Management of primary spontaneous pneumothorax: Did practice change after a landmark multicentre study?

OBJECTIVE

To compare management of primary spontaneous pneumothorax (PSP) before and after the completion of multicentre study which showed non-inferiority of conservative compared to interventional treatment for PSP.

METHODS

This is a retrospective study of patients aged 14-50 years with a first diagnosis of medium to large PSP before and after March 2019 in a tertiary ED. Medical record and radiology database review were used to identify demographic, clinical and radiological data.

RESULTS

The proportion of patients receiving an intervention in the ED decreased from 31.3% (10/32) to 12.5% (3/24).

CONCLUSION

Intervention for management of PSP is less frequent, suggesting adoption and implementation of best evidence.

Investigating the Impact of Cannabis Consumption on Hospital Outcomes in Patients With Primary Spontaneous Pneumothorax: A Nationwide Analysis

Introduction Existing data suggest an association between primary spontaneous pneumothorax (PSP) and cannabis consumption, although evidence remains controversial. Methods This study used the 2016-2019 National Inpatient Sample Database to examine inpatients with PSP, categorizing them as cannabis users and non-users. Multivariate regression analyzed continuous variables, chi-square assessed categorical variables, and logistic regression models were built. Propensity score matching (PSM) mitigated the confounding bias. Results A total of 399,495 patients with PSP were admitted during the study period (13,415 cannabis users and 386,080 non-cannabis users). Cannabis users were more likely to be younger (p<0.001) and male (p<0.001) with a lower risk of baseline comorbidities than non-users. Cannabis users had a lower risk of sudden cardiac arrest, vasopressor use, the development of acute kidney injury, venous thromboembolism, the requirement for invasive and non-invasive mechanical ventilation, hemodialysis, ventilator-associated pneumonia, and the need for a tracheostomy. Cannabis use was associated with a 3.4 days shorter hospital stay (p<0.001), as confirmed by PSM analysis (2.3 days shorter, p<0.001). Additionally, cannabis users showed a lower risk of in-hospital mortality (p<0.001), a trend maintained in the PSM analysis (p<0.001). Conclusions Our study revealed correlations suggesting that cannabis users with PSP might experience lower in-hospital mortality and fewer complications than non-cannabis users.

A Rare Presentation of Minimally Invasive Mesothelioma as a Large Tension Pneumothorax

Development of mesothelioma is associated with asbestos exposure. Common presentations are with pleural-based plaques invading the chest wall and/or pleural effusion on chest imaging. The intent of this case report is to describe a rare presentation of mesothelioma, which presented atypically as a large tension pneumothorax. A 93-year-old male presented with a history of dyspnea that started after a coughing episode. On physical examination he was hemodynamically stable, but was hypoxic requiring 2L of supplemental oxygen. Computed tomography of the chest revealed a large right tension pneumothorax. A chest tube was placed and connected to suction (-20cmH20), but he continued to have an unresolving air leak over the following 2-week period. Upon video-assisted thoracotomy there were no blebs or adhesions seen. Right apical wedge resection and talc pleurodesis were performed. Pathologic examination revealed an atypical mesothelial cell proliferation with minimal, focal invasion into the pulmonary parenchyma. Tumor spread along the visceral pleura was thought to be the underlying cause of the pneumothorax. The surgical margins were uninvolved by the tumor, and the patient was later discharged home in stable condition. This was a rare presentation of what could best be described as minimally invasive mesothelioma arising in a background of probable mesothelioma in situ, which presented atypically as a large tension pneumothorax. This case highlighted the importance of establishing a pathologic diagnosis from pleural effusion cytology and/or pleural biopsy in persons presenting with spontaneous pneumothorax, and the difficulty in confirming a pathologic diagnosis of early mesothelial neoplasia.

Rare complication spontaneous pneumothorax and pneumomediastinum in COVID-19 patients: A single center experience

INTRODUCTION

We aimed to describe the clinical characteristics and outcomes of patients with spontaneous pneumothorax (SPT) and pneumomediastinum (SPM) due to COVID-19 pneumonia.

METHODOLOGY

This retrospective study evaluated inpatients at a COVID-19 pandemic hospital. Between March 11, 2020 and March 31, 2021, patients who developed complications of spontaneous pneumothorax (SPT) and pneumomediastinum (SPM) with a confirmed diagnosis of SARS-CoV-2 by polymerase chain reaction (PCR) method were included.

RESULTS

Of the 6,528 hospitalized patients, nine developed complications of SPT and SPM, with an incidence of 0.14%. Four of these patients developed SPT, one developed SPM, one developed SPT + SPM + emphysema, and three developed SPT + SPM. The mean age of the patients was 67.67 ± 13.41 years and the median was 68 (45-88) years. All patients were male. Six patients died, one of whom died of myocardial infarction from uncomplicated causes.

CONCLUSIONS

Studies with more cases are needed to evaluate the causality between COVID-19 and pneumothorax (PT) and pneumomediastinum (PM). However, it should be kept in mind that PT and PM may lead to this clinic when sudden respiratory distress occurs in these patients and rapid diagnosis and treatment should be planned. As observed in this study, PT and PM are important factors in the development of mortality in COVID-19 patients.

A Case of Bilateral Pneumothorax With COVID-19 Infection

Bilateral spontaneous pneumothorax is a serious complication of coronavirus disease 2019 (COVID-19). The incidence of any spontaneous pneumothorax in patients with the aforementioned viral infection when hospitalized is about 1%. Treatment can involve management such as oxygen support, tube thoracostomy, pleurodesis, or even invasive surgery. The associated mortality with this complication is about 33% to 52%. We present a case of bilateral pneumothorax in a patient diagnosed with COVID-19 without any history of smoking or underlying lung disease. Careful vigilance and close monitoring of this serious complication are mandatory in inpatients.

