Recurrence of primary spontaneous pneumothorax

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.

Vaping-Associated Pneumothorax: A Systematic Review of Case Reports and Case Series

Background and Objectives: Pneumothorax is a medical condition characterized by the accumulation of air in the pleural cavity, leading to lung collapse. While cigarette smoking is a well-known risk factor, the role of electronic cigarettes is less understood. This systematic review aimed to evaluate the outcomes of vaping-associated pneumothorax, in addition to its clinical features and management strategies, by compiling published case reports and case series. Materials and Methods: The choice to use case reports and case series was due to the limited availability of other types of studies on this emerging condition, as vaping-associated pneumothorax is relatively rare and primarily reported in isolated cases. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search of six databases for case reports and case series. Data extraction and quality assessment were performed independently by multiple reviewers. Results: Seven case reports and four case series with a total number of 16 patients were included. Most patients were young, underweight men who presented with chest pain and shortness of breath. Conventional cigarette and cannabis use were commonly reported alongside vaping. The main treatment was the insertion of a chest tube, with surgical interventions reserved for severe cases. Patients who were treated non-surgically exhibited a higher recurrence rate. Additionally, specific symptoms such as chest pain radiating to the ipsilateral shoulder were associated with a higher recurrence rate. Conclusions: Clinicians should be vigilant for pneumothorax in at-risk individuals, consider targeted screening for symptomatic vapers, and prioritize early surgical intervention in recurrent cases to reduce complications. Further research is needed to understand the pathophysiology of vaping-associated spontaneous pneumothorax and optimal management strategies.

Statewide Variation in Practices and Charges for Primary Spontaneous Pneumothorax in Maryland, United States: A Retrospective Study

Background

The optimal treatment for primary spontaneous pneumothorax (PSP) remains undefined. Furthermore, the overall utilization and costs of various treatment approaches are incompletely understood. We investigated hospital charges and resource utilization by management strategy across the state of Maryland in adult and pediatric patients with PSP.

Methods

We queried the Maryland Health Services Cost Review Commission database for patients aged 10-40 years admitted with PSP between 2012 and 2020. Patients managed with a chest tube alone (CT) were compared with recipients of video-assisted thoracoscopic surgery (VATS). Subsequently, we analyzed hospital charges for patients undergoing early VATS (<48 hours post-admission) vs. delayed VATS (≥48 hours). The predicted incremental cost of early vs. delayed VATS was calculated.

Results

Overall, 354 admissions were identified, with 211 (59.6%) receiving CT management and 143 (40.4%) undergoing VATS. Patients receiving VATS were more likely to be female (24% vs. 15%, p=0.030) and Black (32% vs. 20%, p=0.035) than CT recipients. The median total hospital charge for CT recipients was $6,493, compared to $20,437 for patients managed surgically (p<0.001). Delayed surgery during the index admission was associated with significantly higher total hospital charges-including operating room, room and board, radiology, and laboratory costs-than early surgery. Applying early VATS to all patients appeared more cost-efficient than delayed VATS (per-patient costs: $18,568 vs. $30,832, p<0.001), although the former had slightly higher recurrence (7.9% vs. 1.5%, p=0.08).

Conclusion

Variations in management strategies, particularly surgical decision-making and timing, impact hospital charges and utilization for patients with PSP.

Utilizing ChatGPT for Curriculum Learning in Developing a Clinical Grade Pneumothorax Detection Model: A Multisite Validation Study

Background: Pneumothorax detection is often challenging, particularly when radiographic features are subtle. This study introduces a deep learning model that integrates curriculum learning and ChatGPT to enhance the detection of pneumothorax in chest X-rays. Methods: The model training began with large, easily detectable pneumothoraces, gradually incorporating smaller, more complex cases to prevent performance plateauing. The training dataset comprised 6445 anonymized radiographs, validated across multiple sites, and further tested for generalizability in diverse clinical subgroups. Performance metrics were analyzed using descriptive statistics. Results: The model achieved a sensitivity of 0.97 and a specificity of 0.97, with an area under the curve (AUC) of 0.98, demonstrating a performance comparable to that of many FDA-approved devices. Conclusions: This study suggests that a structured approach to training deep learning models, through curriculum learning and enhanced data extraction via natural language processing, can facilitate and improve the training of AI models for pneumothorax detection.

Comparative Analysis of Demographic Characteristics, Management, and Outcomes in Primary Versus Secondary Spontaneous Pneumothorax

OBJECTIVES

This study aimed to explore the differences between primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP) in demographic and clinical features, management trends, and outcomes, alongside assessing recurrence risk factors in spontaneous pneumothorax (SP) patients.

METHODS

This retrospective cohort study at New Damietta Hospital, Al-Azhar University, examined data from adults diagnosed with SP, differentiating between PSP and SSP types based on clinical and radiological criteria, to analyze demographics, clinical characteristics, management strategies, and outcomes.

RESULTS

In a study of 170 patients, 42.94% were diagnosed with PSP and 57.06% with SSP, showing significant differences in age distribution (P=0.042) and smoking habits (P<0.001 for both tobacco and cannabis). Management approaches varied, with conservative methods more common in PSP (15.07%) and surgical interventions following intercostal tube (ICT) drainage significantly higher in SSP (40.21%, P=0.001). Length of hospital stay (LOS) and recurrence rates were significantly higher in SSP than PSP (P<0.001 for LOS; P=0.001 for recurrence), with postoperative complications and in-hospital mortality occurring exclusively in SSP (P=0.054 for complications, P<0.001 for mortality). Risk factors for recurrence included older age, presence of blebs/bullae (P<0.001), and lower hemoglobin and hematocrit levels (P=0.009 and P=0.008, respectively), with thoracic drainage duration longer in recurrent cases (P=0.008). Smoking status significantly impacted recurrence risk, with current smokers showing a higher risk compared to never-smokers (P=0.012).

CONCLUSIONS

This study highlights significant demographic, clinical, and management differences between primary and secondary spontaneous pneumothorax, underscoring the importance of tailored treatment strategies to improve patient outcomes. Key findings include the impact of smoking status on recurrence risk and the necessity for individualized management plans, especially in SSP patients who exhibit higher rates of recurrence, longer hospital stays, and greater morbidity.

