SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of the literature according to the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥ 2 cm at the hilum level on frontal chest X-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

SPLF/SMFU/SRLF/SFAR/SFCTCV Guidelines for the management of patients with primary spontaneous pneumothorax: Endorsed by the French Speaking Society of Respiratory Diseases (SPLF), the French Society of Emergency Medicine (SFMU), the French Intensive Care Society (SRLF), the French Society of Anesthesia & Intensive Care Medicine (SFAR) and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV)

INTRODUCTION

Primary spontaneous pneumothorax (PSP) is the presence of air in the pleural space, occurring in the absence of trauma and known lung disease. Standardized expert guidelines on PSP are needed due to the variety of diagnostic methods, therapeutic strategies and medical and surgical disciplines involved in its management.

METHODS

Literature review, analysis of literature according to the GRADE (Grading of Recommendation Assessment, Development and Evaluation) methodology; proposals for guidelines rated by experts, patients, and organizers to reach a consensus. Only expert opinions with strong agreement were selected.

RESULTS

A large PSP is defined as presence of a visible rim along the entire axillary line between the lung margin and the chest wall and ≥2 cm at the hilum level on frontal chest x-ray. The therapeutic strategy depends on the clinical presentation: emergency needle aspiration for tension PSP; in the absence of signs of severity: conservative management (small PSP), needle aspiration or chest tube drainage (large PSP). Outpatient treatment is possible if a dedicated outpatient care system is previously organized. Indications, surgical procedures and perioperative analgesia are detailed. Associated measures, including smoking cessation, are described.

CONCLUSION

These guidelines are a step towards PSP treatment and follow-up strategy optimization in France.

Recommandations formalisées d’experts pour la prise en charge des pneumothorax spontanés primaires

Introduction : Le pneumothorax spontané primaire (PSP) est un épanchement gazeux dans la cavité pleurale, survenant hors traumatisme et pathologie respiratoire connue. Des recommandations formalisées d'experts sur le sujet sont justifiées par les pluralités de moyens diagnostiques, stratégies thérapeutiques et disciplines médicochirurgicales intervenant dans leur prise en charge.

Méthodes : Revue bibliographique, analyse de la littérature selon méthodologie GRADE (Grading of Recommendation Assessment, Development and Evaluation) ; propositions de recommandations cotées par experts, patients et organisateurs pour obtenir un consensus. Seuls les avis d'experts avec accord fort ont été retenus.

Résultats : Un décollement sur toute la hauteur de la ligne axillaire et supérieur ou égal à 2 cm au niveau du hile à la radiographie thoracique de face définit la grande abondance. La stratégie thérapeutique dépend de la présentation clinique : exsufflation en urgence pour PSP suffocant ; en l'absence de signe de gravité : prise en charge conservatrice (faible abondance), exsufflation ou drainage (grande abondance). Le traitement ambulatoire est possible si organisation en amont de la filière. Les indications, procédures chirurgicales et l'analgésie périopératoire sont détaillées. Les mesures associées, notamment le sevrage tabagique, sont décrites.

Conclusion : Ces recommandations sont une étape de l'optimisation des stratégies de traitement et de suivi des PSP en France.

Video-Assisted Thoracoscopic Surgery with Bullectomy and Partial Pleurectomy versus Chest Tube Drainage for Treatment of Secondary Spontaneous Pneumothorax-A Retrospective Single-Center Analysis

Background and objective: Current guidelines recommend chest tube (CT) drainage as the initial treatment of secondary spontaneous pneumothorax (SSP). Surgery should be considered in cases of persistent air leak or recurrent disease. Video-assisted thoracoscopic surgery (VATS) is nowadays an established surgical treatment for complicated spontaneous pneumothorax. However, reports on VATS-bullectomy with partial pleurectomy (VBPP) for treatment of secondary spontaneous pneumothorax (SSP) are limited. The primary aim of this study was to evaluate and compare the clinical outcomes of patients with secondary pneumothorax treated either by VBPP or CT drainage in our institution. Secondly, we assessed underlying clinical parameters to identify potential risk factors for SSP recurrence. Materials and Methods: Eighty-two patients were included in this study. Long-term recurrence rates and potential risk factors for SSP recurrence were analyzed. Results: Thirty-six patients (43.9%) underwent VBPP, whereas 46 (56.1%) patients subsequently underwent CT treatment. During a median follow-up period of 76.5 months, VBPP patients experienced a significantly low recurrence rate compared to CT patients (VBPP vs. CT: 16.7% vs. 41.3%; p = 0.016). However, VBPP was associated with a higher complication rate and significantly longer length of hospital stay (LOS). Male sex (male vs. female: p = 0.021) and CT treatment (VBPP vs. CT: p < 0.001) were identified as potential risk factors for SSP recurrence. Conclusions: VBPP is a suitable surgical treatment for SSP. However, prolonged LOS and possible complications should be discussed prior to VBPP.