Cannabis-Associated Pneumothorax: A Case Report

The use of cannabis for therapeutic and recreational purposes has been on the rise in recent years. This has increased the prevalence of cannabis use disorder across various demographic subgroups. A recent medical literature review describes a few cases demonstrating the association of spontaneous pneumothorax and bullous lung disease in cannabis users without concomitant tobacco use. We herein present a case report of a young male with chronic cannabis use who presented with right-sided spontaneous pneumothorax and bilateral apical blebs.

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).

Visible Apical Blebs on CXR: Are Plain Radiographs Under-Utilized in Primary Spontaneous Pneumothorax?

A primary spontaneous pneumothorax (PSP) is caused by rupture of subpleural emphysematous blebs, without inciting event or pre-existing co-morbidity. A previously healthy 16-year-old male presented with upper chest pain. As expected, chest radiographs (CXR) demonstrated a 13 mm pneumothorax. Additionally, a 4.7 cm apical bleb was identified. After six-hours of observation and non-rebreather oxygen mask therapy, follow-up CXR confirmed stable findings. The patient was subsequently discharged home after symptoms improved. Follow-up CXR at 2-weeks confirmed persistent visible apical bleb. After lengthy discussion addressing patient and parental concerns, elective surgical management was pursued. Current literature suggests blebs are not routinely identified on CXR. While there is no universally accepted management algorithm for PSP in children, visible apical blebs on CXR may influence the decision to pursue surgical intervention. Shared decision making should involve counseling regarding the recurrence risk following surgery, and consideration of patient-specific factors including patient and parental anxiety.

Non-Ventilated Patients with Spontaneous Pneumothorax or Pneumomediastinum Associated with COVID-19: Three-Year Debriefing across Five Pandemic Waves

Spontaneous pneumothorax and pneumomediastinum (SP-SPM) are relatively rare medical conditions that can occur with or independently of COVID-19. We conducted a retrospective analysis of SP-SPM cases presented to the emergency departments (EDs) of two University-affiliated tertiary hospitals from 1 March 2020 to 31 October 2022. A total of 190 patients were identified: 52 were COVID-19 cases, and 138 were non-COVID-19 cases. The primary outcome we were looking for was in-hospital mortality. The secondary outcomes concerned the disease severity assessed by (a) days of hospitalization; (b) required mechanical ventilation (MV); and (c) required intensive care (IC). All were investigated in the context of the five pandemic waves and the patients' age and comorbidities. The pandemic waves had no significant effect on the outcomes of these patients. Logistic regression found age (OR = 1.043; 95%CI 1.002-1.085), COVID-19 (OR = 6.032; 95%CI 1.757-20.712), number of comorbidities (OR = 1.772; 95%CI 1.046-3.001), and ground-glass opacities over 50% (OR = 5.694; 95%CI 1.169-27.746) as significant risk predictors of in-hospital death while controlling for gender, smoking, the pandemic wave, and the extension of SP-SPM. The model proved good prediction performance (Nagelkerke R-square = 0.524) and would hold the same significant predictors for MV and IC.

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.

Which Role for Muscle-Sparing Posterolateral Thoracotomy in the Treatment of Spontaneous Pneumothorax?

Objective  This study aims to show the place of muscle-sparing posterolateral thoracotomy in the treatment of spontaneous pneumothorax. Methods  It was a single-center study performed in the Department of Thoracic Surgery of Teaching hospital Hassan II of Fez for 8 years. We adopted the nosological definition, which classifies spontaneous pneumothorax into three categories. We included patients over 15 years of age with primary or secondary spontaneous pneumothorax operated by posterolateral thoracotomy without muscle section, and we analyzed the specific indications of this approach. It included 49 patients with primary or secondary spontaneous pneumothorax, operated by muscle-sparing posterolateral thoracotomy. Data were collected from regularly updated computer files of patients, entered by Excel 2013, and analyzed using SPSS.20 software. These data are: epidemiological, clinical, radiological, surgical exploration, surgical procedure, the result of the surgery and the evolution. Results  The average age was 42 years. Smoking was found in 61% of cases and pulmonary tuberculosis in 10% of cases. Thoracic computed tomography (CT) showed bullae and blebs in 31% of cases, pleural adhesions and pachypleuritis in 50% of cases, and hydropneumothorax with pachypleuritis in 37% of cases. There is a statistical correlation between pleuropulmonary decortication and pachypleuritis ( p  = 0.002) or hydropneumothorax ( p  = 0.001) on CT. Bullae and blebs resection was performed in 53% of cases and pleuropulmonary decortication in 63% of cases. A right pleuropneumonectomy was performed in one case. The follow-up was uneventful in 82% of cases. Conclusion  Muscle-sparing posterolateral thoracotomy remains the best approach and leads to good results.

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

BACKGROUND

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

RESEARCH QUESTION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

Catamenial Pneumothorax: A Rare Diagnosis Among Menstruating Women

Catamenial Pneumothorax is a rare condition often associated with endometriosis in menstruating women. Due to the rarity of this condition, its etiology is not well studied and, thus, effective treatment regimens have not been well established. We present a case of a 21-year-old female with no significant past medical history who developed recurrent episodes of spontaneous pneumothorax, chronologically associated with her menstrual cycle. This pattern is known as the sine qua non criteria and is one of the only established criteria in current literature for diagnosing catamenial pneumothorax. Our aim with this case report is to expand the current collection of published knowledge about this rare condition and to bring awareness so that those affected by catamenial pneumothorax can be diagnosed and treated more efficiently. Additional research on the pathophysiology of this disease needs to be done to aid in the development of effective treatment regimens.

Morbidity, mortality, and surgical treatment of secondary spontaneous pneumothorax

BACKGROUND

Pneumothorax in patients with underlying lung pathology is called secondary spontaneous pneumothorax (SSP). It is an important health problem worldwide, with significant morbidity, high health-care expenses, and possibility of mortality. This study aimed to evaluate the epidemiological characteristics, risk factors for mortality and morbidity, and treatment options of SSP.