Retreatment after primary spontaneous pneumothoraxes managed with primary tube thoracostomy or surgery

BACKGROUND AND AIMS

There is a paucity of data on later healthcare visits and retreatments after primary treatment of spontaneous pneumothorax. The main purpose of this study was to describe retreatment rates up to 5 years after primary spontaneous pneumothorax treated with either surgery or tube thoracostomy (TT) at index hospitalization in Finland between 2005 and 2018 to estimate the burden of primary spontaneous pneumothorax on the healthcare system.

METHODS

Retrospective registry-based study of patients with primary spontaneous pneumothorax treated with TT or surgery in Finland in 2005-2018. Rehospitalization and retreatment for recurrent pneumothorax and complications attributable to initial treatment were identified.

RESULTS

The total study population was 1594 patients. At 5 years, 53.2% (384/722) of TT treated and 33.8% (295/872) of surgically treated patients had undergone any retreatment. Surgery was associated with a lower risk of recurrence than TT (hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.43-0.56, p < 0.001). Male sex was associated with a lower risk of recurrent treatment (HR 0.75, 95% CI 0.63-0.90, p = 0.001). Higher age decreased the risk of recurrent treatment (HR 0.99, 95% CI 0.99-0.99, p < 0.001). At 5 years, 36.0% (260/722) of the TT treated and 18.8% (164/872) of the surgically treated had undergone reoperation at some point.

CONCLUSIONS

Reintervention rates and repeat hospital visits after TT and surgery were surprisingly high at long-term follow-up. Occurrences of retreatment and reoperation were significantly higher among primary spontaneous pneumothorax patients treated with TT at index hospitalization than among patients treated with surgery.

Methods of measurement for pneumothorax in pediatric patients: a systematic review

Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.

[Diagnosis and management of idiopathic spontaneous pneumothorax in adolescents]

INTRODUCTION

Due to the absence of consensual definition and agreed-upon pediatric treatment, pneumothorax (PNO) in children and adolescents often remains difficult to properly apprehend.

STATE OF THE ART

While initial diagnostic suspicion is clinical, confirmation necessitates chest imaging, and lung ultrasound has become increasingly prevalent, often at the expense of chest radiography. The goal of treatment is twofold, on the one hand to a fully re-expand the lungs, and on the other hand to forestall PNO recurrence. Depending on PNO severity and clinical tolerance, it may be advisable to envision conservative management, oxygen supplementation, needle exsufflation, or chest tube drainage.

PERSPECTIVES

In order to harmonize clinical practices, guidelines for the precise definition and graduated management of PNO in children and adolescents are highly advisable.

CONCLUSIONS

Idiopathic spontaneous PNO frequently occurs in teenage populations, and its likewise frequent recurrence is not satisfactorily predicted by chest CT findings. It is of paramount importance that patients be fully informed of the risk of recurrence.

The contemporary management of spontaneous pneumothorax in adults

Spontaneous pneumothorax is a common presentation, and there has been a recent surge of research into the condition. With the recent publication of the new British Thoracic Society guidelines and the upcoming European Respiratory Society guidelines, we provide a concise up-to-date summary of clinical learning points. In particular we focus on the role of conservative or ambulatory management, as well as treatment options for persistent air leak and guidance for when to refer to thoracic surgeons for the prevention of the recurrence of pneumothorax.

Educational aims

To give up-to-date guidance on the acute management of spontaneous pneumothorax, including the role of conservative or ambulatory managementTo discuss the different treatment options for persistent air leak.To guide physicians on when to refer patients to thoracic surgeons for the prevention of the recurrence of pneumothorax.

Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis

BACKGROUND

Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed.

RESEARCH QUESTION

Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility?

STUDY DESIGN AND METHODS

A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed.

RESULTS

Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I2 = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I2 = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I2 = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I2 = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations.

INTERPRETATION

Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.

The Descriptive Features of Primary Spontaneous Pneumothorax Patients in King Abdulaziz Medical City, Riyadh, Saudi Arabia

Background Primary spontaneous pneumothorax (PSP) is a fairly prevalent disorder in emergency medicine. PSP most frequently affects tall, thin male smokers and is most prevalent during adolescence. Published literature contains a wide range of Primary Spontaneous Pneumothorax (PSP) recurrence rates, but there is limited information on the variables affecting recurrence. Objective To identify the descriptive features of PSP in King Abdulaziz Medical City, Riyadh, Saudi Arabia. Methods This retrospective cross-sectional study was conducted in Surgery King Abdulaziz Medical City, Riyadh, Saudi Arabia. Including all PSP patients from 2016-2021, excluding pediatric and geriatric patients. Participants were selected using a simple random sampling technique, and data were collected from hospital records. Data analysis was conducted by using SPSS. Results In this study, we included a total of 131 participants. Most were males (93.1%), and most were aged between 21-30 years. Our findings showed that most PSP events occurred in winter (28.6%). Followed by fall (25.7%), summer (25.0%), and spring (20.7%). Concerning the smoking status of our respondents, our results revealed that most of them were active smokers (72.5%). Left-PSP was the most commonly reported type of PSP (43.5 %), followed by right-PSP (38.9%), non-simultaneous bilateral PSP (14.5%), and bilateral simultaneous PSP (3.1%). Moreover, we found that the recurrence rate of PSP was 42%. Regarding the management of PSP, almost half of the respondents were managed initially by Chest tube. The most frequently used surgical option was VATS- Bullectomy with Abrasion Pleurodesis. Finally, the recurrence rate of PSP was 42% among the patients. The percentage of patients with one recurrence only was 65.5% among the patients with recurrent PSP, second recurrence at 29.1%. Third, Fourth, and Fifth had the same recurrence percentage of 1.8%, and these percentages came to be statistically significant. (P value < 0.001) Conclusion Our study concluded that PSP was more prevalent in tall, thin, young male smokers. Almost half of the respondents suffered from at least one recurrence attack of PSP. The majority of the patients with recurrences experienced one recurrence only, and the second recurrence was estimated to be almost one-third. There is no significant association between the occurrence and seasons of the attack at a time. Most of the participants were managed initially by a chest tube. The most frequently used surgical option was Video Assisted Thoracoscopic Surgery (VATS) with abrasion pleurodesis.