Efficacy and safety of surgery for spontaneous pneumothorax in elderly patients

OBJECTIVES

There is no clear consensus on the surgical indications for spontaneous pneumothorax in elderly patients. In this study, we aimed to assess the efficacy and safety of surgical treatment of spontaneous pneumothorax in patients aged ≥70 years. We also sought to identify the risk factors for postoperative prolonged air leaks and complications in such patients.

METHODS

Data pertaining to 104 elderly patients who underwent surgery out of 206 patients (aged ≥70 years) who were diagnosed with spontaneous pneumothorax at our institution between 1994 and 2018 were retrospectively reviewed. The incidences of postoperative persistent air leaks (≥2 days) and postoperative complications (≥grade 3; Clavien-Dindo classification) were analysed for efficacy and safety assessment, respectively.

RESULTS

Median postoperative air leaks continued for 0 days (range 0-25); 14.4% patients developed ≥grade 3 postoperative complications. On the basis of results of multivariable analysis, it was observed that a higher PaCO2 level was significantly associated with prolonged postoperative air leaks [odds ratio (OR) 1.08, 95% confidence interval (CI) 1.00-1.17; P = 0.047]. Poorer performance status was associated with a significantly increased risk of postoperative complications, as assessed by multivariable analysis (OR 6.13, 95% CI 1.38-27.3; P = 0.017). The recurrence rate was 4.8%; mortality rate of patients was 2.9%. Three-year survival rate after surgery was 73.8%.

CONCLUSIONS

Surgical treatment of spontaneous pneumothorax may be effective and safe in selected elderly patients. Moreover, higher PaCO2 and poorer performance status were independent risk factors for postoperative persistent air leaks and complications, respectively.

Surgical treatment for elderly patients with secondary spontaneous pneumothorax

OBJECTIVES

Our objective was to evaluate the validity of surgery for secondary spontaneous pneumothorax (SSP) by comparison with other treatments or with perioperative results for primary spontaneous pneumothorax (PSP).

METHODS

Between January 2009 and March 2015, 144 patients with SSP, aged 60 years or over, were treated in our institution. We reviewed the patients' characteristics, perioperative results, and relapse rate. Treatment to arrest air-leakage included surgery (n = 79), drainage only (n = 30), and pleurodesis (n = 35), and the pneumothorax relapse rate or mortality before discharge was compared for each. Additionally, we compared the perioperative results or relapse rate between SSP (n = 70) and PSP (n = 70) in patients who underwent 3-port thoracoscopic surgery.

RESULTS

There was a significant difference in the relapse rate between the surgery and non-surgery groups (5.3 vs. 27.4 %, p = 0.0006). However, no significant difference in mortality before discharge was determined (p = 0.66). Significant differences were identified between the SSP and PSP groups for operation time, duration of chest drainage, and the length of postoperative hospitalization, and the postoperative morbidity were greater in the SSP group (p < 0.0001 for all). However, there was no significant difference in postoperative 30-day mortality or the relapse rate (p = 0.5, p = 0.68, respectively).

CONCLUSIONS

Surgical treatment under general anesthesia for SSP is effective for arresting persistent air leaks or avoiding pneumothorax relapse, compared with drainage or pleurodesis, and is feasible if the appropriate perioperative management is performed.

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.

Treatment outcomes of pneumothorax with chronic obstructive pulmonary disease

BACKGROUND

Coexisting pulmonary fibrosis and emphysema in the same individual has received increased attention. We retrospectively investigated treatment outcomes of secondary spontaneous pneumothorax in chronic obstructive pulmonary disease patients with both pulmonary fibrosis and emphysema.