METHODS

Outcomes of 133 patients with SSP were evaluated retrospectively. Patients with SP with evidence of underlying lung disease or a smoking history over 50 years of age were considered SSP. The patients were analyzed in terms of epidemiological fea-tures, underlying diseases, treatment methods, complications, and mortality. The treatment options included thoracotomy (T), video-assisted thoracoscopic surgery (VATS), tube thoracostomy, and conservative treatment.

RESULTS

The mean age was 50.50±20.374 years, and the age range was 16-95. Ninety-three (69.9%) of the patients were smokers. The most common clinical finding was dyspnea in 77 (57.9%) patients. The most common underlying disease was chronic obstructive pulmonary disease in 62 patients (46.6%). Six (4.5%) patients received conservative treatment, a chest tube was placed in 89 (66.9%) patients, and 38 (28.6%) patients were treated with surgery. As an operative procedure, lung wedge resection was performed in 24 (18.0%) patients and bulla resection was performed in 6 (4.5%) patients. Parietal pleurectomy was performed in 27 (20.3%) patients. Axillary mini-T or T was performed more frequently in large pneumothorax, smokers, and in obstructive pulmonary disease. Tube thoracostomy was used more frequently in poor physical performance, comorbidities, and infectious diseases. Complications were ob-served in 55 patients (41.4%). The most common complication was persistent air leakage in 18 (13.5%) patients. Complications were associated with large pneumothorax (P=0.003), poor physical performance (P=0.009), infectious diseases (P= 0.030), and occupational risk factors (P=0.032). Recurrence was developed in 12 (9.0%) patients. Postoperative recurrence was observed in 1 patient. Four (3%) patients died. Mortality was higher in patients with poor physical performance (P=0.027), comorbidities (P=0.008), and patients with complications (P=0.027). The length of stay in the hospital was high in mini-axillary T (AT)/T (P<0.001) and VATS (P<0.001). There was no significant relationship between the mini-AT/T and VATS in terms of length of hospital stay.

CONCLUSION

Large pneumothorax, poor physical performance, and comorbidity are associated with morbidity and mortality. Conservative treatment for small pneumothorax and chest tube for large pneumothorax is the most appropriate initial treatment. Resection of the bullous region through VATS or mini-AT/T is the most appropriate surgical technique.

The Rare Presentation of Spontaneous Pneumothorax in a Pediatric Patient

Children presenting to the Emergency Department (ED) with upper respiratory infection (URI) symptoms of unresolved cough are not uncommon. Differentiation of the child's symptoms with thorough history and physical and when appropriate, further evaluation with blood work and imaging is the responsibility of the ED physician. In a clinical environment with increasing ED visits due to nonspecific URIs in children, it is also important not to overutilize an emergent workup with unnecessary testing. Our case involves a patient with atypical symptoms and hopes to highlight the importance of keeping a broad differential for all patients upon initial evaluation. Spontaneous pneumothorax is a potentially life-threatening condition. Our five-year-old patient presented with an unresolved cough being treated by an outpatient physician. He had no prior airway disease diagnosis. Severe cough in the absence of prior airway disease is notably less likely, but not an unseen cause of spontaneous pneumothorax. Our patient, however, developed just that. He was officially diagnosed with a right-sided pneumothorax on chest x-ray, underwent supplemental oxygen therapy, and was ultimately transferred to a pediatric hospital for continuation of care. Once there, our patient gradually improved was diagnosed as an asthmatic, and was started on appropriate maintenance medications. It is important to remain vigilant when examining multiple pediatric patients in a shift and to keep in mind that even otherwise healthy pediatric patients are at risk for spontaneous pneumothorax.  Spontaneous pneumothorax is a potentially life-threatening condition. Our five-year-old patient had no prior airway disease diagnosis making spontaneous pneumothorax notably less likely, however, from severe cough our patient developed just that. He was officially diagnosed with right-sided pneumothorax, underwent supplemental oxygen therapy, and was transferred to a pediatric hospital. Once there patient gradually improved, he was diagnosed as an asthmatic and started on appropriate medication to keep his breathing stable. It is essential to keep in mind that even otherwise pediatric patients are at risk for spontaneous pneumothoraxes and we as emergency physicians must keep this in mind during our evaluation.

Recommendations on scuba diving in Birt-Hogg-Dubé syndrome

INTRODUCTION

Although very uncommon, severe injury and death can occur during scuba diving. One of the main causes of scuba diving fatalities is pulmonary barotrauma due to significant changes in ambient pressure. Pathology of the lung parenchyma, such as cystic lesions, might increase the risk of pulmonary barotrauma.

AREAS COVERED

Birt-Hogg-Dubé syndrome (BHD), caused by pathogenic variants in the FLCN gene, is characterized by skin fibrofolliculomas, an increased risk of renal cell carcinoma, multiple lung cysts and spontaneous pneumothorax. Given the pulmonary involvement, in some countries patients with BHD are generally recommended to avoid scuba diving, although evidence-based guidelines are lacking. We aim to provide recommendations on scuba diving for patients with BHD, based on a survey of literature on pulmonary cysts and pulmonary barotrauma in scuba diving.

EXPERT OPINION

In our opinion, although the absolute risks are likely to be low, caution is warranted. Given the relative paucity of literature and the potential fatal outcome, patients with BHD with a strong desire for scuba diving should be informed of the potential risks in a personal assessment. If available a diving physician should be consulted, and a low radiation dose chest computed tomography (CT)-scan to assess pulmonary lesions could be considered.

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

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

Bilateral spontaneous pneumothorax as a late complication of COVID-19, a clinical case report

Key Clinical Message

Bilateral spontaneous pneumothorax and sudden dyspnea can occur as late complication in patients with COVID-19 even without any history of mechanical ventilation usage.