Surgical Management of Pneumothorax and Pleural Space Disease

Pleural space diseases constitute a wide range of benign and malignant conditions, including pneumothorax, pleural effusion and empyema, chylothorax, pleural-based tumors, and mesothelioma. The focus of this article is the surgical management of the 2 most common pleural disorders seen in modern thoracic surgery practice: spontaneous pneumothorax and empyema.

Effectiveness of Video-Assisted Thoracoscopic Surgery with Bullectomy and Partial Pleurectomy in the Treatment of Primary Spontaneous Pneumothorax-A Retrospective Long-Term Single-Center Analysis

Background: Video-assisted thoracoscopic surgery (VATS) with bullectomy and partial pleurectomy (VBPP) is an increasingly used and well-established surgical treatment for primary spontaneous pneumothorax (PSP). However, reports on its effectiveness and long-term outcomes are limited. The aim of this study was to assess and compare long-term recurrence rates following VBPP and chest tube (CT) treatment and to identify potential risk factors for disease recurrence in patients with PSP. Methods: A total of 116 patients treated either by VBPP or CT were included in this study. Long-term recurrence rates and associations between clinical parameters and recurrence of pneumothorax were analyzed. Results: Sixty-two patients (53.4%) underwent VBPP, whereas 54 (46.6%) patients underwent CT treatment only. During a median follow-up period of 76.5 months, VBPP patients experienced a significantly lower recurrence rate compared to CT patients (6/62 vs. 35/54; p < 0.0001). CT treatment (VBPP vs. CT; p < 0.001) and a large initial pneumothorax size (Collins < 4 vs. Collins ≥ 4; p = 0.018) were independent risk factors for pneumothorax recurrence. Conclusion: VBPP is an effective and safe surgical treatment for PSP. Therefore, patients with a large pneumothorax size might benefit from VBPP, as they are at high risk for disease recurrence.

A deep learning-based system capable of detecting pneumothorax via electrocardiogram

PURPOSE

To determine if an electrocardiogram-based artificial intelligence system can identify pneumothorax prior to radiological examination.

METHODS

This is a single-center, retrospective, electrocardiogram-based artificial intelligence (AI) system study that included 107 ECGs from 98 pneumothorax patients. Seven patients received needle decompression due to tension pneumothorax, and the others received thoracostomy due to instability (respiratory rate ≥ 24 breaths/min; heart rate, < 60 beats/min or > 120 beats/min; hypotension; room air O₂ saturation, < 90%; and patient could not speak in whole sentences between breaths). Traumatic pneumothorax and bilateral pneumothorax were excluded. The ECGs of 132,127 patients presenting to the emergency department without pneumothorax were used as the control group. The development cohort included approximately 80% of the ECGs for training the deep learning model (DLM), and the other 20% of ECGs were used to validate the performance. A human-machine competition involving three physicians was conducted to assess the model performance.

RESULTS

The areas under the receiver operating characteristic (ROC) curves (AUCs) of the DLM in the validation cohort and competition set were 0.947 and 0.957, respectively. The sensitivity and specificity of our DLM were 94.7% and 88.1% in the validation cohort, respectively, which were significantly higher than those of all physicians. Our DLM could also recognize the location of pneumothorax with 100% accuracy. Lead-specific analysis showed that lead I ECG made a major contribution, achieving an AUC of 0.930 (94.7% sensitivity, 86.0% specificity). The inclusion of the patient characteristics allowed our AI system to achieve an AUC of 0.994.

CONCLUSION

The present AI system may assist the medical system in the early identification of pneumothorax through 12-lead ECG, and it performs as well with lead I ECG alone as with 12-lead ECG.

Aetiology of Primary Spontaneous Pneumothorax

Air in the pleural cavity is termed pneumothorax. When this occurs in the absence of trauma or medical intervention, it is called spontaneous pneumothorax. Primary spontaneous pneumothorax typically occurs in young patients without known lung disease. However, the idea that these patients have “normal” lungs is outdated. This article will review evidence of inflammation and respiratory bronchiolitis on surgical specimens, discuss the identification of emphysema-like change (i.e., blebs and bullae), the concept of pleural porosity and review recent data on the overexpression of matrix metalloproteinases in the lungs of patients who have had pneumothorax.

Current opinion and comparison of surgical procedures for the treatment of primary spontaneous pneumothorax

INTRODUCTION

Although three-port video-assisted thoracoscopic surgery (VATS) is the standard radical treatment for primary spontaneous pneumothorax (PSP), several issues need to be addressed as the postoperative recurrence rate remains relatively high. Although bullectomy is effective in preventing the postoperative recurrence of PSP, recurrent pneumothorax often occurs, requiring additional methods such as pleural covering with absorbable mesh sheets, surgical chemical pleurodesis, pleural abrasion, or pleurectomy. In addition, minimally invasive approaches that exceed three-port VATS are required according to the social demand. These approaches, such as uniportal VATS, reduced port surgery, and needlescopic surgery, have cosmetic merits, lower postoperative pain, and similar surgical results as three-port VATS.

AREAS COVERED

We focused on conventional and novel treatments for PSP in this article.

EXPERT OPINION

Effective methods that prevent postoperative recurrence and minimally invasive approaches will become popular in the near future.

Pneumothorax: Classification and Etiology

Pneumothorax is a common problem worldwide. Pneumothorax develops secondary to diverse aetiologies; in many cases, there may be no recognizable lung abnormality. The pathogenetic mechanism(s) causing spontaneous pneumothorax may be related to an interplay between lung-related abnormalities and environmental factors such as smoking. Tobacco smoking is a major risk factor for primary spontaneous pneumothorax; chronic obstructive pulmonary disease is most frequently associated with secondary spontaneous pneumothorax. This review article provides an overview of the historical perspective, epidemiology, classification, and aetiology of pneumothorax. It also aims to highlight current knowledge and understanding of underlying risks and pathophysiological mechanisms in pneumothorax development.

Management of Pneumothorax

Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.

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.

