with these diseases.

Secondary spontaneous pneumothorax: which associated conditions benefit from pigtail catheter treatment?

OBJECTIVE

The study aimed to assess the clinical efficacy of pigtail catheter drainage for patients with a first episode of secondary spontaneous pneumothorax (SSP) and different associated conditions.

METHODS

We retrospectively reviewed the records of patients with SSP who received pigtail catheter drainage as their initial management between July 2002 and October 2009. A total of 168 patients were included in the analysis; 144 (86%) males and 24 (14%) females with a mean age of 60.3 ± 18.3 years (range, 17-91 years). Data regarding demographic characteristics, pneumothorax size, complications, treatments, length of hospital stay, and associated conditions were analyzed.

RESULTS

In total, 118 (70%) patients were successfully treated with pigtail catheter drainage, and 50 (30%) patients required further management. Chronic obstructive lung disease was the most common underlying disease (57% of cases). Secondary spontaneous pneumothorax associated with infectious diseases had a higher rate of treatment failure than SSP associated with obstructive lung conditions (19/38 [50%] successful vs 78/104 [75%] successful, P = .004) and malignancy (19/38 [50%] successful vs 13/16 [81%] successful, P = .021). Moreover, patients with SSP associated with infectious diseases had a longer length of hospital stay than those with obstructive lung conditions (23.8 vs 14.5 days, P = .003) and malignancy (23.8 vs 12.1 days, P = .017). No complications were associated with pigtail catheter drainage.

CONCLUSIONS

A higher rate of treatment failure was noted in SSP patients with infectious diseases; thus, pigtail catheter drainage is appropriate as an initial management for patients with SSPs associated with obstructive lung conditions and malignancy.

Simultaneous bilateral spontaneous pneumothorax: a rare emergency clinical condition

OBJECTIVE

Spontaneous pneumothorax is a disease that may cause serious respiratory distress and can be a life-threatening condition. A total of 1.3% of all spontaneous pneumothorax cases are simultaneous bilateral spontaneous pneumothorax (SBSP). In this study, because of its rarity, we discuss SBSP cases in light of previously reported cases.

MATERIALS AND METHODS

Between January 2004 and December 2009, SBSP was detected in five patients.

RESULTS

All patients were male, and the mean patient age was 18.6 (between 16 and 22 years of age). All patients had various degrees of dyspnea and chest pain. All diagnoses were established by chest X-rays. Two patients (40%) had primary spontaneous pneumothorax (PSP), and three (60%) had secondary spontaneous pneumothorax (SSP) (two patients had silicosis, and one had Staphylococcus aureus pneumonia). Previously, bilateral tube thoracostomies were performed on all patients. One PSP patient had a left apical pleurectomy with axillary thoracotomy; the other had a right apical pleurectomy. Tetracycline pleurodesis was performed on one of the silicosis patients. No additional surgical procedure or pleurodesis was performed on the other silicosis patient or on the pneumonia patient. No recurrence of pneumothorax was observed in any patient.

CONCLUSIONS

SBSP could be a life-threatening condition; therefore, urgent diagnosis and appropriate treatment of this condition can save patients' lives.

Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated?

OBJECTIVES

More than 50% of patients with primary spontaneous pneumothorax have contralateral blebs/bullae, and about a quarter will develop a contralateral pneumothorax. The purpose of this prospective study was to determine the need for elective treatment of asymptomatic contralateral blebs/bullae in patients presenting with primary spontaneous pneumothorax.

METHODS

From May 2006 through June 2008, results from 35 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs receiving unilateral video-assisted thoracic surgery, 35 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery, and 16 patients with ipsilateral primary spontaneous pneumothorax receiving bilateral video-assisted thoracic surgery for positive contralateral blebs were collected. Their demographic and operating data were also recorded.

RESULTS

There was no significant difference in age, gender, smoking percentage, body mass index (kg/m(2)), blood loss, and postoperative pain among groups. There was longer operative time and length of stay in group receiving bilateral surgery. Within the follow-up period of 16.68 +/- 9.91 months (median, 17.50), no recurrence on either lung was found in the group operated on both sides, while contralateral occurrence was found in 17.14% of the group with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery within the period of 18.15 +/- 8.07 months (median, 21).

CONCLUSION

The study showed that the preemptive video-assisted thoracic surgery for the contralateral blebs/bullae effectively prevented the contralateral occurrence.