Abstract

Bilateral spontaneous pneumothorax can occur as a late complication in patients with COVID-19, even without any history of mechanical ventilation. Here, we present a patient with mild COVID-19 pneumonia with a left massive pneumothorax in the third week of hospitalization and the addition of a right pneumothorax.

Spontaneous pneumothorax with isolated pulmonary Langerhans cell histiocytosis in an adult case: A common manifestation of rare disease

Key Clinical Message

Pulmonary Langerhans cell histiocytosis should be evaluated even in adults with no previous medical history and no history of cigarette smoking who have spontaneous pneumothorax and evidence of multiple lung cystic lesions, and other organs should also be checked for multi organ Langerhans cell histiocytosis involvement.

Abstract

A 30-year-old man presented with sudden chest pain and evidence of multiple cystic lesions in both upper and lower lobes of lungs, as well as left-sided pneumothorax in high resolution computed tomography. In lung samples, hematoxylin and eosin- stained sections and IHC for CD1a, S100, and BRAF V600 were positive. The patient was diagnosed with isolated pulmonary Langerhans cell histiocytosis and was treated accordingly.

Features of medical approaches]

Soft tissue emphysema (including subcutaneous emphysema) is common in pneumothorax. In most cases, this condition is of little clinical significance and regresses under standard medical procedures. However, progressive soft tissue emphysema poses a threat to the patient's life in case of compression of the upper respiratory tract in some cases. The world literature describes various approaches to the treatment of these patients. Standard medical care for progressive soft tissue emphysema following pneumothorax is pleural drainage with active aspiration. Despite unequivocal treatment tactics, this may not be enough in case of massive air release. Surgical treatment may be accompanied by surgical and anesthetic difficulties including difficult intubation. The authors present persistent tension pneumothorax and soft tissue emphysema, features of surgical and anesthetic management, as well as current treatment options.

Birt-Hogg-Dubé syndrome with c.1579_1580insA variant in a Chinese family: a case report

Birt-Hogg-Dubé (BHD) syndrome, is a rare genetic disease with heterogeneous manifestations in different populations. In this study, we reported a Chinese female BHD case and her family members with c.1579_1580insA variant in FLCN gene, who were characterized by diffused pulmonary cysts/bulla, and reviewed another five familial BHD cases in China. Based on these cases, recurrent spontaneous pneumothorax is likely to be the first symptom for BHD in Chinese patients, with particularly but not limited to c.1579_1580insA variant. Therefore, attention to the early diagnosis of BHD in China should focus on pulmonary signs, but skin or kidney lesions still can not be neglected.

Hemoptysis after COVID-19 and the importance of differential diagnosis: Birt-Hogg-Dubé syndrome

Birt-Hogg-Dubé syndrome is a genodermatosis of autosomal dominant inheritance characterized by mutations in the folliculin (FLCN) gene. There is an inappropriate inhibition/activation of a protein, the foliculin, which may cause tumor lesions in skin, renal and lung lesions; they could have more risk of developing pneumothorax compared to the normal population. A 38-year-old male patient with bronchial asthma who consulted for hemoptysis three weeks after recovery from COVID-19 infection. A chest tomography was requested, showing an air cyst in the left lower lobe. Physical examination shows evidence of thoracic skin lesions which a skin biopsy was performed on. The results were compatible with fibrofolliculoma. Differential diagnoses were proposed. A genetic disorder associated with skin lesions was suspected. A multi-genetic panel that includes BRCA1, BRCA2, TP53 and FLCN genes was requested, which reported the mutation of the FLCN gene in heterozygosis classified as pathognomonic of Birt-Hogg-Dubé syndrome. Patient is currently under clinical follow-up while genetic counseling was requested for relatives.

The miRNA-24, miRNA-21 expressions and matrix metalloproteinase-7 level in exhaled breath condensate of children with primary spontaneous pneumothorax

Bullous lung diseases may cause primary spontaneous pneumothorax (PSP) in children. The microRNAs (miRNAs) are non-coding RNAs that participate in regulation of inflammation and cancer. We hypothesized that children with bullous lung disease and PSP may have altered miRNA expressions in their exhaled breath condensates (EBCs). Therefore, a prospective study was performed to evaluate the miRNA-24 and 21 expression, and the matrix metalloproteinase-7 (MMP-7) levels in EBC of children with PSP. Children with PSP were evaluated for age, gender, clinical features and results of surgical treatment. EBC samples (500-1000 ml) were collected to evaluate the miRNA-21, 24 expressions, and MMP-7, and tissue-inhibitor-MMP-1 (TIMP-1) levels. miRNA expressions and MMP levels of patients were compared with healthy controls (control group (CG),n= 12). Subjects (n= 16) with a mean age of 15 years (10-19 years), and a male-to-female ratio of 14:2 were enrolled in this study. The most common presenting symptom was sudden chest pain (n= 14). In 62.5% of the cases an underlying bullous lung disease were detected. During an average of 16.6 months (1-60 months) follow up period, four subjects relapsed. The mean MMP-7 (1.74-1.57 ng ml^-1), and TIMP-1 (1.92-1.84 ng ml^-1) levels were similar between both groups (p> 0.05). miRNA-24 expression was significantly decreased in the PSP group, when compared to the CG (0.16-1 2^-ΔΔCT,p< 0.05). In addition, the miRNA-21 expression was not different between the two groups (p> 0.05). In conclusion, the miRNA-24 levels were significantly decreased in children with PSP. Taken together, children with PSP, especially those with bullous disease, should be closely monitored in the long-term period.