Feasibility of application of an absorbable topical collagen hemostat sheet (INTEGRAN®) for prevention of postoperative recurrence of pneumothorax in youths

Background

Staple-line coverage is an effective method for prevention of postoperative recurrence of pneumothorax. However, the recurrence rate in young patients is still unsatisfactory using this method. Moreover, there is no consensus about the optimal material for use in this technique. To explore new material for this technique, we conducted this study to evaluate the safety of an absorbable topical collagen hemostat (INTEGRAN^®) for staple-line coverage in pneumothorax surgery in young patients.

Methods

A single-arm prospective interventional study was performed in 25 patients (age <25 years old) with primary spontaneous pneumothorax (PSP) who underwent wedge resection with staple-line coverage with INTEGRAN^® between 2017 and 2020. The rate of material-related adverse events (defined as a body temperature ≥38 ℃ continuing for ≥2 days, postoperative WBC >18,000/mm³ and/or CRP >15 mg/dL, or acute empyema within 30 postoperative days) was defined as the primary endpoint. The 1-year postoperative rates of recurrence and of new bullae around the staple-line were also measured.

Results

The median age was 19 years old. None of the patients had a body temperature ≥38 ℃ continuing for ≥2 days, extra-abnormal examination data, and acute empyema findings. At 1-year postoperatively, the recurrence rate was 12.0%, and the rate of new bullae around the staple-line was 16.7%.

Conclusions

This study showed the safety of use of INTEGRAN^® for staple-line coverage in pneumothorax surgery in young adults. The short-term recurrence rate was acceptable given the high-risk cohort examined in the study. A prospective randomized controlled study is needed for evaluation of the efficacy of INTEGRAN^® for prevention of recurrence of PSP.

Trial Registration

UMIN000026530 at UMIN Clinical Trials Registry

Sudden unexpected death due to spontaneous pneumothorax caused by ruptured bilateral pulmonary bullae

Sudden unexpected death due to pneumothoraces caused by spontaneous rupture of bilateral pulmonary bullae is rare. This article reports the case of a 16-year-old girl who experienced this rare phenomenon without any precipitating factors. The patient did not have a history of chest pains or smoking but experienced chest tightness in the early morning and collapsed and died 4 h later. Autopsy identified the cause of death to be bilateral pneumothoraces and massive bilateral pulmonary collapse (atelectasis) due to ruptured apical bullae of the bilateral lungs. No injuries or other significant pathological findings were identified. A low body mass index (16.5) may have been a risk factor for the spontaneous tension pneumothoraces. In some situations, genetic counseling and testing may be helpful in identifying a heritable process associated with spontaneous pneumothoraces.

Risk factors for recurrent spontaneous pneumothorax: A population level analysis

BACKGROUND

We sought to determine the rate and risk factors of recurrent spontaneous pneumothorax in a diverse population.

METHODS

Cohort study using the California Public Discharge Data file (1995-2010). We identified patients with first-time spontaneous pneumothorax. The primary outcome was recurrent pneumothorax. Associations with clinical, patient, and hospital characteristics were assessed using Cox regression analysis.

RESULTS

Among 14,609 patients with a first-time episode of spontaneous pneumothorax, 26.2% developed a recurrence. Risk factors included age <35 (Hazard Ratio [HR] 1.24 95%-Confidence Interval [CI] 1.14-1.36), Asian race (HR 1.24, CI 1.13-1.37), and tube thoracostomy (HR 1.2, CI 1.15-1.31). Mechancial pleurodesis (HR 0.37 CI 0.31-0.45) was superior to chemical pleurodesis (HR 0.71 CI 0.58-0.86) in reducing recurrence risk.

CONCLUSIONS

The risk of recurrent pneumothorax is greatest in patients age <35, Asians, and those requiring a tube thoracostomy. The risks of operative intervention should be balanced against patient risk for recurrence.

Cannabis Use Is Associated With Recurrence After Primary Spontaneous Pneumothorax

Purpose: Primary spontaneous pneumothorax (PSP) is a frequently encountered entity that carries a high rate of recurrence. The current study aims to investigate if cannabis use at time of initial PSP is associated with disease recurrence.

Methods: Patients presenting with PSP between 2010 and 2018 at a single institution were identified. Exclusion criteria included secondary pneumothorax, severe chronic lung disease, lung cancer, and lost to follow-up. Patients were compared relative to their cannabis usage with Fisher's exact test, Wilcoxon rank-sum test, and logistic regression.

Results: Overall, 67 patients (53 male) met inclusion criteria with a median body mass index (BMI) of 21.5 kg/m² (IQR 19.1–25.2) and age of 34 years (IQR 22–53). Initial treatment consisted of chest tube in 42 patients (63%), video-assisted thoracoscopic surgery wedge resection in 19 patients (28%), and observation in 6 patients (9%). Cannabis users (n = 28; 42%) had a higher rate of tobacco use (79 vs. 38%; p = 0.005), lower BMI [21.0 kg/m² (IQR 18.3–23.1) vs. 22.2 kg/m² (IQR 19.9–28.6), p = 0.037], and were more likely to require intervention at first presentation compared with non-marijuana users. Cannabis use was associated with PSP recurrence when adjusting for tobacco use, BMI, and height (OR 1.85, 95% CI 1.38–18.3, p = 0.014).

Conclusion: There is a high rate of cannabis usage in patients presenting with PSP. Cannabis usage is associated with PSP recurrence and eventual need for operative intervention.

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.

New insights into spontaneous pneumothorax: A review

A spontaneous pneumothorax is a pneumothorax that does not arise from trauma or an iatrogenic cause. Although the traditional classification of either primary or secondary spontaneous pneumothorax based on the absence or presence of overt underlying lung disease is still widely used, it is now well recognised that primary spontaneous pneumothorax is associated with underlying pleuropulmonary disease. Current evidence indicates that computed tomography screening for underlying disease should be considered in patients who present with spontaneous pneumothorax. Recent evidence suggests that conservative management has similar recurrence rates, less complications and shorter hospital stay compared with invasive interventions, even in large primary spontaneous pneumothoraces of >50%. A more conservative approach which is based on clinical assessment rather than pneumothorax size can thus be followed during the acute management in selected stable patients. The purpose of this review is to revisit the aetiology of spontaneous pneumothorax, identify which patients should be investigated for secondary causes and to give an overview of the management strategies at initial presentation as well as secondary prevention.

