Management of spontaneous pneumothorax: state of the art

Update on the management of first episode primary spontaneous pneumothorax in an Australian hospital network

International guidelines and recent research favour a less interventional approach to primary spontaneous pneumothorax (PSP). A retrospective clinical audit of 68 first-episode PSP was undertaken at a major tertiary teaching hospital network in Melbourne, Australia, found that most patients presenting with a moderate to large pneumothorax received initial intercostal catheter insertion (56%), though many (81%) would have met criteria for consideration of conservative management. The results suggest continued deviation from clinical guidelines in the management of PSP.

Feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax patients

OBJECTIVES

Although early removal of postoperative chest drains can facilitate postoperative recovery, there are risks of undetected bleeding and a need for re-drainage to treat delayed pulmonary air leaks. In this study, we aimed to prospectively examine the feasibility of tubeless thoracoscopic bullectomy in primary spontaneous pneumothorax (PSP) patients.

METHODS

Between January 2021 and November 2021, 30 PSP patients were enrolled in this prospective study. The absence of air leakage was confirmed and radiographic evidence of lung expansion was acquired; the tube was then removed in the operating room. The primary endpoint was postoperative air leakage requiring re-drainage among patients who underwent tube removal in the operating room. The secondary endpoints were postoperative pain (numerical rating scale) on postoperative days (PODs) 1, 7, and 28, morbidity, and postoperative hospitalization time.

RESULTS

Four (13.3%) patients were excluded because of underlying pulmonary disease (n = 2) and air leaks (n = 2) detected in the operating room. Chest drainage tubes were removed in the operating room for the remaining 26 patients; none of them required re-drainage. The mean postoperative hospitalization time was 1.2 ± 0.4 days. The mean numerical rating scale scores were 4.2 ± 2 (median: 4.5), 1.6 ± 1.6 (median: 1), and 0.4 ± 0.8 (median: 0) on PODs 1, 7, and 28, respectively. Only one case of hemoptysis occurred as a postoperative complication.

CONCLUSIONS

Tubeless thoracoscopic bullectomy for PSP is feasible and may reduce the postoperative hospitalization time; however, it does not significantly reduce pain on POD1.

[Treatment of chronic obstructive pulmonary disease and emphysema]

We summarized the available data on therapeutic, surgical and endoscopic treatment of chronic obstructive pulmonary disease and emphysema that may be used like a bridge to lung transplantation. Treatment of chronic obstructive pulmonary disease and emphysema is expensive. Certain limitations in lung transplantation make to create new methods of treatment of severe emphysema. However, one should be ready for possible complications and carefully select patients for certain treatment to avoid false negative results. Reducing costs or developing cheaper treatments is important for the future and availability of care. The risks and complications associated with surgical treatment of emphysema can make endoscopic surgery preferable for these patients, and this undoubtedly requires further research.

Pressure-dependent persistent air leak in a patient with secondary spontaneous pneumothorax

An air leak lasting more than 5-7 days (persistent air leak, PAL) can complicate up to 40% of patients with secondary spontaneous pneumothorax. Chronic obstructive pulmonary disease is the most common cause of secondary spontaneous pneumothorax, and early surgical intervention has been recommended for patients with PAL. Bullectomy or blebectomy with concomitant mechanical pleurodesis by medical thoracoscopy or video assisted thoracoscopic surgery is considered definitive therapy. Unfortunately, the perioperative course following lung resection can also be complicated by air leaks leading to worse clinical outcomes. Post lung resection air leak can be pressure independent or pressure dependent (also known as drainage-related air leak). The distinction between these two entities is crucial as the management varies drastically. Pleural manometry may play an important role in the early diagnosis of pressure-dependent PAL preventing further unnecessary surgical procedures from being performed.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BACKGROUND

Pleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures.

OBJECTIVES

To test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis.

METHODS

35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter.

RESULTS

In the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air).

CONCLUSIONS

Talc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

The Collateral Damage of the Pandemic on Non-COVID Related Pneumothorax Patients: A Retrospective Cohort Study

Background: Since the onset of the COVID-19 pandemic, there have been many reported cases showing the consequences—or the collateral damages—of COVID-19 on patients with non-COVID-related diseases. This study aimed to compare the clinical manifestations and treatment results of non-COVID-related pneumothorax patients before and during the pandemic. Methods: We retrospectively reviewed non-COVID-related pneumothorax patients who visited our hospital before the onset of the pandemic and during the pandemic. The primary outcome was the difference in the amount of pneumothorax between the two periods, and the secondary outcome was the difference in the treatment results between them. Multivariable logistic regression was conducted to find risk factors related to massive pneumothorax. Results: There were 122 and 88 patients in the pre-pandemic and pandemic groups, respectively. There was no significant difference between the two groups with respect to the preoperative demographic variables. However, the median amount of pneumothorax was significantly higher in the pandemic group (pre-pandemic: 34.75% [interquartile range (IQR) 18.30–62.95] vs. pandemic: 53.55% [IQR 33.58–88.80], p < 0.0001) and massive pneumothorax were more frequent in the pandemic group (52.3% vs. 30.3%, p = 0.002). Furthermore, more patients experienced re-expansion pulmonary edema after treatments during the pandemic (p = 0.0366). In multivariable analysis, the pandemic (OR: 2.70 [95% CI 1.49–4.90], p = 0.0011) was related to the occurrence of massive pneumothorax. Conclusion: During the pandemic, patients presented with a larger size of pneumothorax and had more re-expansion pulmonary edema, even in a country that handled the COVID-19 pandemic relatively well.