Influence of meteorological factors on development of spontaneous pneumothorax

This study investigated the correlation between spontaneous pneumothorax (SP) and meteorological factors during different seasons. Patients who visited emergency rooms (ERs) in large cities in Korea and were discharged with SP from 2014 to 2016 were included in this study. Data on temperature, air pressure, and wind speed for each region were collected to obtain each factor's daily maximum, minimum, average, and changes. Days with more than 1 case of SP per million were referred to as pneumothorax days (PD) and those with less than 1 case of SP per million were referred to as non-pneumothorax days (NPD). The environmental factors were assessed on the same day (Day 0), 1 day prior (Day-1), and 2 days prior (Day-2) to PD and NPD per season. A total of 17,846 patients were included in this study. During winter, 4080 patients with SP visited the ERs of large cities with low population densities. The maximum temperature (0.16°C vs 0.76°C, 0.04°C vs 0.87°C, and 0.09°C vs 0.91°C), change in temperature (0.24°C vs 0.90°C, 0.38°C vs 0.81°C, and 0.41°C vs 0.83°C), average atmospheric pressure (0.16 vs 0.52 hPa, 0.25 vs 0.42 hPa, 0.34 vs 0.40 hPa), and maximum atmospheric pressure (0.15 vs 0.53 hPa, 0.28 vs 0.49 hPa, 0.33 vs 0.71 hPa) were greater for Day 0, Day-1, and Day-2, respectively, in PD than in NPD. Meanwhile, the average (0.31 vs 0.48 m/s, 0.28 vs 0.46 m/s, 0.20 vs 0.40 m/s), minimum (0.20 vs 0.31 m/s, 0.18 vs 0.25 m/s, 0.16 vs 0.25 m/s), and maximum (0.44 vs 0.67 m/s, 0.36 vs 0.71 m/s, 0.26 vs 0.58 m/s) wind speeds were slower, and the changes in wind speed (0.44 vs 0.67 m/s, 0.36 vs 0.71 m/s, 0.16 vs 0.25 m/s) were lower for all 3 days in PD than in NPD. High average and change in temperature, slow and unchanging wind speed, and high average and maximum atmospheric pressure were associated with SP. Since many findings of this study were contradictory to previous studies, it is assumed that the interaction of various factors affects SP.

Natural History of Contralateral Bullae/Blebs After Ipsilateral Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax: A Retrospective Cohort Study

BACKGROUND

Contralateral bullae/blebs are frequently found in patients who are scheduled to undergo ipsilateral video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP).

RESEARCH QUESTION

Should visible contralateral bullae/blebs be simultaneously resected when ipsilateral VATS bullectomy is performed?

STUDY DESIGN AND METHODS

In this single-center, retrospective cohort study, we included patients aged ≤ 30 years who underwent ipsilateral VATS for PSP from April 2009 to December 2019. Electronic medical records, radiograph images, and preoperative high-resolution CT images were reviewed. The primary end point was recurrence-free survival (no contralateral pneumothorax) after discharge of ipsilateral VATS for PSP, determined via Kaplan-Meier analysis. Recurrence was compared between the group with and that without contralateral bullae/blebs by using the log-rank test. A multivariable Cox proportional hazards model was constructed to investigate risk factors for contralateral pneumothorax.

RESULTS

Among 567 patients, contralateral pneumothorax occurred in 86 of them after ipsilateral VATS (15.2%) during a median follow-up period of 51.3 (interquartile range, 67.2) months. The 1-, 5-, and 10-year recurrence-free survival rates were 92.2%, 83.7%, and 79.9%, respectively. Contralateral recurrence was higher in the group with (82/455, 18.0%) than in that without (4/112, 3.6%) contralateral bullae/blebs (P < .001). Age (hazard ratio [HR], 0.701; 95% CI, 0.629-0.780; P < .001), current smoking (HR, 2.106; 95% CI, 1.158-3.831; P = .015), and the presence of bullae/blebs (increasing with size, HR, 4.818-8.980; all P < .05) were independent risk factors for contralateral pneumothorax. The annual rates of contralateral pneumothorax in the group with (4.0%) and in that without (0.7%) contralateral bullae/blebs declined over time.

INTERPRETATION

Although contralateral bullae/blebs were common in patients who underwent ipsilateral VATS for PSP and were statistically significantly associated with future pneumothorax, the annual rate of pneumothorax was 4.0% in such patients, and it decreased over time. Therefore, a conservative approach on unruptured contralateral bullae/blebs is recommended.

An uncommon cause of spontaneous pneumothorax in a febrile infant: Atypical Kawasaki disease

Kawasaki disease after respiratory viral infections is often observed but following Human Metapneumovirus infection (HMPV) is uncommon. Pulmonary presentation of Kawasaki disease without its classical features, though uncommon, can present as bronchopneumonia refractory to routine supportive care and antibiotics treatment. Lung collapse and pneumothorax as a pulmonary presentation of atypical Kawasaki disease are described very infrequently. We report an infant with atypical Kawasaki disease secondary to Human Metapneumovirus infection where the above pulmonary complications were observed.

Computed tomography in secondary spontaneous pneumothorax: Reading the fine print

Objectives:

To identify specific characteristics, distribution and associated findings of lesions causing secondary spontaneous pneumothorax (SSP)

Methods:

Computed tomography (CT) chest of 37 patients (between October 2011 and January 2020) was evaluated by two radiologists. They were classified into ‘Infectious’ and ‘Non-infectious’ groups, based on cause of pneumothorax. A scoring system (score 0–10) was proposed based on parameters which were statistically significant

Results:

Out of 37 patients with pneumothorax, 18 could be attributed to infectious aetiology and remaining 19 were due to noninfectious causes. The most common infectious cause of spontaneous pneumothorax was tuberculosis and noninfectious cause was chronic obstructive airway disease (COAD). Statistically significant difference was found for lesion wall thickness and presence of solid component between these two groups. No significant difference was found between both groups when comparing age, gender, lesion size and lesion distribution. The presence of pleural thickening, consolidation and mediastinal lymphadenopathy were statistically significant. Pleural effusion was never present in the noninfectious group. The area under receiver operating characteristic for differentiating patients in the two groups was 0.931 (standard error, 0.038; 95% CI, 0.856–1.000), and optimal threshold score for identifying patients with infectious causes was 4.5, with 77.8% sensitivity and 89.5% specificity

Conclusion:

Pneumothorax is almost equally common due to infectious and noninfectious causes. The most common infectious cause of spontaneous pneumothorax was tuberculosis and noninfectious cause was COAD. Based on certain CT findings, we have proposed a scoring system to differentiate between these two groups.

