Prolonged air leakage in secondary spontaneous pneumothorax: is proportion of emphysema important?

Surgery for Secondary Spontaneous Pneumothorax with Chronic Lung Diseases

PURPOSES

Secondary spontaneous pneumothorax (SSP) is occasionally observed in elderly patients suffering from diffuse lung diseases. The purpose of this study was to analyze the outcomes of surgical treatment of SSP patients with chronic lung diseases.

METHODS

In total, 242 patients who underwent surgery for spontaneous pneumothorax at Chiba University Hospital from January 2006 to October 2016 were included in this study. The patients' records were reviewed retrospectively for data on their background, surgical treatment, morbidity, mortality, and recurrence.

RESULTS

Of the spontaneous pneumothorax cohort, primary spontaneous pneumothorax (PSP) accounted for 144 patients. Among the 98 patients with SSP, 57 cases were caused by chronic obstructive pulmonary disease (COPD) and 21 were caused by interstitial pneumonia (IP). The postoperative complication rate was 19.3% in the COPD group, 42.9% in the IP group, and 11.1% in the PSP group. The recurrence rate was 5.3% in the COPD group, 28.6% in the IP group, and 21.5% in the PSP group.

CONCLUSIONS

The morbidity and recurrence were comparable between PSP and SSP cases with COPD, whereas these values were unfavorable in SSP cases with IP compared with PSP ones. Surgical intervention should be carefully considered in SSP patients with IP.

Meta-analysis of the association between emphysematous change on thoracic computerized tomography scan and recurrent pneumothorax

OBJECTIVES

At least a third of patients go on to suffer a recurrence following a first spontaneous pneumothorax. Surgical intervention reduces the risk of recurrence and has been advocated as a primary treatment for pneumothorax. But surgery exposes patients to the risks of anaesthesia and in some cases can cause chronic pain. Risk stratification of patients to identify those most at risk of recurrence would help direct the most appropriate patients to early intervention. Many studies have addressed the role of thoracic computerized tomography (CT) in identifying those individuals at increased risk of recurrence, but a consensus is lacking.

AIM

Our objective was to clarify whether CT provides valuable prognostic information for recurrent pneumothorax.

DESIGN

Meta-analysis.

METHODS

We conducted an exhaustive search of the literature for thoracic CT imaging and pneumothorax, and then performed a meta-analysis using a random effects model to estimate the common odds ratio and standard error.

RESULTS

Here, we show by meta-analysis of data from 2475 individuals that emphysematous change on CT scan is associated with a significant increased odds ratio for recurrent pneumothorax ipsilateral to the radiological abnormality (odds ratio 2.49, 95% confidence interval 1.51-4.13).

CONCLUSIONS

The association holds true for primary spontaneous pneumothorax when considering emphysematous changes including blebs and bullae. Features, such as bullae at the azygoesophageal recess or increased Goddard score similarly predicted recurrent secondary pneumothorax, as shown by subgroup analysis. Our meta-analysis suggests that CT scanning has value in risk stratifying patients considering surgery for pneumothorax.

Risk factors related to the recurrence of pneumothorax in patients with emphysema

Background

Pneumothorax refers to the abnormal presence of air in the thoracic cavity. Pulmonary emphysema (PE) is often detected during computed tomography (CT), one of the radiological investigations used to diagnose pneumothorax and devise treatment plans in former or current smokers who present with pneumothorax. However, there are few reports that describe the recurrence rate and risk factors associated with recurrence in patients with PE and pneumothorax.

Methods

This study retrospectively cross-sectional analyzed the medical records of 164 patients diagnosed with their first episode of secondary spontaneous pneumothorax and admitted to a tertiary care hospital, between March 2013 and February 2019. The CT scans of 98 patients revealed PE, and 49 patients of those underwent pulmonary function tests (PFTs) after the resolution of pneumothorax. Risk factors for recurrence were analyzed using Cox proportional hazard regression.

Results

All the subjects were male and former or current smokers, with a median age of 72 years. Thirty-seven (75.5%) patients were treated with tube thoracostomy alone, whereas 12 (24.5%) patients underwent chemical pleurodesis via chest tube or video-assisted thoracoscopic surgery. After recovery from pneumothorax, these patients underwent PFT within a median time period of 5.8 months. Median forced vital capacity and forced expiratory volume in 1 second (FEV₁) were 3.02 L (91% predicted) and 1.58 L (67% predicted), respectively. In the current study, the recurrence rate of pneumothorax was observed to be 30.6%, within a median time period of 12.4 months. In multivariable-adjusted analysis, decreased FEV₁ was observed to be significantly higher in the patients who exhibited recurrence of pneumothorax than in those who did not (adjusted hazard ratio, 0.408; P=0.025).

Conclusions

In patients with PE and pneumothorax, PFT, performed after recovery, could be a useful test for predicting the recurrence of pneumothorax.

Radiologically Guided Management of Secondary Spontaneous Pneumothorax

Secondary spontaneous pneumothorax is a serious medical condition that typically occurs in patients with an underlying lung pathology such as chronic obstructive pulmonary disease. Those patients are usually compromised and more amenable to higher morbidity and mortality rates. Moreover, they are poor candidates for general anesthesia and mechanical ventilation due to their poor health condition. We report a case of an 86-year-old male, who presented with a non-ST-elevation myocardial infarction and was incidentally found to have secondary spontaneous pneumothorax on a routine chest x-ray. The results of his blood work, international normalized ratio and liver function test were abnormal. Therefore, a novel intervention was introduced to control the air-leak by injecting a sealant material (Progel™, Warwick, Rhode Island, USA) through a thoracostomy tube guided by computed tomography fluoroscopy. The procedure was demonstrated to be a successful method of air-leak repair with minimal complications; as the patient was followed for two and a half years without any evidence of recurrence.

Fate of spontaneous pneumothorax from middle to old age: how to overcome an irritating recurrence?

Background

The causes and treatment of pneumothorax in older patients are different from those in younger patients. However, studies on this topic are limited thus; pneumothorax in older patients is often inadequately managed. The purpose of this research was to investigate the characteristics of pneumothorax in patients over 45 years old, understand patterns of management and factors of recurrence, and propose reasonable guidelines for the treatment of older patients.

Methods

Of 438 consecutive patients with spontaneous pneumothorax between 2013 and 2017, 120 patients were enrolled and divided into two groups: (I) 45-64 years and (II) ≥65 years. Basic demographics, treatment modality, and patterns of surgery/recurrence were described. Clinical variables were compared between groups, and risk factors of recurrence were analyzed using logistic regression.

Results

The study population was divided into group A (younger, n=61) and B (older, n=59). Chest tube drainage was the most common procedure for both groups and chemical pleurodesis was applied more often in B (27% vs. 11%, P=0.03). The length of hospital stay was longer in B (8.8 vs. 5.9 days, P<0.01) but complications and recurrence rate did not differ between groups (P=0.09 and 0.93). The choice of procedures in recurrent pneumothorax was different (P=0.02). Specifically, invasive procedures such as surgery occurred more often in A, but non-invasive procedures occurred more often in B. Multivariate analysis revealed that bullae/blebs (odds ratio=5.57) and emphysema (odds ratio=3.83) showed a positive association with recurrence whereas surgery (odds ratio=0.11) was negative.

Conclusions

Radiological findings of emphysema or bullae/blebs are risk factors for recurrence of pneumothorax in elderly patients. Surgery in selected patients is an effective method for decreasing the recurrence rate.