Long-term risk of pneumothorax in asthmatic children: A 12-year population-based cohort study

Pneumothorax is a life-threatening complication during acute asthma attack. However, long-term risk of pneumothorax in asthmatic children remains unknown.In this retrospective cohort study, 333,657 children were defined as asthma cohort and a 1:1 matched non-asthma cohort were generated from 2000 to 2011. At the end of 2012, the incidence of pneumothorax in asthma and non-asthma cohorts and asthma to non-asthma hazard ratios (HRs) with confidence intervals (CIs) of pneumothorax were analyzed.The incidence of pneumothorax was 1.35-fold higher in the asthma cohort than that in the non-asthma cohort. The asthma to non-asthma HRs of pneumothorax were higher in children younger than 6 years (1.76, 95% CI: 1.21-2.57) and in girls (2.27; 95% CI: 1.23-4.16). The HRs of pneumothorax were higher in asthmatic children with more asthma-related out-patient clinic visits/per year (>5 visits; HR: 2.81; 95% CI: 1.79-4.42), more emergency department visits/per year (>4 visits; HR: 1.68; 95% CI: 1.02-2.78), and longer hospitalization days due to asthma (>4 days; HR: 3.42; 95% CI: 1.52-6.94) (P < .0001, the trend test).Asthmatic children had greater risk for pneumothorax, particularly in young children and in those with severe and uncontrolled asthma.

Is conventional management of primary spontaneous pneumothorax appropriate?

OBJECTIVE

This study aimed to evaluate the recurrence rate after primary and secondary conservative treatments and to clarify the validity of current primary spontaneous pneumothorax management by comparing secondary conservative treatment and surgical outcomes.

METHODS

Data from 166 patients with primary spontaneous pneumothorax treated at a single site between September 2015 and March 2019 were retrospectively evaluated. Patient characteristics of those who received primary conservative therapy (n = 166) and secondary conservative therapy (n = 28) were summarized. The outcomes from patients who experienced recurrence (n = 64) were compared based on those who underwent surgery (n = 24) and those who underwent secondary conservative therapy (n = 28).

RESULTS

The post-treatment day 60 recurrence rate was 27.1 and 49.5% cases in the primary and secondary treatment groups, respectively, which was significantly higher after secondary treatment than after primary treatment with conservative therapy (p = 0.032). The post-treatment one-year recurrence rate was 13.5 and 57.9% in patients who underwent surgery and secondary conservative treatment, respectively; secondary conservative treatment resulted in a significantly higher recurrence rate than surgery (p < 0.001).

CONCLUSIONS

There is evidence for guidelines that recommend surgery for recurrent primary spontaneous pneumothorax after primary conservative therapy based on its lower and more delayed post-treatment recurrence rate than secondary treatment with conservative therapy.

Pediatric Spontaneous Pneumothorax: Does Initial Treatment Affect Outcomes?

BACKGROUND

Primary spontaneous pneumothorax (PSP) commonly occurs in adolescents, most commonly in males, and has recurrence rates between 20% and 60%. Surgical therapy has long been debated regarding its role in preventing recurrence, with no current consensus on guidelines for care. The purpose of this study is to examine the effect of treatment type on recurrence rates in pediatric PSP.

METHODS

This is a single-institution, institutional review board-approved retrospective analysis of patients aged 1 to 18 diagnosed with their first occurrence of PSP between 2009 and 2017. Patient demographics, hospital course, and outcomes over a 2-y period were collected. Patients were divided into nonoperative (oxygen therapy only) management, chest tube placement, and surgical management. The primary outcome was the recurrence rate.

RESULTS

Sixty-four patients diagnosed with PSP met inclusive criteria. The mean age was 15.5, and 48 (75%) of patients were men. Twenty-one patients (33%) underwent nonoperative treatment, 24 patients (37.5%) underwent operative treatment with video-assisted thoracoscopic surgery or open thoracotomy, and 19 patients (30%) underwent chest tube or pigtail placement alone. Fifteen patients (23.4%) experienced a recurrence within 2 y: 6 patients (29%) from the nonoperative treatment group, 4 (21%) who were treated with the chest tube only, and 5 (21%) who underwent video-assisted thoracoscopic surgery or open thoracotomy. No statistically significant difference in recurrence rates was found between treatment groups. Pneumothorax size was found to differ between treatment type; larger pneumothoraces were more likely to undergo surgical intervention (P = 0.0003). Smaller pneumothoraces were associated with higher rates of recurrence on multivariate logistic regression analysis (P = 0.046).

CONCLUSIONS

Recurrence of PSP in adolescents was found to be 23.4% after 2-y follow-up. Smaller-sized pneumothoraces were associated with higher rates of recurrence, but treatment type did not significantly affect recurrence rates.

Chest Tube Drainage Versus Conservative Management as the Initial Treatment of Primary Spontaneous Pneumothorax: A Systematic Review and Meta-Analysis

Objectives: This systematic review and meta-analysis aimed to compare chest tube drainage and conservative management as the initial treatment of primary spontaneous pneumothorax (PSP). Methods: Studies including PSP patients who received tube drainage or conservative management as the initial treatment were searched in OVID-MEDLINE and Embase through 14 February 2020. The primary outcome was the relative risk (RR) of PSP recurrence, and secondary outcomes were RRs of PSP resolution and adverse events during treatment. A random-effect model using the Mantel–Haenszel method was used to pool RRs. Subgroup and meta-regression analyses were performed to investigate significant predictors of PSP recurrence. Results: In total, 11,922 PSP cases from eight studies were analysed, of which 6344 were treated with tube drainage and 5578 were treated with conservative management. The pooled RR of PSP recurrence for conservative management against tube drainage was 0.98 (95% confidence interval [CI], 0.75–1.28; p = 0.894). Subgroup and meta-regression analyses revealed that study design (p = 0.816), allocation of the PSP amount in each management group (p = 0.191), and assessment time for recurrence had no significant impact on PSP recurrence (p = 0.816). There was no publication bias (p = 0.475). The risk of adverse events of conservative management was significantly lower than that of tube drainage (pooled RR, 0.22; 95% CI, 0.08–1.15; p = 0.003). However, no difference was found between the two groups in terms of PSP resolution (pooled RR, 1.01; 95% CI, 0.9–1.15; p = 0.814). Conclusions: As the initial treatment for PSP, conservative management is comparable to chest tube drainage in terms of PSP recurrence and resolution after treatment, with fewer adverse events during treatment.