Treating Recurrent Pleural Disease: A Review of Indications and Technique for Chemical Pleurodesis for the Interventional Radiologist

Pleural space diseases such as recurrent pleural effusion and pneumothorax inflict a significant symptomatic burden on patients. Guidelines and studies are available to guide best practices in the setting of refractory effusions, mostly in the setting of malignancy, and recurrent pneumothorax. Less data is available to guide management of refractory transudative effusions. Recurrent pleural effusions can be treated with tunneled pleural catheters or catheter-based pleurodesis. While refractory transudative effusions can benefit from tunneled pleural catheter, this is an area of ongoing research. Regarding recurrent pneumothorax, video-assisted thoracoscopic surgery (VATS) pleurodesis using mechanical or laser/argon beam coagulation is the most effective means of preventing recurrence. Catheter based pleurodesis, a less invasive means of administering chemical sclerosant via percutaneous thoracostomy tube, is only used when surgery is not an option. However, both approaches induce inflammation of the pleural space, resulting in adherence of the parietal and visceral pleura to prevent fluid or air re-accumulation. This article will discuss catheter based chemical pleurodesis geared toward the interventional radiologist, including a review of disease processes and indications, technique, and strategies to mitigate complications as well as a literature review comparing percutaneous chemical pleurodesis to other therapies.

Pneumopericardium, Epidural Pneumatosis, and Muscular Emphysema: Rare Complications of Spontaneous Pneumomediastinum Due to Refractory Hyperemesis Gravidarum

Various complications of hyperemesis gravidarum and pneumomediastinum have been documented in the literature. Commonly, these cases resolve spontaneously or with the use of antiemetics and supportive care. In rare instances, these symptoms persist into the second trimester and are associated with an increased risk of complications. Herein, we present a case of a healthy 20-year-old female with a history of marijuana use who presented with intractable nausea and vomiting and was found to have multiple rare complications of spontaneous pneumomediastinum.

Spontaneous pneumothorax with pulmonary Langerhans cell histiocytosis (PLCH) in an adult heavy cigarette smoker-A case report

Pulmonary Langerhans cell histiocytosis is a rare disease caused by the proliferation of CD1a‐positive histiocyte‐like cells infiltrating the lung's interstitial layer. Most cases affect young to middle‐aged persons, especially adult heavy cigarette smokers. A 49‐year‐old male heavy smoker (40 pack‐year), with non‐productive cough, dyspnoea and desaturation, presented with a right‐sided pneumothorax on chest x‐ray with total atelectasis. Chest computed tomography (CT) revealed bilateral multiple thick‐walled infiltrated cysts and multiple ground‐glass nodules throughout the entire lung. Surgery with minimal invasive thoracoscopic lung biopsy and pleurodesis was performed. Pathology showed histiocyte‐like cells aggregates in the pulmonary parenchyma. Immunohistochemical stain demonstrated CD1a(+), S100(+) and CD68(+). After 3 months of smoking cessation, clear improvement was evidenced with a chest CT showing bilateral multiple thin‐walled rounded cysts and multiple ground‐glass nodules that are smaller in size and decreased in numbers. Early minimal invasive thoracoscopic lung biopsy and pleurodesis can also be a choice if the development of secondary spontaneous pneumothorax occurs.

A holistic investigation of the global outcomes of spontaneous pneumothorax during 1980-2021, including the COVID-19 pandemic A bibliometric approach

BACKGROUND

During coronavirus pandemic, despite the increase in the number of studies on spontaneous pneumothorax (SP), there is not enough bibliometric study in the literature. In this study, it was aimed to analyze scientific articles published on SP.

METHODS

Studies published on SP between 1980 and 2021 were obtained from the Web of Science database and analyzed using statistical and bibliometric methods. Spearman correlation coefficient was used for correlation studies. The exponential smoothing estimator was used to forecast publication trend for coming years. Network visualization maps were used to analyze citations and identify trending topics.

RESULTS

A total of 2422 publications were found. 1403 (57.9%) of these publications were articles. The articles on SP have increased with a non-linear trend in recent years. The top 5 contributors to the literature were USA (231, 16.4%), Japan (161, 11.4%), United Kingdom (98, 6.9%), France (81, 5.7%), and Taiwan (78, 5.5%). The top 3 most active institutions were National Taiwan University Hospital (22, 1.5%), Catholic University Korea (19, 1.3%), and National Taiwan University (19, 1.3%). The top 3 journals that published the most articles were Chest (51), Annals of Thoracic Surgery (46), and Journal of Thoracic Disease (45). The most studied subjects were primary SP, recurrence, thoracoscopy, pleurodesis, video-assisted thoracoscopic surgery, COVID-19, video-assisted thoracic surgery, chest tube(s), and secondary spontaneous pneumothorax. According to trend topics analysis, the keywords studied in recent years are COVID-19, chest tubes, pneumonia, subcutaneous emphysema, risk factors, dyspnea, primary SP, FLCN gene, tension pneumothorax, uniportal, postoperative recurrence, secondary spontaneous pneumothorax, chronic obstructive pulmonary disease, and uniportal.

CONCLUSION

In this comprehensive bibliometric study, we summarized 1403 articles about SP, which has an increasing trend in the number of articles during the COVID-19 pandemic process. This article can be a useful resource for clinicians and scientists through presenting a summary of worldwide studies related to SP, including the ones during COVID-19 pandemic.

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.

Air leak with COVID-19 - A meta-summary

INTRODUCTION

There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes.

METHODS

The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium).

RESULTS

A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p < 0.001) and required escalation of respiratory support (39%, p = 0.006).

CONCLUSION

Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.

