Spontaneous Pneumothorax

Age-Specific Body Shape Characteristics in the Onset of Spontaneous Pneumothorax: A Comparison Between Teens and 20s

BACKGROUND

Primary spontaneous pneumothorax (PSP) has been the subject of many studies, but its pathogenesis remains unclear. Most juvenile PSPs have a tall stature, thin build, and flat thorax, which is described as a "pneumothorax body shape." In this study, we compared the body shapes of spontaneous pneumothorax (SP) patients in their teens and 20s and examined the characteristics of SP patients.

METHODS

Among PSPs operated on in our hospital, we compared the body shapes of males in their teens and 20s. In addition to height, weight, and body mass index (BMI), we measured the size of the thorax using computed tomography (CT) and analyzed the relationship between the two groups and height.

RESULTS

A total of 77 cases of PSP in teens and 39 cases of PSP in 20s were entered into the study. Teenage PSPs had significantly lower BMI and were slimmer than those in their 20s. However, there were no differences in thorax size and height other than transverse diameter (TD). Furthermore, almost all thorax sizes of PSPs in their 20s were positively correlated with height, whereas those of PSPs in their teens were not correlated except for TD and vertical length.

CONCLUSION

The study highlights significant differences in body shape characteristics between teenagers and individuals in their 20s at the onset of SP. These findings emphasize the need for age-specific considerations in the clinical approach to this condition. Further research is required to understand the underlying mechanisms and to optimize treatment strategies accordingly.

Risk of pneumothorax in Birt-Hogg-Dubé syndrome during pregnancy and birth

Birt-Hogg-Dubé syndrome (BHDS) is a genetic disorder characterized by fibrofolliculomas, renal cell cancer and lung cysts. Patients are at risk to develop pneumothorax but the magnitude of this risk during pregnancy is unknown. Information was obtained from 46 women with BHDS that had at least one pregnancy (BHDS-with preg), 18 female BHDS relatives without pregnancies (BHDS-no preg) and 25 non-BHDS female relatives with at least one pregnancy (noBHDS-with preg). In total, 77 pneumothoraces occurred in the BHDS-with preg group (mean 1.7/patient) and 11 in the BHDS-no preg group. Comparison of patient years for the first two groups showed pneumothorax incidence rates of 0.054 and 0.016, respectively. The incidence rate difference was significant [0.038 (CI 0.02-0.057), value of p-value 0.0001]. This difference is not caused by an increased number of patients with pneumothorax but by an increased number of pneumothoraces per patient. Pregnancy in BHDS therefore might be a risk factor for multiple pneumothoraces.

Persistent Air Leak Due to Chest Drain Malposition

Persistent or prolonged air leak (PAL) is one of the common complications that may happen after many procedures in thoracic surgery. The treatment may change based on the cause, and accordingly, the understanding and awareness of the causes and the exclusion of the rare causes are very important in the treatment of this condition. Here, we present an unusual case with PAL due to chest drain malposition with intraparenchymal insertion in an elderly patient who presented initially with a secondary spontaneous pneumothorax (SSP).

Probability of sporadic lymphangioleiomyomatosis in women presenting with spontaneous pneumothorax

BACKGROUND

Sporadic lymphangioleiomyomatosis (S-LAM) is a rare low-grade neoplasm of young women characterized by multiple pulmonary cysts leading to progressive dyspnea and recurrent spontaneous pneumothorax (SP). The diagnosis of S-LAM may be delayed by several years. To reduce this delay, chest computed tomography (CT) screening has been proposed to uncover cystic lung disease in women presenting with SP. However, the probability to discover S-LAM in this population has not been determined precisely. The aim of this study was to calculate the probability of finding S-LAM in women presenting with (a) SP, and (b) apparent primary SP (PSP) as first manifestation of S-LAM.

METHODS

Calculations were made by applying the Bayes theorem to published epidemiological data on S-LAM, SP and PSP. Each term of the Bayes equation was determined by meta-analysis, and included: (1) the prevalence of S-LAM in the general female population, (2) the incidence rate of SP and PSP in the general female population, and (3) the incidence rate of SP and apparent PSP in women with S-LAM.

RESULTS

The prevalence of S-LAM in the general female population was 3.03 per million (95% confidence interval 2.48, 3.62). The incidence rate of SP in the general female population was 9.54 (8.15, 11.17) per 100,000 person-years (p-y). The incidence rate of SP in women with S-LAM was 0.13 (0.08, 0.20). By combining these data in the Bayes theorem, the probability of finding S-LAM in women presenting with SP was 0.0036 (0.0025, 0.0051). For PSP, the incidence rate in the general female population was 2.70 (1.95, 3.74) per 100,000 p-y. The incidence rate of apparent PSP in women with S-LAM was 0.041 (0.030, 0.055). With the Bayes theorem, the probability of finding S-LAM in women presenting with apparent PSP as first disease manifestation was 0.0030 (0.0020, 0.0046). The number of CT scans to perform in women to find one case of S-LAM was 279 for SP and 331 for PSP.