Management of pneumothorax: an update

PURPOSE OF REVIEW

Pneumothorax is a global health problem. To date, there is still significant variation in the management of pneumothorax. For the past few years, there have been significant developments in the outpatient management of both primary and secondary spontaneous pneumothorax (SSP). We will review the latest evidence for the management of nontraumatic pneumothorax (spontaneous and iatrogenic) to include pneumothorax associated with COVID-19 infection.

RECENT FINDINGS

Outpatient management of both primary and SSP may be safe and feasible.

SUMMARY

Outpatient management of both primary and SSP should be included in treatment options discussion with patients.

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 Impact of Vaping on Primary Spontaneous Pneumothorax Outcomes

INTRODUCTION

Cigarette smoking is associated with primary spontaneous pneumothorax (PSP). Electronic cigarettes (E-cigarettes) are touted as a healthier alternative to cigarettes; however, the impact E-cigarette use has on PSP management is not known. The goal of this study was to determine if E-cigarette use is associated with inferior outcomes after PSP, compared to never smokers and cigarette smokers.

METHODS

We conducted a retrospective cohort study of patients in a large tertiary care hospital system in an urban area who presented with PSP from September 2015 through February 2019. Primary spontaneous pneumothorax patients were identified from the institutional Society of Thoracic Surgeon (STS) database. Patients with pneumothoraces from traumatic, iatrogenic, and secondary etiologies were excluded. Baseline clinical and demographic data and outcomes including intervention(s) required, length of stay, and recurrence were evaluated.

RESULTS

Identified were 71 patients with PSP. Seventeen (24%) had unverifiable smoking history. Of the remaining, 7 (13%) currently vaped, 27(50%) currently smoked cigarettes, and 20(37%) were never smokers. Mean age was 33 years; 80% male. All vapers required tube thoracostomy vs 74% of current smokers and 75% of never smokers. Vaping was associated with increased odds of recurrence compared to never smokers (OR 2.00, 95% CI 0.35,11.44). Vapers had the shortest median time to recurrence after initial hospitalization (10 d[4,18] v 20 d[5,13] cigarette smokers v 27 d[13 275] never smokers, P < .001).

CONCLUSION

Vaping may complicate PSP outcomes. As vaping use increases, especially among adolescents, it is imperative that the manner of tobacco use is documented and considered when caring for patients, especially those with pulmonary problems.

Electrocardiographic changes in young patients with spontaneous pneumothorax: A retrospective study

Primary spontaneous pneumothorax (PSP) commonly occurs in adolescents. PSP symptoms can mimic cardiac event. We aimed to examine electrocardiography (ECG) changes that accompanied PSP in relation to side and size of pneumothorax.A retrospectively reviewed 57 adolescents presented with PSP and underwent a cardiac evaluation.Overall, 49 patients (86%) were male, median age of 16 years. Of these, 1 patient had a known mitral valve prolapse. In 56 patients the initial episode of PSP was unilateral (16 left sided and 40 right sided), and 1 was bilateral. The main initial symptom was chest pain or dyspnea and chest pain 66.6% and 33.3% respectively. Small pneumothorax was right and left sided in 1and 8 patients respectively, medium right (n = 8) medium left (n = 22), large right (n = 7) and large left (n = 10). One additional patient had medium bilateral pneumothorax. ECG findings were abnormal in 12 patients (21%) and included ST elevation in 5 patients, inverted T wave in 2 patients, incomplete right bundle branch block in 2 patients, poor R wave progression, left axis deviation and low QRS voltage in 1 patient each. Only 2 patients had abnormal echocardiography findings, MPV (n = 1) and minimal mitral and tricuspid regurgitation (n = 1). Serum troponin-T levels were normal in all patients.ECG changes were found in 21% among pediatric patients with PSP. No correlation was observed between ECG changes and side/size of pneumothorax. It is important to rule out pneumothorax among children presented with chest pain, dyspnea and ECG changes.

[Ambulatory management of bilateral secondary spontaneous pneumothorax in palliative care]

INTRODUCTION

Secondary spontaneous pneumothoraces account for 35% of all pneumothoraces after the age of 50. Their management is still debated and can be challenging due to the underlying respiratory condition. In our observation, the use of small-bore chest tubes allowed prolonged ambulatory care in a palliative setting.

CASE REPORT

We report the case of a 54-year-old woman suffering from a leiomyosarcoma with multiple pulmonary metastases who had repeated episodes of pneumothorax, one of which was bilateral. Treatment involved the bilateral insertion of 8.5F pigtail catheters connected to Heimlich valves that allowed management as an outpatient. Recurrences were treated similarly, in association with oncological management, providing great additional benefits for patient comfort in this palliative context.

CONCLUSION

Altogether, this case report confirms the applicability of outpatient management for drained spontaneous secondary pneumothoraces, even bilateral, especially in a palliative-care setting.