Thoracoscopic bullectomy for primary spontaneous pneumothorax in pediatric patients

INTRODUCTION

Primary spontaneous pneumothorax is a condition that carries significant morbidities and mortalities if not managed properly. Thoracotomy with bullectomy has been the treatment of choice for persistent air leak or recurrence after initial chest drain insertion. With the advancement in minimal invasive surgery, the thoracoscopic approach can dramatically reduce the complications of open thoracotomy. We review our experience in managing spontaneous pneumothorax in children using thoracoscopy.

MATERIALS AND METHODS

The medical records of all patients who were discharged with the diagnosis of spontaneous pneumothorax from 1997 to 2007 were reviewed. The demographic data and management were noted. For those patients who underwent thoracoscopic surgery, the intra-operative findings, post-operative outcomes and complications were compared.

RESULTS

A total of 15 patients with spontaneous pneumothorax were identified. They all received chest drain insertion as the primary treatment modality. Nine patients, with mean age 16.1 +/- 0.9 years, failed the initial management and subsequently received thoracoscopic surgery with a mean interval of 7.6 +/- 2.5 days after initial chest drain insertion. Among these patients, bullae were found in seven patients (two patients had more than one bulla). The bullae were excised with mean operative time being 63.9 +/- 25.2 min. No conversion to thoracotomy was reported. All patients received paracetamol as pain control and there was no associated complication. No recurrence was found at follow-up till now.

CONCLUSION

This study confirms that the presence of bulla is commonly seen in patients with spontaneous pneumothorax who fail initial management. Thoracoscopic bullectomy, a safe and effective operation, should be offered to this group of patients.

Acute airway distress secondary to iatrogenic injury during Tracheostomy

Laceration and perforation of the membranous trachea are uncommon. We present a case of bilateral Pneumothorax, which developed subsequent to iatrogenic injury during tracheostomy.

[Guidelines for the diagnosis and treatment of spontaneous pneumothorax]

This is the fourth update of the guidelines for the diagnosis and treatment of pneumothorax published by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). Spontaneous pneumothorax, or the presence of air in the pleural space not caused by injury or medical intervention, is a significant clinical problem. We propose a method for classifying cases into 3 categories: partial, complete, and complete with total lung collapse. This classification, together with a clinical assessment, would provide sufficient information to enable physicians to decide on an approach to treatment. This update introduces simple aspiration in an outpatient setting as a treatment option that has yielded results comparable to conventional drainage in the management of uncomplicated primary spontaneous pneumothorax; this technique is not, as yet, widely used in Spain. For the definitive treatment of primary spontaneous pneumothorax, the technique most often used by thoracic surgeons is video-assisted thoracoscopic bullectomy and pleural abrasion. Hospitalization and conventional tube drainage is recommended for the treatment of secondary spontaneous pneumothorax. This update also has a new section on catamenial pneumothorax, a condition that is probably underdiagnosed. The definitive treatment for a recurring or persistent air leak is usually surgery or the application of talc through the drainage tube when surgery is contraindicated. Our aim in proposing algorithms for the management of pneumothorax in these guidelines was to provide a useful tool for clinicians involved in the diagnosis and treatment of this disease.

Video-assisted thoracoscopic surgery (VATS) for bilateral primary spontaneous pneumothorax

OBJECTIVE

To review our experience of the treatment of bilateral primary spontaneous pneumothorax (PSP) by video-assisted thoracoscopic surgery (VATS).

MATERIALS AND METHODS

Retrospective chart review was followed by an on-clinic or telephone interview. Patients were cared for by one thoracic surgeon in four medical centers or community hospitals in Northern and Central Taiwan. Thirteen patients with bilateral PSP underwent bilateral VATS simultaneously or sequentially from July 1994 to December 2005.

RESULTS

Twelve males and one female, with age ranging from 15 to 36 years (mean 23.1 years), were treated with VATS for bilateral PSP, under the indications of bilateral pneumothoracis simultaneously (n=4) or sequentially (n=9). The interval between the first and second contra-lateral VATS procedure for non-simultaneous PSP patients ranged from 7 d to 6 years. Eleven of 13 patients (84.6%) had prominent pulmonary bullae/blebs, and underwent bullae resection with mechanical or chemical pleurodesis. The mean operative time was (45.6+/-18.3) min (range 25 approximately 96 min) and (120.6+/-28.7) min (range 84 approximately 166 min) respectively for the non-simultaneous (second VATS for the recurrence of contralateral side after first VATS) and simultaneous (bilateral VATS in one operation) procedures. There was no postoperative mortality. However, prolonged air leakage (>7 d) occurred in one patient (7.7%) who recovered after conservative treatment. The mean duration of chest tube drainage was 3.1 d and the median follow up period was 3.4 years.