Analysis of Pneumothorax in Noninvasive Ventilator Users With Duchenne Muscular Dystrophy

BACKGROUND

With the advancement of cardiorespiratory interventions, the survival rate among patients with Duchenne muscular dystrophy (DMD) has increased. Subsequently, pneumothorax has become a significant problem in patients with prolonged ventilatory support.

RESEARCH QUESTION

What are the frequency, recurrence rate, risk factors, and prognosis of pneumothorax in patients with DMD requiring noninvasive ventilation (NIV)? Also, are there known risk factors of pneumothorax on chest CT scans?

STUDY DESIGN AND METHODS

This retrospective longitudinal cohort study included 176 patients treated between 2006 and 2019. We collected information regarding location, severity, treatment methods, recurrence frequency, abnormal findings on CT scanning, and date of death. We compared the pneumothorax and nonpneumothorax groups. We calculated the estimated survival probabilities from the age at NIV application according to pneumothorax occurrence.

RESULTS

Sixteen of the 176 patients (9.0%) experienced pneumothorax (median age at diagnosis, 24.6 years; range, 20.7-33.7 years). Among the 16 patients, 15 demonstrated pneumothorax after NIV application (median time between diagnosis and initial NIV application, 5.6 years; range, 3 days-9.6 years). Sixteen patients experienced 31 episodes of pneumothoraces (range, one-five episodes); among them, seven episodes (22.6%) were asymptomatic. Known risk factors not clearly visible by radiography scans were found in chest CT scan in 11 patients (68.8%). Seven of 16 patients (43.8%) eventually sustained severe lung damage with pulmonary fibrosis. No significant between-group differences were found in body weight, BMI, and age at NIV application; however, the pneumothorax group showed a significantly higher mortality rate after NIV application.

INTERPRETATION

On pneumothorax occurrence in patients with DMD, recurrences and severe lung damage are common; moreover, these patients show higher mortality rates than patients without pneumothorax. Chest CT scans should be performed to identify risk factors, and treatment should be initiated accordingly. In addition, physicians should consider chest CT scanning in the case of suspected pneumothorax, even if no radiographic abnormality is found.

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.

Recurrence of spontaneous pneumothorax six years after VATS pleurectomy: evidence for formation of neopleura

Background

Primary Spontaneous Pneumothorax (PSP) is considered an absolute and definitive contraindication for scuba diving and professional flying, unless bilateral surgical pleurectomy is performed. Only then is there a sufficiently low risk of recurrence to allow a waiver for flying and/or diving.

Case presentation

A young fit male patient who suffered a PSP 6 years ago, and underwent an uncomplicated videoscopic surgical pleurectomy, presented with a complete collapse of the lung on the initial PSP side. Microscopic examination of biopsies showed a slightly inflamed tissue but otherwise normal mesothelial cells, compatible with newly formed pleura.

Conclusions

Even with pleurectomy, in this patient, residual mesothelial cells seem to have had the capacity to create a completely new pleura and pleural space. The most appropriate surgical technique for prevention of PSP may still be debated.

Patients with spontaneous pneumothorax have a higher risk of developing lung cancer: A STROBE-compliant article

Lung cancer is a common malignancy worldwide, and risk factors include bronchitis, asthma, tuberculosis, smoking, and air pollution. These are also risk factors for spontaneous pneumothorax, a benign disease. We hypothesized that patients who experience a spontaneous pneumothorax have a greater risk to develop lung cancer, and designed a study to determine if this is so.We used the population-based Taiwan Health Insurance Research Database to perform a retrospective cohort study. The database includes more than 99% of the population of Taiwan. We established a 27,405-person pneumothorax cohort and a 109,620 person comparison cohort with data from 2000 to 2009 to evaluate the relationship between spontaneous pneumothorax and lung cancer.Multivariable analysis showed that patients who have had a spontaneous pneumothorax have a greater relative risk to develop lung cancer. The overall hazard ratio was 2.09 (95% confidence interval 1.69-2.58) adjusted by age, gender, hypertension, diabetes mellitus, and chronic lung diseases such as chronic obstructive pulmonary disease, tuberculosis, asthma, bronchitis, and emphysema. A dose effect was present; a high frequency of spontaneous pneumothorax was associated with a greater relative risk to develop lung cancer. If the spontaneous pneumothorax frequency was greater than 2 times per year, the hazard ratio was 34.09 (95% confidence interval 22.74-51.10)Patients with spontaneous pneumothorax have an increased relative risk to develop lung cancer, especially among patients 35 to 49 years of age. The more frequent the occurrence of spontaneous pneumothorax, the greater the relative risk of lung cancer. If the spontaneous pneumothorax frequency was greater than 2 times per year, the increase in risk of lung cancer was more than 30-fold.

Recurrence of primary spontaneous pneumothorax: Associated factors

INTRODUCTION

Determining the risk of recurrence of primary spontaneous pneumothorax is challenging. The objective of this study was to develop a risk assessment model to predict the probability of recurrence in patients with spontaneous pneumothorax.

METHODS

A retrospective study was performed of all episodes of pneumothorax diagnosed in the last 12 years in a hospital, in patients not initially submitted to surgery. Logistic regression was used to estimate the probability of recurrence. Based on a set of variables, a predictive model was built with its corresponding ROC curve to determine its discrimination power and diagnostic precision.

RESULTS

Of the 253 patients included, 128 (50.6%) experienced recurrence (37% within the first year). Recurrence was detected within 110 days in 25% of patients. The median of time to recurrence for the whole population was 1120 days. The presence of blebs/bullae was found to be a risk factor of recurrence (OR: 5.34; 95% CI: 2.81-10.23; p=0.000), whereas chest drainage exerted protective effect (OR: 0.19; 95% CI: 0.08-0.40; p=0.000). The variables included in the regression model constructed were hemoglobin and leukocyte count in blood, treatment received, and presence of blebs/bullae, with a fair discriminative power to predict recurrence [AUC=0.778 (95% CI: 0.721-0.835)].