Primary Spontaneous Pneumothorax in a 32-Week Complicated Pregnancy

Primary spontaneous pneumothorax during pregnancy is a very rare entity. We present a 37-year-old Caucasian woman with spontaneous pneumothorax during the 32nd week of her fourth pregnancy who was treated with intercostal chest drain and was followed up with chest ultrasound. The patient experienced two more episodes of recurrent pneumothorax during pregnancy and puerperium and a uniportal video-assisted thoracoscopic surgery (VATS) was performed. Few such cases have been reported previously in the literature, and there are no relevant medical guidelines. Treatment options include surveillance of a collapsed lung, conservative management with intercostal chest drain, and surgical management with the use of VATS.

Breath emulator for simulation and modelling of expired tidal breath carbon dioxide characteristics

BACKGROUND

In this work we describe a breath emulator system, used to simulate temporal characteristics of exhaled carbon dioxide (CO₂) concentration waveform versus time simulating how much CO2 is present at each phase of the human lung respiratory process. The system provides a method for testing capnometers incorporating fast response non-dispersive infrared (NDIR) CO₂ gas sensing devices - in a clinical setting, capnography devices assess ventilation which is the CO₂ movement in and out of the lungs. A mathematical model describing the waveform of the expired CO₂ characteristic and influence of CO₂ gas sensor noise factors and speed of response is presented and compared with measured and emulated data.

OBJECTIVE

A range of emulated capnogram temporal waveforms indicative of normal and restricted respiratory function demonstrated. The system can provide controlled introduction of water vapour and/ or other gases, simulating the influence of water vapour in exhaled breath and presence of other gases in a clinical setting such as anaesthetic agents (eg N₂O). This enables influence of water vapour and/ or other gases to be assessed and modelled in the performance of CO₂ gas sensors incorporated into capnography systems. As such the breath emulator provides a means of controlled testing of capnometer CO₂ gas sensors in a non-clinical setting, allowing device optimisation before use in a medical environment.

METHODS

The breath emulator uses a unique combination of mass flow controllers, needle valves and a fast acting switchable pneumatic solenoid valve (FASV), used to controllably emulate exhaled CO₂ temporal waveforms for normal and restricted respiratory function. Output data from the described emulator is compared with a mathematical model using a range of input parameters such as time constants associated with inhalation/ exhalation for different parts of the respiratory cycle and CO₂ concentration levels. Sensor noise performance is modelled, taking into account input parameters such as sampling period, sensor temperature, sensing light throughput and pathlength.

RESULTS

The system described here produces realistic human capnographic waveforms and has the capability to emulate various waveforms associated with chronic respiratory diseases and early stage detection of exacerbations. The system has the capability of diagnosing medical conditions through analysis of CO₂ waveforms. Demonstrated in this work the emulator has been used to test NDIR gas sensor technology deployed in capnometer devices prior to formal clinical trialling.

Efficacy of hyperthermia pleurodesis: A comparative experimental study on serous membrane of abdominopelvic and thoracic cavities of rats

BACKGROUND

Pleurodesis is a common technique for treating the accumulation of air or liquid in the pleural space caused by pneumothorax or pleural effusion, it is based on the bounding of pleural layers through induced inflammatory lesions. There are several pleurodesis procedures.

OBJECTIVES

To test and describe the inflammatory effect of hyperthermia on the pleural and peritoneal mesothelia of rats, with the aim of testing the effectiveness of this process for inducing pleurodesis.

METHODS

35 Sprague-Dawley (male/female) rats were randomized into four treatment groups: Group A (Talc, 10 individuals); group B (control, 5 individuals); group C (hyperthermic isotonic saline, 10 individuals); and group D (filtrate air at 50°, 10 individuals). Inflammatory effect of hyperthermia was the primary outcome parameter.

RESULTS

In the talc group, minimal adhesions between both pleural and peritoneal layers were observed in seven rats. Talc produced peritoneal mesothelium inflammation and fibrosis associated to foreign body giant cells in 80% (8/10) of the sample. Furthermore, clear evidence of a granulomatous foreign-body reaction was detected. No macroscopic and/or microscopic damage was registered in the remaining three groups (control, hyperthermic, and filtrate air).

CONCLUSIONS

Talc is an excellent method for producing pleuro-peritoneal inflammatory lesions. On the contrary, hyperthermia apparently does not induce the macroscopic and microscopic damage that is required for efficient pleurodesis. Therefore, hyperthermia should not be used for pleurodesis procedures.

Clinical application of a digital thoracic drainage system for objectifying and quantifying air leak versus the traditional vacuum system: a retrospective observational study

Background

Digital thoracic drainage systems have recently been introduced and widely used in clinical practices in developed countries. These systems can monitor intrathoracic pressure changes and air leaks in real time, and also allow for objective and quantitative analyses, which aid in managing patients with a prolonged persistent air leak into the pleural space. We investigated the feasibility and effectiveness of such a new device versus the traditional vacuum system for treating patients with pneumothorax.