Unexpected Histopathological Diagnosis of Placental Transmogrification of the Lung after Bullectomy for Recurrent Spontaneous Pneumothorax: A Case Report and Literature Review

We report a 33-year-old man who presented with recurrent right pneumothorax. Computed tomography (CT) showed the presence of a large bulla with a maximum diameter of 8 cm in the right middle lobe; he subsequently underwent bullectomy. Histopathology revealed that pulmonary parenchyma adjacent to the bulla represented nodular proliferation of clear cells characterized by a papillary structure resembling placental chorionic villi. Immunohistochemically, clear cells were positive for CD10, suggesting placental transmogrification of the lung (PTL). We reviewed 36 surgical cases of PTL, and only 2 cases (5.6%), including our case, were operated for spontaneous pneumothorax. Bullous lesions secondary to PTL tend to appear as unilateral large cystic masses in non-upper lobes, which is atypical for primary spontaneous pneumothorax (PSP). Although PTL is considered a very rare cause of secondary pneumothorax, we must carefully differentiate this condition.

A Case Report of Life-Threatening Hemopneumothorax as a Result of Spinal Manipulation Performed by Chiropractor

Chiropractic is a very popular alternative medicine practice in the United States. Despite that, this practice has been associated with several complications raising concerns for its safety. We report the case of an otherwise healthy 36-years-old, tall and thin male who presented with sudden onset shortness of breath associated with chest pain two days after chiropractic spinal manipulation. Chest imaging revealed left-sided hemopneumothorax required treatment with left-sided chest tube placement. Patients with a high risk of developing primary or secondary pneumothorax should consider avoiding chiropractic chest or spinal manipulations due to possible complications.

Pleurabrade: A Spiral Brush for Mechanical Pleurodesis and a Review of the Literature

Background  While the optimal treatment for primary spontaneous pneumothorax remains unclear, mechanical pleurodesis is a well-established treatment. The Pleurabrade is a spiral brush designed for mechanical pleurodesis during thoracoscopy. We present two patients who underwent mechanical pleurodesis with the Pleurabrade. Case Description  Two patients with spontaneous pneumothorax underwent operative intervention including mechanical pleurodesis with the Pleurabrade. Chest tubes were removed within 48 hours postoperatively and they were discharged home. Both patients remain recurrence free at 11 and 22 months, respectively. Conclusion  While further testing is needed, these case reports and operative video highlight the Pleurabrade as an efficient device for thoracoscopic mechanical pleurodesis.

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.

The first reported use of autologous blood pleurodesis for treatment of prolonged air leak in COVID-19-related spontaneous pneumomediastinum and pneumothorax: A case report

Spontaneous pneumomediastinum (SPM) and pneumothorax (PTX) have been described as rare complications of COVID-19 pneumonia. We present a case of COVID-19 pneumonia which was complicated by SPM on Day 13 of admission with progression to spontaneous PTX 2 days later which necessitated intercostal chest drainage. It was complicated by prolonged air leak (PAL) for the next 9 days despite being on continued low-dose suction and another additional larger bore intercostal drain inserted. Surgical pleurodesis was not an option in view of anaesthesia and operative risk expected in COVID-19. In view of this, autologous blood pleurodesis (ABP) to address the alveolar pleural leak was opted. ABP has been previously used for PAL in cases of non-COVID-19-related intractable spontaneous PTX. The air leak ceased with subsequent lung re-expansion, with good clinical and radiological improvement. He was discharged well after resolution of PTX which required intercostal drain for a total of 15 days.

The role of telomerase in the etiology of primary spontaneous pneumothorax

Background

This study aims to investigate the role of telomerase activity in the risk of primary spontaneous pneumothorax, which is most frequently encountered in the practice of thoracic surgery.

Methods

A total of 61 patients (56 males, 5 females; median age: 29.4 years; range, 17 to 43 years) who underwent treatment for primary spontaneous pneumothorax and 19 age- and sex-matched healthy controls (10 males, 9 females; median age: 29.1 years; range, 23 to 43 years) were included in this prospective study between January 2018 - August 2018. Telomerase activity was evaluated with enzyme-linked immunosorbent assay. The correlation between telomerase activity and clinical and demographic parameters was examined.

Results

The mean serum telomerase level was 3.4±0.6 ng/mL in the primary spontaneous pneumothorax group and 1.9±0.5 ng/mL in the control group, indicating significantly higher levels in the patient group (p<0.001). There was no significant association between the telomerase levels and presence of blebs and/or bullae on thoracic computed tomography, extent of pneumothorax, laterality (right, left, or bilateral), and pack years of cigarette smoking.

Conclusion

Telomerase levels of patients with primary spontaneous pneumothorax are significantly higher than healthy individuals. Future genetic studies may ultimately clarify a potential relationship between primary spontaneous pneumothorax and short telomere syndrome.

Spontaneous Pneumothorax: Management and Prognosis

This review article will review treatment and prognosis of spontaneous pneumothorax in dogs and cats. The advantages of surgical and medical management in dogs and cats, as well as current treatment practices, including autologous blood pleurodesis and small-bore chest tubes, will be discussed.

Conservative management of a complete primary spontaneous pneumothorax

Large primary spontaneous pneumothorax (PSP) has traditionally been managed with needle aspiration, chest tube drainage and, in refractory cases, thoracic surgery. A recent randomized trial, however, provided evidence that a conservative observational approach was safe and 85% of patients recovered without requiring pleural drainage interventions. A conservative approach provided similar re-expansion rates at 8 weeks compared with chest tube drainage and offered the advantages of early hospital discharge, fewer days off work and avoidance of procedural risks. Nonetheless, clinicians are understandably anxious with conservative (non-drainage) management for patients with very large pneumothorax. Here, we report a patient with a right-sided PSP and total lung collapse that was managed successfully without intervention with minimal time in hospital or off work.

