Bronchopleural fistula resulting from the use of a thoracic vent: a case report and review

Effectiveness of Ambulatory Tru-Close Thoracic Vent for the Outpatient Management of Pneumothorax: A Prospective Pilot Study

Objective

This study aimed to assess the technical feasibility, procedural safety, and long-term therapeutic efficacy of a small-sized ambulatory thoracic vent (TV) device for the treatment of pneumothorax.

Materials and Methods

From November 2012 to July 2013, 18 consecutive patients (3 females, 15 males) aged 16–64 years (mean: 34.7 ± 14.9 years, median: 29 years) were enrolled prospectively. Of these, 15 patients had spontaneous pneumothorax and 3 had iatrogenic pneumothorax. A Tru-Close TV with a small-bore (11- or 13-Fr) catheter was inserted under bi-plane fluoroscopic assistance.

Results

Technical success was achieved in all patients. Complete lung re-expansion was achieved at 24 hours in 88.9% of patients (16/18 patients). All patients tolerated the procedure and no major complications occurred. The patients' mean numeric pain intensity score was 2.4 (range: 0–5) in daily life activity during the TV treatment. All patients with spontaneous pneumothorax underwent outpatient follow-up. The mean time to TV removal was 4.7 (3–13) days. Early surgical conversion rate of 16.7% (3/18 patients) occurred in 2 patients with incomplete lung expansion and 1 patient with immediate pneumothorax recurrence post-TV removal; and late surgical conversion occurred in 2 of 18 patients (11.1%). The recurrence-free long-term success rate was 72.2% (13/18 patients) during a 3-year follow-up period from November 2012 to June 2016.

Conclusion

TV application was a simple, safe, and technically feasible procedure in an outpatient clinic, with an acceptable long-term recurrence-free rate. Thus, TV could be useful for the immediate treatment of pneumothorax.

Outpatient Treatment of Pneumothorax with a Thoracic Vent: Economic Benefit

BACKGROUND

Since rising medical costs currently represent a growing problem worldwide, finding cost-effective treatment options is important. In our hospital, outpatient treatment of pneumothorax using a thoracic vent began in December 2012.

OBJECTIVES

We aimed to test our hypothesis that outpatient treatment of pneumothorax with a thoracic vent can reduce medical expenses.

METHODS

Patients were classified into four groups based on treatment: thoracic vent with or without surgery or conventional intercostal chest tube drainage with or without surgery. We compared mean medical expenses, duration of hospitalization and number of physician visits among these four groups.

RESULTS

During a 2-year period, 65 patients were treated with a thoracic vent (36 patients) or conventional intercostal chest tube drainage (29 patients). Patients treated with a thoracic vent who underwent surgery had a shorter mean duration of hospitalization (5.0 ± 1.3 vs. 10.3 ± 3.4 days; p < 0.0001) and lower overall cost, at JPY 971,830.00 ± 81,291.80 (USD 10,400.40 ± 1,464.90) versus JPY 1,179,791.10 ± 198,383.10 (USD 13,888.90 ± 1,965.30; p < 0.0001) compared with conventional intercostal chest tube drainage. Nonsurgical patients treated with a thoracic vent had lower overall costs, at JPY 79,960.00 ± 25,643.60 (USD 890.10 ± 352.30) versus JPY 268,588.80 ± 94,636.50 (USD 2,932.80 ± 903.50; p < 0.0001) compared with conventional intercostal chest tube drainage. No serious complications were observed.

CONCLUSIONS

Outpatient thoracic vent treatment can significantly reduce medical expenses and thereby have a major economic impact.

Treatment of spontaneous pneumothorax

Spontaneous pneumothorax (SP) continues to be a frequent management problem. The lack of universally accepted management guidelines and a myriad of treatment options contribute to the current heterogeneous approach to SP. Forthcoming guidelines may improve management. Meantime, simple observation in stable patients with a primary spontaneous pneumothorax (PSP) is reasonable, and encouraging smoking cessation is paramount. More aggressive management of a patient with a secondary spontaneous pneumothorax (SSP) is advisable and should include at least chest tube drainage with chest tube size selection key. Careful assessment of recurrence risk and early corrective intervention for patients with a persistent air leak will improve care of both PSP and SSP patients. If chest tube-directed pleurodesis is chosen for recurrence prevention, talc is the most successful agent available. However, no more than 5 g of talc should be utilized, given the potential increased risk for acute respiratory failure at higher doses, and patients should be advised of alternatives such as doxycycline. No overwhelming clinical outcome advantages for a thoracoscopic over a limited thoracotomy approach to SP management has been reported in any randomized controlled trial. Institutional experience with and the availability of thoracoscopy or limited thoracotomy should dictate the operative approach to SP recurrence prevention and air leak correction until further study clarifies the choice.