Methods

Closed thoracostomy drainage was carried out on 100 adult patients with primary or secondary pneumothorax between January 2017 and December 2018. All the patients were aged ≥18 years and treated with a chest tube at a single medical center by the same cardiothoracic surgeons and intensivists. Patients who underwent closed thoracostomy drainage using an indwelling 24-French chest tube were divided into 2 groups immediately before closed thoracostomy: the digital thoracic drainage group (digital group, n=50) and the traditional analogue thoracic drainage group (analogue group, n=50). The detailed information about demographic data, treatment outcome, duration of indwelling catheterization., hospital days, cost-effectiveness and patient satisfaction was evaluated. We also evaluated whether digitally recorded intrapleural pressure changes and air leaks would predict chest tube removal timing and outcome.

Results

The baseline parameters of the 2 groups were comparable with no significant differences in sex, age, weight or body mass index. The mean hospital day was shorter in the digital group than in the analogue group (17.96±12.23 vs. 18.32±16.64, P=0.902), and there was no statistically significant difference in the hospital length of stay between the 2 groups. Air leaks through the chest tube and duration of chest tube indwelling hours showed no significant statistical differences between the digital and analogue groups (213.47±219.80 vs. 261.94±184.47, P=0.235 and 223.44±218.75 vs 275.29±186.06, P=0.205, respectively). Total drainage amount and ambulation time per day were significantly higher in the digital group than in the analogue group [209.62±139.63 vs. 162.48±80.42 (P=0.042) and 6.42±3.62 vs.3.94±1.74 (P<0.001), respectively]. Hours of full expansion were significantly shorter and sleep disturbance caused by the noise of chest tube drainage was less in the digital group than in the analogue group [25.64±14.55 vs. 46.52±25.53 (P<0.001) and 2.38±1.03 vs. 5.70±2.87 (P<0.001), respectively].

Conclusions

To date, there is no definite consensus and guidelines on the standardized digital suction system in pneumothorax. This study proposed the guidelines for the application of digital thoracic drainage systems in pneumothorax and also suggested that digital thoracic drainage systems might be a valuable tool to determine chest tube removal timing and reducing the length of hospital stay in patients with pneumothorax.

Pneumothorax as a Complication of Liposuction

Background

Pneumothorax is a rare complication of liposuction resulting from injury to the lung parenchyma.

Objectives

This study aimed to determine the incidence of pneumothorax complicating liposuction, describe an archetypal presentation, identify risk factors, and propose options for risk reduction.

Methods

In a retrospective chart review, liposuction procedures performed over a 16-year period by 8 surgeons in 1 practice were screened for pneumothorax. Cases featuring pneumothorax were analyzed to ascertain risk factors, presentation, and pathogenesis.

Results

Among the 16,215 liposuction procedures performed during the study period, 7 pneumothoraxes were identified (0.0432%). Six (85.7%) were female. Three (42.9%) had previous liposuction. Six cases (85.7%) included liposuction of the axillary region. All cases featured depression of intra/postoperative oxygen saturations as the initial sign. Three (42.9%) were identified intraoperatively. All patients were transferred to a hospital for imaging. Five (71.4%) underwent chest tube placement. Two (28.6%) were treated with observation alone. Pneumothoraxes were left-sided in 4 cases (57.1%), and right-sided in 3 cases (42.9%). In early cases, 1.5-mm infiltration cannulas were used; in 2016 cannula size was changed to 3-4 mm for infiltration and 4-5 mm for liposuction.

Conclusions

Possible risk factors for pneumothorax include liposuction of the axilla, use of flexible infiltration cannulas, and scarring from previous liposuction. We recommend including pneumothorax as a potential complication during informed consent, performing infiltration with a stiff >3.5-mm cannula, minimizing positive-pressure ventilation, emphasized awareness of cannula tip location in all patients but particularly in patients with previous liposuction or scar tissue, and increased caution when operating in the axillary area.

Level of Evidence: 4

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.

Safety and complications of medical thoracoscopy in the management of pleural diseases

BACKGROUND

Medical thoracoscopy is considered an overall safe procedure, whereas numbers of studies focus on complications of diagnostic thoracoscopy and talc poudrage pleurodesis. We conduct this study to evaluate the safety of medical thoracoscopy in the management of pleural diseases and to compare complications in different therapeutic thoracoscopic procedures.

METHODS

A retrospective study was performed in 1926 patients, 662 of whom underwent medical thoracoscopy for diagnosis and 1264 of whom for therapeutic interventions of pleural diseases. Data on complications were obtained from the patients, notes on computer system, laboratory and radiographic findings. Chi-square test was performed to compare categorical variables and Fisher's exact test was used for small samples.

RESULTS

The mean age was 51 ± 8.4 (range 21-86) years and 1117 (58%) were males. Diagnostic procedure was taken in 662 (34.4%) patients, whereas therapeutic procedure was taken in 1264 (65.6%) patients. Malignant histology was reported in 860 (44.6%) and 986 (51.2%) revealed benign pleural diseases. Eighty patients (4.2%) were not definitely diagnosed and they were considered as unidentified pleural effusion. One patient died during the creation of artificial pneumothorax, and the causes of death were supposed as air embolism or an inhibition of phrenic motoneurons and circulatory system. Complication of lung laceration was found in six patients (0.3%) and reexpansion pulmonary edema was observed in two patients (0.1%). Higher incidence of prolonged air leak was observed in bulla electrocoagulation group, in comparison with pleurodesis group. Moreover, pain and fever were the most frequently complications in pleurodesis group and cutaneous infection in entry site was the most frequently reported complication in pleural decortication of empyema group.