Thoracoscopy for Spontaneous Pneumothorax

Video-assisted thoracic surgery (VATS) is the treatment of choice for recurrence prevention in patients with spontaneous pneumothorax (SP). Although the optimal surgical technique is uncertain, bullous resection using staplers in combination with mechanical pleurodesis, chemical pleurodesis and/or staple line coverage is usually undertaken. Currently, patient satisfaction, postoperative pain and other perioperative parameters have significantly improved with advancements in thoracoscopic technology, which include uniportal, needlescopic and nonintubated VATS variants. Ipsilateral recurrences after VATS occur in less than 5% of patients, in which case a redo-VATS is a feasible therapeutical option. Randomized controlled trials are urgently needed to shed light on the best definitive management of SP.

Subcutaneous emphysema, pneumothorax and pneumomediastinum as a complication of an asthma attack

Introduction:

Simultaneous subcutaneous emphysema, spontaneous pneumothorax, and pneumomediastinum are complications rarely observed synchronously during an acute exacerbation of bronchial asthma. Although spontaneous pneumothorax has already been reported in asthma patients in the literature, its concurrence with subcutaneous emphysema and pneumomediastinum is extremely rare except for iatrogenic conditions.

Case Study:

We describe a patient who presented to the emergency room with progressive dyspnea and chest pain. Three days before, she consulted her general physician with a history of violent dry cough and wheezing. An acute asthma exacerbation was diagnosed, and an inhaled short-acting beta 2 agonist and oral prednisone were prescribed. The patient developed simultaneous subcutaneous emphysema, spontaneous pneumothorax, and pneumomediastinum, a rare complication of an asthma attack.

Conclusions:

Our aim is to emphasize that occult pneumothoraces should be considered in a patient presenting with an acute asthma attack failing to respond to conventional medical therapy.

Spontaneous Pneumothorax: Pathophysiology, Clinical Presentation and Diagnosis

Spontaneous pneumothorax, which may have an acute or insidious onset in dogs and cats, results in respiratory difficulty and has the potential to be life threatening.^1-3 Dogs commonly develop spontaneous pneumothorax due to bullae or blebs, while cats typically have underlying inflammatory disease, like feline allergic airway disease. Urgent therapeutic intervention is essential in animals with respiratory distress. The recommended therapeutic strategies are typically different in each of these species due to underlying etiology. The first part of this review article will focus on physiology, clinical presentation, and diagnosis of spontaneous pneumothorax in dogs and cats. Advances in diagnostics, especially the recent utility of point of care ultrasound, will be discussed. The second part of the series will provide an overview of therapeutic options and management of patients with spontaneous pneumothorax, as well as information on prognosis.

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

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

Secondary Spontaneous Pneumothorax in a COVID-19 Recovered Patient

Coronavirus disease 2019 (COVID-19) is an infectious disease primarily affecting the lungs with a spectrum of post-viral complications. There are well-described examples of pneumonia, empyema, pneumomediastinum, and spontaneous pneumothorax cases following COVID-19 infection within the literature. However, there is insufficient evidence implicating the cause of spontaneous pneumothorax in COVID-19 recovered patients. We present a previously infected COVID-19 patient who developed a secondary spontaneous pneumothorax two weeks after recovering. A review of the literature for similar cases was limited and therefore includes a summary of recommendations. Overall, the literature establishes that pneumothorax can occur during different phases of COVID-19 in patients without a history of pulmonary disease or barotrauma and is not necessarily associated with the severity of the viral infection. As in the case of our patient, the culmination of chronic inflammatory changes and an acute exacerbation from COVID-19 further predisposed him to a secondary spontaneous pneumothorax. In summary, all cases of recovered COVID-19 patients should maintain close follow-up with their physician and seek medical attention if acute respiratory symptoms develop.

Air leak with COVID-19 - A meta-summary

INTRODUCTION

There are various reports of air leaks with coronavirus disease 2019 (COVID-19). We undertook a systematic review of all published case reports and series to analyse the types of air leaks in COVID-19 and their outcomes.

METHODS

The literature search from PubMed, Science Direct, and Google Scholar databases was performed from the start of the pandemic till 31 March 2021. The inclusion criteria were case reports or series on (1) laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, (2) with the individual patient details, and (3) reported diagnosis of one or more air leak syndrome (pneumothorax, subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, pneumopericardium).

RESULTS

A total of 105 studies with 188 patients were included in the final analysis. The median age was 56.02 (SD 15.53) years, 80% males, 11% had previous respiratory disease, and 8% were smokers. Severe or critical COVID-19 was present in 50.6% of the patients. Pneumothorax (68%) was the most common type of air leak. Most patients (56.7%) required intervention with lower mortality (29.1% vs. 44.1%, p = 0.07) and intercostal drain (95.9%) was the preferred interventional management. More than half of the patients developed air leak on spontaneous breathing. The mortality was significantly higher in patients who developed air leak with positive pressure ventilation (49%, p < 0.001) and required escalation of respiratory support (39%, p = 0.006).

CONCLUSION

Air leak in COVID-19 can occur spontaneously without positive pressure ventilation, higher transpulmonary pressures, and other risk factors like previous respiratory disease or smoking. The mortality is significantly higher if associated with positive pressure ventilation and escalation of respiratory support.

An evidence-based review of primary spontaneous pneumothorax in the adolescent population

Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.

[Are multiple trichodiscomas/fibrofolliculomas the Birt-Hogg-Dubé syndrome?]

Birt-Hogg-Dubé syndrome is a rare autosomal dominant disease caused by a mutation in the FLCN gene and presents with a triad of multiple fibrofolliculomas, trichodiscomas, and masses that clinically resemble fibroepithelial polyps (acrochordones), accompanied by an increased risk of kidney tumors and lung cysts. The paper provides a literature review supplemented by clinical cases and the morphological pattern of skin lesions. It presents the clinical and morphological features of cutaneous manifestations of the syndrome and gives diagnostic criteria.