CONCLUSION

The probability of discovering S-LAM at chest CT in women presenting with apparent PSP as first disease manifestation was low (0.3%). Recommending chest CT screening in this population should be reconsidered.

Spontaneous Pneumothorax: A Tale of Two Unique Cases

We herein present two cases of spontaneous pneumothorax. The first one is occurring in an elderly female who has an extensive history of smoking and an underlying chronic obstructive lung disease, whereas the second case represents a congenital bleb in a male patient who has no other underlying pulmonary disorder. Both cases presented to our facility with a spontaneous pneumothorax following pulmonary bleb rupture. Both patients underwent thoracoscopic surgery with subsequent partial pleurectomy and pleurodesis.

A rare complication of secondary pneumothorax following exploratory laparotomy for a small bowel obstruction: Case report

INTRODUCTION

Small bowel obstruction (SBO) is recognized as the most common surgical emergency following abdominal procedures. Moreover, a pneumothorax secondary to an SBO is an infrequent phenomenon less commonly reported in recent literature. Clinical presentation includes progressive dyspnea and fatigue. The diagnosis was made with imaging. In this case report, the authors present a rare case of concurrent surgical complications (pneumothorax, SBO, perforation of the stomach, and hiatal hernia).

CASE PRESENTATION

A 62 years-old African American patient who presented with severe sudden onset difficulty breathing two days following laparoscopic toupet fundoplication procedure. She was given oxygen via cannula and the underwent chest tube insertion. She was then transferred to different facility under care of a cardio thoracic surgeon.

CLINICAL DISCUSSION

Although SBO is most common emergency following an abdominal procedure, pneumothorax is rarely reported. This case report depicts a unique presentation of pneumothorax secondary to SBO and a discussion section conferring complication risk versus benefits of diverse management modalities (surgical or conservative), and a review of recent literature, further aiding healthcare professionals in the diagnosis and management of patients with SBO complications.

CONCLUSION

Review of this case and the literature show a rare presentation of secondary pneumothorax following exploratory laparotomy for SBO. Recognizing the clinical signs and even a small suspicion should prompt one to order imaging. Chest X-ray is inexpensive and can rapidly rule out pneumothorax. These complications have high mortality in patients above the age of 60 years, hence, timely management is of utmost importance.

Obstructive Shock, from Diagnosis to Treatment

Shock is a life threatening pathological condition characterized by inadequate tissue oxygen supply. Four different subgroups of shock have been proposed according to the mechanism causing the shock. Of these, obstructive shock is characterized by reduction in cardiac output due to noncardiac diseases. The most recognized causes include pulmonary embolism, tension pneumothorax, pericardial tamponade and aortic dissection. Since obstructive shock typically cannot be stabilized unless cause for shock is resolved, diagnosis of the underlying disease is eminent. In this review, we therefore focus on diagnosis of obstructive shock and suggest a structured approach in three steps including clinical examination, ultrasound examination using the rapid ultrasound in shock (RUSH) protocol and radiological imaging if needed.

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.

Prevalence of Birt-Hogg-Dubé Syndrome Determined Through Epidemiological Data on Spontaneous Pneumothorax and Bayes Theorem

Background: Birt-Hogg-Dubé syndrome (BHD) is a rare inherited disorder characterized by cutaneous fibrofolliculomas, multiple pulmonary cysts, recurrent spontaneous pneumothorax (SP), and renal tumors. More than 40 years after its description, the prevalence of BHD in the general population remains unknown. This study aimed at determining the prevalence of BHD by applying the Bayes theorem of conditional probability to epidemiological data on SP. Methods: We performed a meta-analysis of published data on: (1) the probability of having BHD among patients with apparent primary SP (4 studies), (2) the incidence rate of primary SP in the general population (9 studies), and (3) the probability of experiencing a SP in BHD (16 studies). Results were corrected for SP relapses, stratified by gender and year of study publication (before and after 2000), and computed with the Bayes equation. Results: The probability of having BHD among patients with apparent primary SP was 0.09 (95% confidence interval: 0.07, 0.11) or 9%. It was 0.20 (0.14, 0.27) in women and 0.05 (0.04, 0.07) in men. The incidence rate of primary SP in the general population was 8.69 (6.58, 11.46) per 100,000 person-years (p-y). It was 3.44 (2.36, 4.99) per 100,000 p-y in women and 13.96 (10.72, 18.18) per 100,000 p-y in men, and was about 2 times higher in studies published after 2000 than in those published before 2000. The probability of experiencing at least one SP among patients with BHD was 0.43 (0.31, 0.54) or 43%, without gender difference. By combining these data in the Bayes equation, we found a prevalence of BHD in the general population of 1.86 (1.16, 3.00) per million, with values of 1.86 (1.02, 3.39) per million in men, and 1.88 (0.97, 3.63) per million in women. Conclusion: The prevalence of BHD in the general population is about 2 cases per million, without difference between genders.