CONCLUSIONS

Medical thoracoscopy is generally a safe and effective method, not only in the diagnosis of undiagnosed pleural effusions, but also in the management of pleural diseases. Mastering medical thoracoscopy well, improving patient management after the procedure and attempts to reduce the occurrence of post-procedural complications are the targets that physicians are supposed to achieve in the future.

Comparison of additional minocycline versus iodopovidone pleurodesis during video-assisted thoracoscopic bleb resection for primary spontaneous pneumothorax: a propensity score-matched analysis

Background

The optimal chemical agent for additional pleurodesis during video-assisted thoracoscopic surgery (VATS) bleb resection in primary spontaneous pneumothorax (PSP) remains controversial. We compared the efficacy and safety of iodopovidone with those of minocycline for additional chemical pleurodesis during VATS bleb resection.

Methods

Of 332 patients who underwent VATS bleb resection, 299 patients diagnosed with PSP were enrolled in this study. The patients were divided into two groups according to the chemical agents used for additional pleurodesis (iodopovidone versus minocycline). Propensity score matching was performed on the basis of the preoperative clinical parameters. Postoperative complications, chest tube indwelling time, postoperative hospital stay, and recurrence rate were compared between the two groups.

Results

The median duration of follow-up was 14 months (range, 1-94 months). After propensity score matching, 94 patients from the iodopovidone group and 94 patients from the minocycline group were matched. The perioperative outcomes, including fever, prolonged air-leak, prolonged-effusion, postoperative bed-side pleurodesis, and rehospitalization because of complications, were not significantly different between the two groups. However, the amount of drainage during the first two postoperative days, duration of chest tube indwelling, and duration of hospitalization were significantly shorter in the minocycline group (P<0.001).

Conclusions

This study confirmed the safety of both minocycline and iodopovidone for additional pleurodesis. However, we carefully recommend minocycline over iodopovidone for pleurodesis because of faster postoperative recovery.

Efficacy of treatments in primary spontaneous pneumothorax: A systematic review and network meta-analysis of randomized clinical trials

BACKGROUND

Primary spontaneous pneumothorax (PSP) remains a significant global health problem. Despite general agreement, an official algorithm for the management of PSP still does not exist.

OBJECTIVES

Evaluating the efficacy of all available treatments in PSP.

METHODS

A systematic search of 12 electronic databases was performed to identify all randomized controlled trials (RCTs) of any treatments in PSP. The primary endpoint was recurrence incidence; secondary were an immediate success, complication and hospitalization days. All available outcomes were included in frequentist network meta-analysis.

RESULTS

4262 patients of 29 RCTs were included. In patients with first episode of PSP, video-assisted thoracoscopic surgery (VATS), tube drainage and aspiration had no significant difference regarding recurrence. Chemical pleurodesis significantly reduced the recurrent incidence of 46% compared with aspiration and 54% compared with tube drainage. VATS and aspiration significantly decreased hospitalization days compared with tube drainage. In patients with recurrent or persistent PSP, thoracotomy with mechanical pleurodesis has a higher rank than VATS with or without pleurodesis in preventing recurrence, with no significant difference. VATS alone significantly reduced complications compared with all others treatments, except thoracotomy with abrasion.

CONCLUSIONS

Aspiration and tube drainage have no significant difference in treating patients with first episode of PSP regarding recurrence. Aspiration reduced hospitalization days when compared with tube drainage. Thoracotomy with mechanical pleurodesis and VATS with or without pleurodesis are not significantly different in preventing recurrence in patients with recurrent or persistent PSP. VATS alone reduced complications compared with others treatments except for thoracotomy with abrasion.

Clinical features of secondary spontaneous pneumothorax complicated with silicosis

BACKGROUND

Few studies have focused on the management of secondary spontaneous pneumothorax (SSP) as a complication of pneumoconiosis. The aim of this study was to investigate the clinical features and therapeutic course of SSP associated with silicosis.

METHODS

Between April 2005 and March 2015, 17 patients with silicosis underwent chest tube drainage for SSP in our institution. We retrospectively analyzed patient characteristics, type of treatment, clinical course, rate of recurrence, and survival time, and compared them with those of 30 patients diagnosed with chronic obstructive pulmonary disease (COPD) during the same period.

RESULTS

Fourteen patients with silicosis had performance status score ≥ 2 and modified Medical Research Council Grade ≥ 2; these were significantly different from those in patients with COPD (P = 0.047, P = 0.026). Patients with silicosis had a significantly longer duration of chest tube placement and hospital stay. Recurrent pneumothorax occurred in 47.1% of patients with silicosis, which was not significantly different from the proportion of patients with COPD (40.9%, P = 0.843). However, in the silicosis group, patients treated with chest tube drainage alone tended to have a higher rate of ipsilateral recurrence than those who had pleurodesis, although this was not statistically significant. The median overall survival time of patients with silicosis was 82.6 months, while that of patients with COPD was 104.1 months.

