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

Risk factors and age-specific monthly patterns of primary spontaneous pneumothorax: a multicenter study

Background

Primary spontaneous pneumothorax (PSP) is characterized by sudden lung collapse without external injury or underlying lung disease. However, detailed research on its causes and recurrence patterns is lacking, prompting investigating monthly epidemiology and factors influencing recurrence. Therefore, we aimed to assess the monthly trends in PSP occurrence and identify factors contributing to its recurrence, with a focus on teenagers due to the high incidence rates in this population, while also examining risk factors across other age groups.

Methods

We conducted a multicenter retrospective study involving 4,231 cases of PSP from five hospitals in Korea. Patients aged 10-39 years were included, wherein monthly incidence patterns were assessed. Statistical analyses using physical parameters and laboratory data were performed to determine factors influencing recurrence.

Results

Our analysis revealed that July was the most common diagnosis month in teenagers, followed by October and March. This month-based pattern differed from that observed in the other age groups. Multivariate analysis revealed body mass index (BMI) at initial diagnosis to be a significant risk factor for first recurrence in male patients aged 16-19 years [hazard ratio (HR), 0.98; 95% confidence interval (CI): 0.97-0.99; P=0.001] and in male patients older than 20 years (HR, 0.99; 95% CI: 0.98-0.99; P<0.001). In male patients aged ≥20 years, the monocyte-lymphocyte ratio (MLR) at initial diagnosis was also a significant factor for first recurrence (HR, 1.20; 95% CI: 1.10-1.32; P<0.001). In female patients aged ≥20 years, MLR at the time of the first pneumothorax was significantly associated with recurrence (HR, 1.41; 95% CI: 1.07-1.87; P=0.01).

Conclusions

Our study provided valuable insights into the month-based epidemiology of PSP in Korea, highlighting differences in incidence patterns among teenagers compared with those in the other age groups. Moreover, the reported link between BMI, inflammation, and pneumothorax recurrence might be a basis for future prospective studies aimed to prevent and treat pneumothorax.

Recurrent Pneumothorax: A Chest Tube Complication

Chest tubes are widely used for the management of primary spontaneous pneumothorax. The most common complication of the chest tube is a nonfunctioning chest tube, which might lead to recurrent pneumothorax during hospital admission. We describe a case of a 13-year-old tall and thin-built African American male who presented to the emergency department (ED) with a large right-sided pneumothorax diagnosed with a chest X-ray (CXR). Pneumothorax was managed with the three-compartment chest tube drainage system. Serial CXR revealed improvement in pneumothorax after the chest tube insertion. The patient had recurrent pneumothorax on the right side on the second day of admission attributed to the kinking of a chest tube. Relieving the kink led to the resolution of pneumothorax. The provider needs to be aware of the common complications of chest tube insertion and their management. Alternative treatment options with fewer complications like needle tube insertion for the management of primary spontaneous pneumothorax in children and adolescents need to be considered.

Outcomes of mobilization in the first hour following uniportal video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

Introduction

Although primary spontaneous pneumothorax is a common disease in young adults, each thoracic surgery department performs different procedures for its management.

Aim

The optimal time of postoperative mobilization is not yet standardized in lung surgery.

Material and methods

This study included male patients with a primary spontaneous pneumothorax who underwent wedge resection of the upper lobe of the lungs via uniportal video-assisted thoracoscopic surgery. Patients were encouraged to stand up within the first postoperative hour. Mobilization was defined as standing and walking at least 100 m from the bed. If orthostatic hypotension occurred, mobilization was postponed for 30 min. Immediately after surgery, intravenous fluids were discontinued, and patients were instructed to drink water. The analgesic treatment needs, length of hospitalization, drainage, and discharge times were recorded.

Results

A total of 43 patients were operated on by the same surgeon. All operations were ended with uniportal video-assisted thoracoscopic surgery. Wedge resection is most commonly indicated for recurrent ipsilateral pneumothorax. Patients walked 345 (range: 150-510) m on the department corridor following bed rest. Paracetamol (2 g) and dexketoprofen (100 mg) were intravenously administered as postoperative analgesia to 76.7% of patients. Narcotic drugs were not needed.

Conclusions

Mobilization was recommended in the first hour following uniportal video-assisted thoracoscopic surgery for primary spontaneous pneumothorax.

Hypoxemia in School-age Children Undergoing One-lung Ventilation: A Retrospective Cohort Study from the Multicenter Perioperative Outcomes Group

BACKGROUND

Risk factors for hypoxemia in school-age children undergoing one-lung ventilation remain poorly understood. The hypothesis was that certain modifiable and nonmodifiable factors may be associated with increased risk of hypoxemia in school-age children undergoing one-lung ventilation and thoracic surgery.