CONCLUSION

The overall recurrence rate was high and was associated with the presence of blebs/bullae, failure to perform an active intervention (chest drainage) and low levels of hemoglobin and leukocytes in blood. Recurrence rarely occurs later than three years after the first episode. Once validated, this precision model could be useful to guide therapeutic decisions.

The results and outcome of primary spontaneous pneumothorax in adolescents

AIM

Primary spontaneous pneumothorax (PSP) is a rare pulmonary pathology that occurs in the absence of known lung disease. A retrospective study was performed to evaluate the results and outcome of PSP treatment in adolescents.

METHODS

The cases with PSP from January 2004 to December 2017 were evaluated for age, sex, family and smoking history, clinical and radiological findings and results of treatment.

RESULTS

Ten cases with PSP were included. The mean age of the patients was 15 years (10-17 years) and the male to female ratio was 9:1. Two of the patients (20%) had family history of PSP and four cases (40%) had smoking history. The initial complaints were chest pain (n=8), acute onset of cough (n=1) and breathing difficulty (n=1). Tube thoracostomy was performed in nine cases in which three of them were bilateral. Chest computed tomography (CT) demonstrated bullae (n=4; 40%) and subpleural blebs (n=2; 20%). Pleurodesis with talc was performed in four patients with pneumothorax for longer than a week in follow-up (n=4; 40%). Five cases had recurrent PSP within one year (n=5; 50%) and underwent pleurodesis with talc (n=4), autologous-blood (n=1) and bleomycin (n=1). Bleb excision was performed in two cases with persistent pneumothorax despite pleurodesis.

CONCLUSION

Tube thoracostomy and oxygen supplementation, are considered as initial and adequate treatment of PSP in most of the adolescents. Prolonged air leaks require pleurosdesis as the first line treatment and surgical excision of blebs should be reversed for the patients who are unresponsive to other treatment options.

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.

Contralateral bulla neogenesis associated with postoperative recurrences of primary spontaneous pneumothorax in young patients

Background

Video-assisted thoracoscopic surgery (VATS) is considered an acceptable treatment for recurrent primary spontaneous pneumothorax (PSP). However, recent reports have described a high postoperative recurrence rate in young patients with PSP. We hypothesized that ineffective VATS may have been performed for these patients (aged <25 years). We evaluated the factors preventing postoperative recurrence in young PSP patients in order to identify patients with effective surgery.

Methods

Between April 2009 and December 2018, we retrospectively evaluated 92 patients aged <25 years who underwent first VATS bullectomy for PSP. Factors such as gender, smoking habit, history of contralateral PSP, family history, body mass index (BMI), and contralateral bulla neogenesis on high-resolution computed tomography were evaluated.

Results

The mean BMI was 18.8±1.8. Contralateral bulla neogenesis was present in 31 patients (33.7%). The median period of observation for postoperative recurrence was 401.5 days. Thirty cases (32.6%) developed postoperative recurrence. Univariate and multivariable analyses showed that a BMI ≥18.0 and no contralateral bulla neogenesis were significant factors preventing postoperative recurrence (P=0.018, hazard ratio: 0.41 and P=0.0046, hazard ratio: 0.25, respectively).

Conclusions

Although the patients aged <25 years have a high rate of postoperative recurrence, the patients with BMI ≥18.0 and no contralateral bulla neogenesis have a significantly lower rate of postoperative recurrence rate.

Epidemiology and management of primary spontaneous pneumothorax: a systematic review

Clinical trial registration number

International Prospective Register of Systematic Reviews (PROSPERO): CRD42018084247.

Epidemiology and medical service use for spontaneous pneumothorax: a 12-year study using nationwide cohort data in Korea

OBJECTIVE

This study aimed to promote an understanding of spontaneous pneumothorax by analysing the prevalence rate and medical service use by patients with spontaneous pneumothorax according to sociodemographic characteristics.

DESIGN

A 12-year nationwide study.

SETTING

Data obtained from the Korean National Health Insurance Service Sharing Service.

PARTICIPANTS

A total of 4658 participants who used medical services due to spontaneous pneumothorax between 2002 and 2013 in Korea.

OUTCOME MEASURES

For those diagnosed with spontaneous pneumothorax, use of medical services, hospitalisation data, sociodemographics, comorbidity, treatment administered and medication prescribed were recorded.

RESULTS

The annual prevalence of spontaneous pneumothorax ranged from 39 to 66 per 100 000 individuals, while the prevalence of hospitalisation due to spontaneous pneumothorax ranged from 18 to 36 per 100 000 individuals. The prevalence rate of spontaneous pneumothorax in Korea has increased since 2002. The male to female ratio was approximately 4-10:1, with a higher prevalence rate in men. By age, the 15-34 years old group, and particularly those aged 15-19 years old, showed the highest prevalence rate; the rate then declined before increasing again for those aged 65 years or older. In total, 47%-57% of patients with spontaneous pneumothorax underwent hospitalisation. The average number of rehospitalisations due to pneumothorax was 1.56 per person, and more than 70% of recurrences occurred within 1 year. Chronic obstructive pulmonary disease was the most common comorbidity. The average treatment period was 11 days as an outpatient and 14 days in-hospital. The average medical costs were $94.50 for outpatients and $2523 for hospital admissions. The most common treatment for spontaneous pneumothorax was oxygen inhalation and thoracostomy, and the most commonly prescribed medications were analgesics, antitussives and antibiotics.

CONCLUSIONS

We here detailed the epidemiology and treatments for spontaneous pneumothorax in Korea. This information can contribute to the understanding of spontaneous pneumothorax.

Recurrent spontaneous pneumothoraces and vaping in an 18-year-old man: a case report and review of the literature

Background

Primary spontaneous pneumothorax is a common disorder occurring in young adults without underlying lung disease. Although tobacco smoking is a well-documented risk factor for spontaneous pneumothorax, an association between electronic cigarette use (that is, vaping) and spontaneous pneumothorax has not been noted. We report a case of spontaneous pneumothoraces correlated with vaping.