CONCLUSIONS

Patients with silicosis had worse physical status and respiratory functions at the time of occurrence of pneumothorax than those with COPD. Pleurodesis could be an effective treatment for SSP complicating silicosis.

SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.

Partial ambulatory management of severe secondary spontaneous pneumothorax

Secondary spontaneous pneumothorax can be difficult to manage especially in patients with advanced lung disease and respiratory failure. Such patients are unfit for surgery and may endure prolonged hospital stays with chest drains in situ. We describe two such cases where the air leak was persistent despite conventional management. Ambulatory devices which we ordinarily use to manage pneumothoraces in patients with a good lung reserve, were employed as a palliative measure. The strategy not only allowed the patients to return home, but also resulted in healing of the air leak which had persisted with conventional management.

Is it possible to standardize the treatment of primary spontaneous pneumothorax? Part 2: surgical methods of treatment

The present report provides a detailed description of the surgical methods for primary spontaneous pneumothorax (PSP) treatment, from open surgery (thoracotomy) to minimally invasive procedures (video-assisted thoracoscopic surgery - VATS). It describes the methods of preventing pneumothorax recurrence, including partial or complete resection of the parietal pleura and chemical pleurodesis with VATS. The pros and cons of each method are presented. The paper also discusses new techniques for diagnosing pneumothorax, such as fluorescein-enhanced autofluorescence thoracoscopy (FEAT) and infrared thoracoscopy. Finally, the authors propose their own algorithm for the treatment of PSP.

Is it possible to standardize the treatment of primary spontaneous pneumothorax? Part 1: etiology, symptoms, diagnostics, minimally invasive treatment

The authors of this report present the history of primary spontaneous pneumothorax (PSP) treatment, its etiology, clinical symptoms, and diagnostic methodology. Further, they discuss minimally invasive methods of treating PSP such as thoracentesis and chemical pleurodesis. They discuss the pros and cons of each method, emphasizing that, according to the international recommendations, they should be used as the first line of treatment for PSP.

Video-assisted thoracoscopic treatment of primary spontaneous pneumothorax in older children and adolescents

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a relatively rare condition in the pediatric population lacking of specific recommendations regarding the management. Video-assisted thoracoscopic surgery (VATS) has gained widespread consensus during the last 10 years. We retrospectively reviewed our experience of VATS in the treatment of pediatric patients affected by PSP in terms of timing of surgery, operative technique, and postoperative outcome.

METHODS

Between 1998 and 2014, 58 pediatric patients were treated for PSP. Treatment consisted in pulmonary apicectomy in all patients and pleurodesis. Patients received either apical pleurectomy and mechanical pleurodesis or mechanical pleurodesis alone.

RESULTS

Mean age was 16.6 ± 1.6 years (range 10-18) with a male/female ratio of 5:1. Seventeen patients underwent surgery after the first episode of PSP. Apical pleurectomy and mechanical pleurodesis was performed in 30 patients while others received mechanical pleurodesis alone. Conversion to open surgery was needed in four procedures (6.9%). Postoperative complications occurred in 1.7% of cases. Sixteen patients received more than one procedure for contralateral pneumothorax (15 cases) and postoperative recurrence (1 case). The mean follow-up was 95 ± 63 months. Recurrence rate was 12.1%. Univariate analysis showed that recurrence was significantly correlated with younger age (P = 0.044) and postoperative chest tube (P = 0.027). Both univariate and multivariate analysis showed that apical pleurectomy did not prevent recurrences.

CONCLUSIONS

VATS is an effective procedure for PSP in pediatric patients. Apical pleurectomy does not seem to prevent recurrence. Due to the increased risk of recurrence of PSP in younger patients, indication to VATS after the first episode might be considered. Pediatr Pulmonol. 2016;51:713-716. © 2016 Wiley Periodicals, Inc.

Anesthetic management of nephrectomy in a chronic obstructive pulmonary disease patient with recurrent spontaneous pneumothorax

Nephrectomies are usually performed under general anesthesia alone or in combination with regional anesthesia and rarely under regional anesthesia alone. We report the management of a patient with chronic obstructive pulmonary disease with a history of recurrent spontaneous pneumothorax undergoing nephrectomy under regional anesthesia alone.

[Anesthetic management of nephrectomy in a chronic obstructive pulmonary disease patient with recurrent spontaneous pneumothorax]

Nephrectomies are usually performed under general anesthesia alone or in combination with regional anesthesia and rarely under regional anesthesia alone. We report the management of a patient with chronic obstructive pulmonary disease with a history of recurrent spontaneous pneumothorax undergoing nephrectomy under regional anesthesia alone.

Single-port thoracoscopic surgery for pneumothorax under two-lung ventilation with carbon dioxide insufflation

BACKGROUND

The development of single-port thoracoscopic surgery and two-lung ventilation reduced the invasiveness of minor thoracic surgery. This study aimed to evaluate the feasibility and safety of single-port thoracoscopic bleb resection for primary spontaneous pneumothorax using two-lung ventilation with carbon dioxide insufflation.