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.

Characteristics of 30-day readmission in spontaneous pneumothorax in the United States: a nationwide retrospective study

Objective: Our study aimed to determine the national estimates of the 30-day all-cause readmission rate among patients with spontaneous pneumothorax and to investigate the burden of these readmissions in terms of mortality, length of stay and hospitalization costs in the USA.

Methods: We utilized the Nationwide Readmission Database for 2013–2014 and identified adults with a primary diagnosis of spontaneous pneumothorax. We analyzed and reported patient- and hospital-level variables of the study cohort. Our primary outcome was 30-day readmission rate, including the reasons for readmission. Our secondary outcomes included all-cause mortality, resources utilization and predictors of readmissions.

Results: We identified 47,108 index admissions with spontaneous pneumothorax. The 30-day readmission rate was 13.6%. The most common reason for admission was recurrent pneumothorax. In index admissions, the in-hospital mortality rate was 3.1%; whereas, in readmissions, the mortality was higher (4.6%, p < 0.001). Both age group 45–64 (HR: 1.31, 95% CI: [1.15–1.49], p < 0.001) and history of cancer (HR: 1.34, 95% CI: [1.17–1.53], p < 0.001) were found to predict the risk of 30-day readmission.

Conclusion: The 30-day readmission rate in patients with spontaneous pneumothorax was 13.6%, and a recurrent event was the most likely cause. The 30-day readmissions were associated with higher mortality and hospitalization charges. Middle age and history of cancer increase likelihood of 30-day readmission.

Management and recurrence of spontaneous pneumothorax in children

Objective

No guideline clearly prescribes an approach to management of spontaneous pneumothorax in children. The objectives of this study were to evaluate practice variation in the management of spontaneous pneumothorax in children and its probability of recurrence.

Methods

This study was a retrospective chart review followed by a phone follow-up that included all children who had visited a tertiary care paediatric hospital for a first episode of spontaneous pneumothorax between 2008 and 2017. The primary outcomes were the management of pneumothorax (observation, oxygen, needle aspiration, intercostal chest tube, surgery) and the probability of recurrence. All charts were evaluated by a rater using a standardized report form and 10% of the charts were evaluated in duplicate. All children/families were contacted by phone to assess recurrence. The primary analyses were the proportions of each treatment modalities and recurrence, respectively.

Results

During the study period, 76 children were deemed eligible for the study. Among them, 59 had a primary spontaneous pneumothorax while 17 were secondary. The most common first therapeutic approaches were chest tube insertion (31), oxygen alone (27), and observation (14). A total of 54 patients were available for follow-up among whom a recurrence was observed in 28 (37% of the total cohort or 52% of available children).

Conclusion

Chest tube insertion was the first line of treatment in about 40% of children with a first spontaneous pneumothorax. In this population, the recurrence probability is established between 37 and 52% and the majority occurs in the following months.

ADAM10 mediates malignant pleural mesothelioma invasiveness

Malignant pleural mesothelioma (MPM) is an aggressive cancer with limited therapeutic options and treatment efficiency. Even if the latency period between asbestos exposure, the main risk factor, and mesothelioma development is very long, the local invasion of mesothelioma is very rapid leading to a mean survival of one year after diagnosis. ADAM10 (A Disintegrin And Metalloprotease) sheddase targets membrane-bound substrates and its overexpression is associated with progression in several cancers. However, nothing is known about ADAM10 implication in MPM. In this study, we demonstrated higher ADAM10 expression levels in human MPM as compared to control pleural samples and in human MPM cell line. This ADAM10 overexpression was also observed in murine MPM samples. Two mouse mesothelioma cell lines were used in this study including one primary cell line obtained by repeated asbestos fibre injections. We show, in vitro, that ADAM10 targeting through shRNA and pharmacological (GI254023X) approaches reduced drastically mesothelioma cell migration and invasion, as well as for human mesothelioma cells treated with siRNA targeting ADAM10. Moreover, ADAM10 downregulation in murine mesothelioma cells significantly impairs MPM progression in vivo after intrapleural cell injection. We also demonstrate that ADAM10 sheddase downregulation decreases the production of a soluble N-cadherin fragment through membrane N-cadherin, which stimulated mesothelioma cell migration. Taken together, we demonstrate that ADAM10 is overexpressed in MPM and takes part to MPM progression through the generation of N-cadherin fragment that stimulates mesothelioma cell migration. ADAM10 inhibition is worth considering as a therapeutic perspective in mesothelioma context.