CONCLUSIONS

VATS is a safe and effective procedure in the treatment of bilateral PSP. Bilateral VATS is only recommended for patients with simultaneously bilateral PSP, because the incidence of recurrence, even with visible bullae, was not so high in my group and in some previous literature. Bilateral VATS in a supine position should only be used in selective cases, because of possible pleural adhesion or hidden bullae on the posterior side.

Simultaneous bilateral primary spontaneous pneumothorax

OBJECTIVE

While primary spontaneous pneumothorax (PSP) is common in adolescents and young adults, simultaneous bilateral PSP (SBPSP) is rare and can be life-threatening if it progresses to tension pneumothorax. This study reviewed cases of PSP to identify the clinical features of SBPSP.

METHODS

All patients with PSP diagnosed and treated between June 1996 and June 2006 were reviewed, and the clinicoradiological features and outcomes were evaluated.

RESULTS

Of the 616 patients with 807 episodes of PSP, 13 had SBPSP (1.6%) at first presentation, and all were male (mean age 20.9 +/- 4.7 years, range 16-25 years). Compared with the non-SBPSP patients, SBPSP patients had significantly lower body weight and BMI (P = 0.018 and <0.001, respectively) and higher body height/body weight ratio (P = 0.004). There was no significant difference in their age, sex, smoking habits or body height. Patients with SBPSP had a significantly higher incidence of bleb/bullae seen in HRCT of the lung compared with non-SBPSP (88.5% vs 63.5%, P = 0.016). In multiple logistic regression analysis, BMI and presence of blebs/bullae were independent risk factors for SBPSP. All patients with SBPSP received bilateral video-assisted thoracoscopic surgery and recovered uneventfully. The mean follow-up period was 3.7 years (range 10 months-7 years).

CONCLUSION

Patients with PSP having a lower BMI, and bilateral bleb/bullae formation are at higher risk for the development of SBPSP. SBPSP needs urgent assessment and management, and bilateral video-assisted thoracoscopic surgery is a safe and effective treatment.

Use of fibrin glue to treat a persistent pneumothorax with bronchopleural fistula

PURPOSE

A case of spontaneous pneumothorax with a subsequent bronchopleural fistula (BPF) treated with endoscopically administered fibrin glue is presented.

SUMMARY

A 76-year-old white man with a history of a benign lung mass and chronic obstructive pulmonary disease was admitted to the hospital with right-sided, anterior, pleuritic chest pain for the past three days and shortness of breath at rest, which worsened during exertion. Initial chest radiograph revealed a right 95% spontaneous tension pneumothorax. A chest tube was immediately placed in the right pleural space, resulting in reinflation of the lung. However, air leaks continued to be present, requiring the need for surgical intervention. The patient required both coronary artery bypass graft surgery and right blebectomy with pleurodesis. Postsurgery, the patient required two pleural chest tubes for the persistence of a BPF. A critical care clinical pharmacist was consulted regarding potential use of an endoscopic fibrin seal. Fiberoptic bronchoscopy was performed, and diffuse bronchiectasis was noted in all right lower respiratory airways. The day after the fibrin sealant was administered, one of the pleural chest tubes was removed because the air leak was significantly reduced in size. The patient was discharged home two days later with a Heimlich chest valve. One week postdischarge, a chest radiograph revealed no pneumothorax.

CONCLUSION

Use of a fibrin sealant injected through a fiberoptic bronchoscope was effective in reducing an air leak associated with a spontaneous pneumothorax and subsequent BPF.

Pneumothorax: an update

Pneumothorax is a relatively common clinical problem which can occur in individuals of any age. Irrespective of aetiology (primary, or secondary to antecedent lung disorders or injury), immediate management depends on the extent of cardiorespiratory impairment, degree of symptoms and size of pneumothorax. Guidelines have been produced which outline appropriate strategies in the care of patients with a pneumothorax, while the emergence of video-assisted thoracoscopic surgery has created a more accessible and successful tool by which to prevent recurrence in selected individuals. This evidence based review highlights current practices involved in the management of patients with a pneumothorax.