METHODS

Between February 2009 and May 2014, 130 patients underwent single-port thoracoscopic bleb resection under two-lung ventilation with carbon dioxide insufflation. Access was gained using a commercial multiple-access single port through a 2.5-cm incision; carbon dioxide gas was insufflated through a port channel. A 5-mm thoracoscope, articulating endoscopic devices, and flexible endoscopic staplers were introduced through a multiple-access single port for bulla resection.

RESULTS

The mean time from endotracheal intubation to incision was 29.2±7.8 minutes, the mean operative time was 30.9±8.2 minutes, and the mean total anesthetic time was 75.5±14.4 minutes. There were no anesthesia-related complications or wound problems. The chest drain was removed after a mean of 3.7±1.4 days and patients were discharged without complications 4.8±1.5 days from the operative day. During a mean 7.5±10.1 months of follow-up, there were five recurrences (3.8%) in operated thorax.

CONCLUSIONS

The anesthetic strategy of single-lumen intubation with carbon dioxide gas insufflation can be a safe and feasible option for single-port thoracoscopic bulla resection as it represents the least invasive surgical option with the potential advantages of reducing operative time and one-lung ventilation-related complications without diminishing surgical outcomes.

Uniportal video assisted thoracoscopic surgery bullectomy and double pleurodesis for primary spontaneous pneumothorax

BACKGROUND

Primary spontaneous pneumothorax (PSP) usually occurs in young adults, with higher incidence in smoker, and patients with narrow chest frame and slim body habitus. Surgery is indicated in the cases of recurrence episodes or persistent lung collapse, and failed conservative management by chest drain insertion. Video assisted thoracoscopic surgery (VATS) bullectomy and pleurodesis is the surgical treatment of choice but uniportal approach has been utilised to further minimise surgical trauma, improve cosmesis without compromising the efficacy of the procedure.

METHODS

This video demonstrated the uniportal procedure for bullectomy and double pleurodesis for PSP. A 2.5 cm incision was made at 4th intercostal space, anterior axillary line. Extra small size wound protector was used and CO₂ insufflation was not needed. Adhesion divided with diathermy and visible apical bullae was resected using endoscopic stapler. Abrasive pleurodesis performed by using scratch patch mounted on Robert clamp, gently running along the parietal pleura within the chest wall. In addition, 5 grams of pure talc was delivered into pleural space. Single drain inserted via the port and lung fully inflated upon resuming ventilation by anaesthetist. Drain remained for 48 hours under negative pressure of -20 mmHg and patient usually went home on day 3 post-operatively.

RESULTS

During the period from 2009 to 2015, over 160 cases of PSP were treated using this method by the author. To date, there is no recurrence reported upon follow up at outpatient clinic. There was no mortality and patients resumed active physical activity 8 weeks after the procedure.

CONCLUSIONS

Uniportal VATS bullectomy and double pleurodesis is a safe procedure for treating PSP and effective in preventing future recurrence of lung collapse. This simple approach should be encouraged and performed by all enthusiastic VATS thoracic surgeons.

Safety and Complications of Medical Thoracoscopy

Objectives. To highlight the possible complications of medical thoracoscopy (MT) and how to avoid them. Methods. A retrospective and prospective analysis of 127 patients undergoing MT in Nagoya Medical Center (NMC) and Toyota Kosei Hospital. The data about complications was obtained from the patients, notes on the computer system, and radiographs. Results. The median age was 71.0 (range, 33.0-92.0) years and 101 (79.5%) were males. The median time with chest drain after procedure was 7.0 (range, 0.0-47.0) days and cases with talc poudrage were 30 (23.6%). Malignant histology was reported in 69 (54.3%), including primary lung cancer in 35 (27.5), mesothelioma in 18 (14.2), and metastasis in 16 (12.6). 58 (45.7%) revealed benign pleural diseases and TB was diagnosed in 15 (11.8%). 21 (16.5%) patients suffered from complications including lung laceration in 3 (2.4%), fever in 5 (3.9%) (due to hospital acquired infection (HAI) in 2, talc poudrage in 2, and malignancy in 1), HAI in 2 (1.6%), prolonged air-leak in 14 (11.0%), and subcutaneous emphysema in 1 (0.8%). Conclusions. MT is generally a safe procedure. Lung laceration is the most serious complication and should be managed well. HAI is of low risk and can be controlled by medical treatment.

A case of recurrent pneumothorax related to oral methylphenidate

Primary spontaneous pneumothorax (PSP) commonly occurs in young, tall, and thin males, without any identifiable cause except for emphysema-like changes (ELCs). However, other risk factors may be overlooked. Herein, we report the case of a 19-year-old male who presented with recurrent spontaneous pneumothorax while taking oral methylphenidate.