Case presentation

An 18-year-old Caucasian man presented twice with recurrent right-sided spontaneous pneumothoraces within 2 weeks. He reported a history of vaping just prior to both episodes. Diagnostic testing was notable for a right-sided spontaneous pneumothorax on chest X-ray and computed tomography scan. His symptoms improved following insertion of a chest tube and drainage of air on each occasion. In the 2-week follow-up visit for the recurrent episode, he was asymptomatic and reported that he was no longer using electronic cigarettes.

Conclusions

Providers and patients should be aware of the potential risk of spontaneous pneumothorax associated with electronic cigarettes.

What is the best treatment strategy for primary spontaneous pneumothorax? A retrospective study

BACKGROUND

Several treatment strategies are available for primary spontaneous pneumothorax (PSP). Surgical procedures are also performed in patients with PSP without an absolute indication for surgery. This study was performed to investigate the best treatment strategy for PSP by comparison of the recurrence rate.

MATERIALS AND METHODS

From January 2006 to December 2013, 149 patients with PSP aged ≤50 years were treated in our institution. We reviewed the recurrence rate of PSP for each treatment strategy and evaluated the association between the recurrence rate of PSP with the clinicopathological characteristics. We also compared the surgery and non-surgery groups.

RESULTS

A significant difference in the PSP recurrence rate was found between the surgery and non-surgery groups (22% vs. 52%, respectively; p < 0.001), patients aged ≥22 and < 22 years (16% vs. 44%, respectively; p < 0.001), and smokers and nonsmokers (13% vs. 43%, respectively; p < 0.001). There were also significant differences in the multivariate analysis (p < 0.001, p = 0.050, and p = 0.001, respectively). In the surgery group, the PSP recurrence rate was significantly different between patients aged ≥22 and < 22 years (7% vs. 38%, respectively; p < 0.001) and smokers and nonsmokers (5% vs. 33%, respectively; p = 0.002). No significant differences were found in the non-surgery group.

CONCLUSIONS

In the surgical treatment of PSP, it is desirable that smokers stop using tobacco and that patients are ≥22 years old. Moreover, when surgery is being considered, the best timing seems to be when air leakage is present because the air leakage sites can be resected.

Video-Assisted Thoracic Surgery (VATS) Talc Pleurodesis Versus Pleurectomy for Primary Spontaneous Pneumothorax: A Large Single-Centre Study with No Conversion

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively common clinical entity with high incidence in the young population. Video-Assisted Thoracic Surgery (VATS) bullectomy and chemical or mechanical pleurodesis are two primary modalities of treatment. There has been much debate on the ideal mode of pleurodesis, but the literature on surgical outcomes comparing VATS pleurectomy with talc pleurodesis has been inconclusive.

METHODS

We performed a single-centre 5-year observational retrospective study of 202 patients who underwent VATS bullectomy with talc pleurodesis or parietal pleurectomy.

RESULTS

There were no significant differences in the demographics, pre-operative and intra-operative characteristics in both groups. Recurrence of pneumothorax, chest tube duration and hospital stay were similar in both groups. However, talc pleurodesis had a shorter operative time compared to pleurectomy.

CONCLUSION

Our study demonstrated comparable outcomes between talc pleurodesis and pleurectomy following VATS bullectomy for patients with PSP.

The Genetics of Pneumothorax

A genetic influence on spontaneous pneumothoraces-those occurring without a traumatic or iatrogenic cause-is supported by several lines of evidence: 1) pneumothorax can cluster in families (i.e., familial spontaneous pneumothorax), 2) mutations in the FLCN gene have been found in both familial and sporadic cases, and 3) pneumothorax is a known complication of several genetic syndromes. Herein, we review known genetic contributions to both sporadic and familial pneumothorax. We summarize the pneumothorax-associated genetic syndromes, including Birt-Hogg-Dubé syndrome, Marfan syndrome, vascular (type IV) Ehlers-Danlos syndrome, alpha-1 antitrypsin deficiency, tuberous sclerosis complex/lymphangioleiomyomatosis, Loeys-Dietz syndrome, cystic fibrosis, homocystinuria, and cutis laxa, among others. At times, pneumothorax is their herald manifestation. These syndromes have serious potential extrapulmonary complications (e.g., malignant renal tumors in Birt-Hogg-Dubé syndrome), and surveillance and/or treatment is available for most disorders; thus, establishing a diagnosis is critical. To facilitate this, we provide an algorithm to guide the clinician in discerning which cases of spontaneous pneumothorax may have a genetic or familial contribution, which cases warrant genetic testing, and which cases should prompt an evaluation by a geneticist.

The three peaks in age distribution of females with pneumothorax: a nationwide database study in Japan

OBJECTIVES

Women are the minority among patients with spontaneous pneumothorax, but catamenial pneumothorax (CP) is unique to them. We aimed to clarify the clinical characteristics of female patients with spontaneous pneumothorax using a nationwide database.

METHODS

Medical records from the Japanese Diagnosis Procedure Combination database for inpatients with pneumothorax between July 2010 and March 2016 were retrospectively reviewed. Age, underlying diseases, body mass index, smoking status, laterality, number of hospitalizations and treatments were studied.

RESULTS

We identified 157 087 patients with pneumothorax, including 27 716 (17.6%) women and 129 371 (82.4%) men. The age distribution of female patients with pneumothorax had 3 peaks: 18 years, around 40 years and 80 years; male patients had 2 peaks: 18 years and 79 years. We identified 873 patients with CP; this number was not sufficient to account for the female-specific peak around 40 years. The characteristics of female patients of reproductive age were significantly different between those with and without CP. The patients with CP were older (average age: 37.9 ± 7.7 years vs 31.3 ± 11.5 years, P < 0.001), were right side dominant (right: 64.9%, left: 6.5%), had more hospitalizations (average number of hospitalizations: 1.6 ± 0.9 vs 1.3 ± 0.6, P < 0.001) and had more frequently undergone surgery (57.1% vs 37.3%, P < 0.001).

CONCLUSIONS

The age distribution of women with pneumothorax had 3 distinct peaks while that of men had 2. CP has different characteristics from other types of pneumothorax, thus requiring different treatment strategies for women of reproductive age.