METHODS

Among 362 consecutive secondary spontaneous pneumothorax patients treated at our hospital from 2003 to 2012, 58 with emphysema-dominant chronic obstructive pulmonary disease (all elderly men with a smoking history) were enrolled and divided into 2 groups based on computed tomography images: emphysema alone (n = 51) and coexisting emphysema and pulmonary fibrosis (n = 7). The clinical characteristics and mortality were compared between the 2 groups.

RESULTS

There was no significant difference in the recurrence rate after nonsurgical treatment. No patient died of pneumothorax-related complications, but one of 2 with pulmonary fibrosis who underwent surgery died of a postoperative respiratory complication. The mortality rate from respiratory failure during follow-up was significantly higher in the group with pulmonary fibrosis (6/7) than in the group without pulmonary fibrosis (11/51, p = 0.002). The median survival was 0.8 years in the group with pulmonary fibrosis vs. and 5.4 years in the group without pulmonary fibrosis.

CONCLUSIONS

The coexistence of pulmonary fibrosis and emphysema on computed tomography images may represent a predictor of respiratory mortality in elderly chronic obstructive pulmonary disease patients with secondary spontaneous pneumothorax. Because of the potential risk of respiratory failure, we recommend nonsurgical treatment for secondary spontaneous pneumothorax in chronic obstructive pulmonary disease patients with these radiological features.

Surgery for secondary spontaneous pneumothorax: risk factors for recurrence and morbidity

OBJECTIVES

Secondary spontaneous pneumothorax (SSP) is more common in elderly patients; it has high rates of recurrence and mortality, even if surgery is performed. There has been little study on the surgical treatment of SSP. Therefore, we analysed the outcomes of surgical treatment of SSP patients, and investigated the risk factors of recurrence and morbidity.

METHODS

We studied 97 consecutive surgical treatments on 94 patients with SSP who had emphysematous changes of lung retrospectively. Emphysematous changes on preoperative computed tomography image were evaluated by the Goddard score, which is a visual scoring system. First, video-assisted thoracoscopic surgery was performed, followed by bullectomy for the responsible lesions.

RESULTS

The rate of morbidity was 20.6% and that of mortality was 4.1%. Recurrence rate was 9.3%. By multivariate analysis, a Goddard score≥7 (odds ratio: 8.93, P=0.033) and treatment of bulla without the use of staplers (odds ratio: 11.57, P=0.019) were significant risk factors for morbidity, while pulmonary fibrosis tended to increase the risk of recurrence (hazard ratio: 4.21, P=0.051), and a Goddard score≥7 (hazard ratio: 7.79, P=0.023) was a significant risk factor for recurrence.

CONCLUSIONS

Surgical treatment in patients with SSP had favourable results. Treatment in which the base of the bulla cannot be definitely shut off with staplers is associated with increased morbidity. Significant emphysematous change on preoperative computed tomography image and pulmonary fibrosis are predictors of recurrence. Patients with these findings should be investigated in terms of the indications of surgery and additional treatment, not only bullectomy.

A modified two-port thoracoscopic technique versus axillary minithoracotomy for the treatment of recurrent spontaneous pneumothorax: a prospective randomized study

BACKGROUND

Currently, most thoracic surgeons perform surgical pleurodesis for recurrent spontaneous pneumothorax (RSP) by video-assisted thoracic surgery (VATS). However, the superiority of VATS over axillary minithoracotomy is not been established in prospective studies to date. A modified two-port VATS technique and axillary minithoracotomy were prospectively evaluated for possible differences in the short- and long-term outcome for patients.

METHODS

In this study, 66 consecutive patients underwent surgical pleurodesis for RSP through either a modified two-port VATS procedure (group A, 33 patients) or axillary minithoracotomy (group B, 33 patients). According to the study design (NCT01192217), the patients were randomly assigned to the two groups, which were similar in terms of age and body mass index. One-lung ventilation time, histology of the available lung parenchyma specimens, early postoperative complications, length of chest tube drainage and hospital stay, recurrence rate, and a score for patient satisfaction with treatment based on the sum of postoperative pain, dependent-arm mobilization, and return to full activity subscores were evaluated. The follow-up period varied from 3 to 53 months (median, 30 months).

RESULTS

The one-lung ventilation and operating times were significantly longer (p < 0.001) in group A than in group B. The overall detection of blebs, bulla, or both was 51.5% in group A and 63.8% in group B. The recurrence rate, complication rate, postoperative chest tube drainage duration, postoperative hospital stay, and incidence of chronic pain did not differ between the two groups. The score for patient satisfaction with treatment was significantly higher in group A than in group B (p < 0.001) according the subscores for better dependent-arm mobilization and return to full activity.