METHODS

The Multicenter Perioperative Outcomes Group database was queried for children 4 to 17 yr of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4 to 9 and 10 to 17 yr of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation, which was defined as an oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or longer continuously, while severe hypoxemia was defined as Spo2 less than 90% for 5 min or longer. Potential modifiable and nonmodifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. The covariates evaluated included age, extremes of weight, American Society of Anesthesiologists Physical Status of III or higher, duration of one-lung ventilation, preoperative Spo2 less than 98%, approach to one-lung ventilation, right operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (defined as tidal volume of 6 ml/kg or less and positive end-expiratory pressure of 4 cm H2O or greater for more than 80% of the duration of one-lung ventilation), and procedure type.

RESULTS

The prevalence of hypoxemia in the 4- to 9-yr-old cohort and the 10- to 17-yr-old cohort was 24 of 228 (10.5% [95% CI, 6.5 to 14.5%]) and 76 of 1,012 (7.5% [95% CI, 5.9 to 9.1%]), respectively. The prevalence of severe hypoxemia in both cohorts was 14 of 228 (6.1% [95% CI, 3.0 to 9.3%]) and 47 of 1,012 (4.6% [95% CI, 3.3 to 5.8%]). Initial Spo2 less than 98% was associated with hypoxemia in the 4- to 9-yr-old cohort (odds ratio, 4.20 [95% CI, 1.61 to 6.29]). Initial Spo2 less than 98% (odds ratio, 2.76 [95% CI, 1.69 to 4.48]), extremes of weight (odds ratio, 2.18 [95% CI, 1.29 to 3.61]), and right-sided cases (odds ratio, 2.33 [95% CI, 1.41 to 3.92]) were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1-yr increment; odds ratio, 0.88 [95% CI, 0.80 to 0.97]) was associated with a decreased risk of hypoxemia.

CONCLUSIONS

An initial room air oxygen saturation of less than 98% was associated with an increased risk of hypoxemia in all children 4 to 17 yr of age. Extremes of weight, right-sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10 to 17 yr of age.

EDITOR’S PERSPECTIVE

Primary Spontaneous Pneumothorax: Open Thoracotomy vs. Video-assisted Thoracoscopic Surgery: A Single-center Retrospective Cohort Study

Background

Primary spontaneous pneumothorax (PSP) is a spontaneous pneumothorax without underlying lung disease. The main goals of this study were to compare the outcomes of video-assisted thoracoscopic surgery (VATS) and open thoracotomy in patients with PSP.

Methods

The current study is a retrospective cohort study of patients who were admitted to the emergency department or general surgery ward at Dr. Masih Daneshvari Hospital (Tehran, Iran) with the diagnosis of PSP and underwent surgery by open or VATS approach from 2006 to 2012. The groups were compared in terms of the length of operation, the length of hospitalization, recurrence, and postoperative complications. Data were analyzed using SPSS version 18.0, and Student's t test, analysis of variance (ANOVA), Chi square, and Fisher's exact test were employed. P values less than 0.05 were considered statistically significant.

Results

PSP was diagnosed in 90 patients who underwent surgery. Open thoracotomy and VATS procedures were performed in 65 (72.2%) and 25 (27.8%) patients, respectively. VATS was converted to open in seven cases (7.7%). Recurrent pneumothorax was the most common surgical indication for PSP. There was no significant difference between the two groups in terms of mean age, sex, smoking, side of the involved lung, previous pneumothorax history, mean length of hospitalization for recurrence, post-operation bleeding, and failure of lung expansion. However, the length of surgery (P=0.011) and air leakage (P=0.048) significantly differed between the two groups.

Conclusion

When compared to open thoracotomy, VATS could be the primary treatment option in the surgical treatment of PSP due to the shorter length of surgery and decreased complications such as air leakage.

Management of primary spontaneous pneumothorax in teenagers: An 11-year study

AIM

Management of teenagers with primary spontaneous pneumothorax (PSP) is not consensual. We report our experience over an 11-year period.

METHODS

For each patient under 20 years hospitalised with PSP from 2008 to 2018, demographic data, smoking habits, clinical presentation, hospitalisation unit, radiological management and its results, therapeutic management (observation, needle aspiration, chest tube drainage and surgery), complications, length of stay, given advice at discharge and recurrence were collected.

RESULTS

Seventy patients were included in different paediatric or adult surgery or pulmonology wards (82.9% boys; 16.8 ± 1.7 years; one severe presentation; 18/58 smokers). Chest CT-scan (n = 42/70, 60%) revealed blebs/bullae in 18/39 examinations (46.2%). Treatment consisted of observation (14/70, 20%), needle aspiration (2/70, 2.9%), chest tube (53/70, 75.7%) and video-assisted thoracoscopy surgery (27/70, 38.6%). Half patients with interventional procedure presented complications. A median of 10 chest X-rays was noted during a median stay of 8 days. Advice concerning sport practice, flying, smoking, etc., was variably delivered. PSP recurrence concerned 35/70 patients (50%) without identified predictive factors.

CONCLUSION

Compared to recent recommendations of a more conservative approach, chest CT-scan and interventional strategy are overused in our teenagers with PSP. Observation, more or less needle aspiration, should be clearly the first-line treatments.