Apex-to-Cupola Distance Following VATS Predicts Recurrence in Patients With Primary Spontaneous Pneumothorax

Our study sought to determine whether the size of the residual apical pleural space in young patients with primary spontaneous pneumothorax (PSP) following video-assisted thoracoscopic surgery is associated with the risk of recurrence. We retrospectively reviewed patients (≤30 years' old) with primary spontaneous pneumothorax following thoracoscopic surgery (2002-2010) in a university-affiliated hospital. The size of residual apical pleural space was estimated by measuring the apex-to-cupola distance on a postoperative chest radiograph at 2 time windows: first between postoperative day (POD) 0 and 3, and second between POD 4 and 14. A total of 149 patients were enrolled with a median follow-up of 11.2 months (interquartile range, 0.95-29.5 months), of whom 141 (94.6%) were male with a mean age of 20 years. The postoperative recurrence rate was 11.4%. Comparing the characteristics between the patients with and without recurrent pneumothorax, the patients with recurrence were younger (18.2 + 2.4 vs 20.7 + 3.7 years, P = 0.008), with a lower rate of pleurodesis (35% vs1 69%, P = 0.037), longer apex-to-cupola distance at POD 0 to 3 (22.41 ± 19.56 vs 10.07 ± 10.83 mm, P < 0.001) and POD 4 to 14 (11.82 ± 9.75 vs 5.54 ± 8.38 mm, P = 0.005) than the patients without recurrence. In a multivariate logistic regression model for recurrent pneumothorax, age <18 years (P = 0.026, odds ratio [OR]: 4.694), apex-to-cupola distance at POD 0 to 3 >10 mm (P = 0.027, OR: 5.319), and no pleurodesis during VATS (P = 0.022, OR: 5.042) were independent risk factors for recurrent pneumothorax. The recurrence rate was not low (11.4%) in young patients with PSP following VATS. Residual apical pleural space with apex-to-cupola distance of 10 mm or greater at POD 0 to 3, younger age, and no pleurodesis would increase postoperative recurrence of primary spontaneous pneumothorax.

An unusual cause of recurrent spontaneous pneumothorax: the Mounier-Kuhn syndrome

We present a case of 63-year-old man who was referred to the emergency department with a right-sided pneumothorax. He had a history of spontaneous pneumothorax for 2 times. The chest computed tomographic scan showed tracheobronchomegaly with an increase in the diameter of the trachea and right and left main bronchus. Fiberoptic bronchoscopy revealed enlarged trachea and both main bronchus with diverticulas. These findings are consistent with a diagnosis of Mounier-Kuhn syndrome. Mounier-Kuhn syndrome is a rare clinical and radiologic condition. It is characterized by a tracheal and bronchial dilation. Diagnosis is made by computed tomography and bronchoscopy. Mounier-Kuhn syndrome should be kept in mind in the differential diagnosis of recurrent spontaneous pneumothorax.

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

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

Initial management of primary spontaneous pneumothorax with video-assisted thoracoscopic surgery: a 10-year experience

OBJECTIVES

First-line conservative treatment of primary spontaneous pneumothorax (PSP) may be challenged by recurrence rates and complications associated with different treatment options. The aim of this study was to evaluate the use of a standardized surgical treatment as 'first-line' treatment.

METHODS

In a 10-year period, 185 patients with PSP were treated with a standardized video-assisted thoracic surgery (VATS) approach including wedge resection and parietal pleurectomy. Data were evaluated retrospectively. All patients with a first event of PSP were included in the study. In addition, follow-up was done by a questionnaire.

RESULTS

Mean follow-up period was 70.8 months (±33.5 months). Sub-pleural emphysematous changes were found in every histopathological specimen. In addition, 70.8% had fibrosis of visceral pleura. Recurrence occurred in 4 patients (2.2%). Ten-year freedom from recurrence was 96.2%. Procedure-related morbidity rate was 7.6%. Approximately 85.7% of patients were satisfied with the procedure and the cosmetic result. Three patients died during follow-up (1.6%).

CONCLUSIONS

Treatment of first episode of PSP by VATS is a safe procedure, with a very low rate of recurrence and a high patient satisfaction. This management of first episode of PSP is based on the underlying pathology. We recommend the use of VATS as the treatment of first choice for patients with PSP.

Video-assisted thoracic surgery and pneumothorax

Video-assisted thoracoscopic surgery (VATS) is a type of thoracic surgery performed using a small video camera that is introduced into the patient's chest via a scope. It is considered a minimally invasive technique where the surgeon is able to view the instruments that are being used along with the anatomy on which the surgeon is operating. The camera and instruments are inserted through separate holes in the chest wall also known as "ports", depending on the patient and problem there are surgeries with one port "uniport", two or three ports. These small ports have the advantage that fewer infections are observed. This allows for a faster recovery. Traditionally, thoracic surgery performed for diagnosis or treatment of chest conditions has required access to the chest through thoracotomy or sternotomy incisions. Vats minimally invasive technique has replaced in many cases thoracotomy or sternotomy. In our current review we will present this technique in detail.

Open thoracotomy for pneumothorax

A thoracotomy is an incision into the pleural space of the chest. It is performed by surgeons (or emergency physicians under certain circumstances) to gain access to the thoracic organs, most commonly the heart, the lungs, or the esophagus, or for access to the thoracic aorta or the anterior spine. This surgical procedure is a major surgical maneuver it is the first step in many thoracic surgeries including lobectomy or pneumonectomy for lung cancer and as such requires general anesthesia with endotracheal tube insertion and mechanical ventilation, rigid bronchoscope can be also used if necessary. Thoracotomies are thought to be one of the most difficult surgical incisions to deal with post-operatively, because they are extremely painful and the pain can prevent the patient from breathing effectively, leading to atelectasis or pneumonia. In the current review we will present the steps of this procedure.