CONCLUSIONS

Axillary minithoracotomy and VATS are equally effective for the treatment of RSP, although the rate for resection of blebs, bulla, or both is higher with the axillary minithoracotomy procedure. Although VATS is more time consuming, it offers to the patient more satisfaction with treatment.

Video-assisted thoracoscopic surgery management of spontaneous pneumothorax--long-term results

OBJECTIVE

Although widely adopted, there is lack of immediate and long-term follow-up data for patients undergoing video-assisted thoracoscopic surgery (VATS) management of pneumothorax. Therefore, we have reviewed our experience with both primary (PSP) and secondary (SSP) spontaneous pneumothorax to assess the perioperative outcomes and long-term efficacy associated with different VATS operative strategies.

METHODS

A retrospective case series review was undertaken on all patients undergoing VATS procedures for PSP or SSP over a 17-year period.

RESULTS

A total of 644 VATS pneumothorax procedures were performed between 1992 and 2008 on 569 patients, of which 550 procedures were performed for PSP and 94 for SSP. Mean age for PSP and SSP groups were 28.4 ± 10.4 and 58.2 ± 14.2 years, respectively. Surgical technique used bullectomy in combination with abrasion (273), poudrage (246) and pleurectomy (46). Isolated poudrage was used in 72 cases. Median postoperative stay was 3 and 4 days, respectively. Major complications occurred in 25 (4.6%) PSP and 18 (19.2%) SSP patients. Two patients in the SSP group died (2.1%). Median follow-up was 73 months. Freedom from further surgery for the two populations was PSP: 98.1% at 5 years (confidence interval (C.I.): 96.9-99.4) and 97.8% at 10 years (C.I.: 96.5-99.2); SSP: 96.1% at 5 years (C.I.: 91.5-1.006) and 96.1% at 10 years (C.I.: 91.5-1.006). Freedom from further operation at 10 years was independent of the pleurodesis technique employed: abrasion 96.4%, poudrage 98.9% and pleurectomy 97.5% (p=0.22).

CONCLUSIONS

VATS management of both PSP and SSP offers good short-term results and excellent long-term freedom from repeat surgery. In combination with bullectomy, results of abrasion and poudrage do not significantly differ from pleurectomy. We recommend abrasion for pleurodesis in young patients reserving poudrage for the elderly. Pleurectomy may not be necessary.

[The treatment of spontaneous pneumothorax--focusing on the use of videothoracoscopy]

AIMS

Videothoracoscopy plays a leading role in the management of spontaneous pneumothorax. This study evaluates various treatment strategies based on early results.

PATIENTS AND METHODS

In a five-year period 243 (184 male, 59 female, mean age: 37.1 years) patients were treated with spontaneous pneumothorax in 302 cases. In case of partial ptx observation was used in 24 (8%) and aspiration in 6 (2%) patients. Chest drain was inserted in 241 (67.6%) cases. Indications for surgery were recurrence of disease, previous contralateral pneumothorax and failure of drainage. Videothoracoscopy was indicated in 71 (23.5%), Jakoscopy in 5 (1.7%), thoracotomy in 13 (4.3%) cases. The operation was completed with partial pleurectomy in 25, talcum or mechanical pleurodesis in 32 and 3 cases, respectively.

RESULTS

Conservative treatment was successful in 24 (80%) of the 30 conservatively treated cases, while chest drainage succeeded in 204 (84.7%) of the 241 cases. Conversion was needed in 8 (11.3%) cases of the 71 VATS. The remaining 63 patients recovered. Thoracotomy and Jakoscopy were successful in all cases. The postoperative complication rate was 6.3% after VATS, and 7.7% after thoracotomy. Reoperation was performed because bleeding in one case after VATS and thoracotomy. In one case empyema, and in another patient pneumonia developed after VATS. Postoperative bleeding occurred in one case after thoracotomy. The mean hospitalization was 8.5 days after drainage, 9.1 days after VATS and 11.3 days after thoracotomy. The postoperative mortality rate was 1.3% (4 patients).

CONCLUSIONS

In case of spontaneous pneumothorax the first choice of therapy is chest tube drainage. VATS is indicated in case of recurrence, failure of drainage and previous contralateral pneumothorax.