Spontaneous pneumothorax: time for some fresh air

Conventional teaching on the mechanisms and treatment of spontaneous pneumothorax is either obviously wrong or based on a misunderstanding of the natural history of the condition. Spontaneous pneumothorax is a generally benign, self‐limiting condition where conservative management should be considered. If intervention is needed, medical thoracoscopy might be the procedure of choice.     

A retrospective comparison between digital to conventional drainage systems for secondary spontaneous pneumothorax related to diffuse interstitial lung disease

Introduction

Secondary spontaneous pneumothorax (SSP) occurs as one of the complications associated with interstitial pneumonia (IP). Chest drainage is performed when there is a large volume of air in the pleural space. Notably, SSP with IP (SSP-IP) is frequently not curable by chest drainage only. A digital drainage system (DDS) provides an objective evaluation of air leakage and maintains a pre-determined negative pressure, compared to an analog drainage system (ADS). Few studies have reported the effectiveness of DDS in the treatment of SSP-IP. This study aimed to assess the usefulness of DDS for SSP-IP.

Methods

This retrospective study included patients with SSP-IP who had undergone chest drainage. We reviewed the included patients' medical records, laboratory data, computed tomography findings, and pulmonary function data.

Results

DDS was used in 24 patients and ADS in 49 patients. The mean duration of chest drainage was 11.4 ± 1.9 days in the DDS group and 14.2 ± 1.3 days in the ADS group, which was not significantly different (p = 0.218). Surgery, pleurodesis, and/or factor XIII administration were performed in 40 patients. Additionally, five (20.8%) patients in the DDS group and nine (18.4%) in the ADS group had a recurrence of pneumothorax within 4 weeks (p = 1.000). One patient (14%) in the DDS group and six (12.2%) in the ADS group (p = 0.414) were cured of pneumothorax but later died.

Conclusion

DDS did not demonstrate a significant difference in the shortening of chest drainage duration. Further study is needed to validate the results of this study.     

Chronic chest pain and paresthesia after video-assisted thoracoscopy for primary pneumothorax

BackgroundThis study aims to identify clinical and surgical risk factors for chronic chest pain and paresthesia after video thoracoscopic surgery for primary spontaneous pneumothorax.MethodsWe retrospectively collected the data of 1,178 consecutive patients <40-years-old undergoing video thoracoscopic surgery for primary spontaneous pneumothorax in 9 Italian centers in 2007–2017. Cases with <2-month follow-up were excluded, leaving 920 patients [80% male; median age: 21 (IQR, 18–27) years] for statistical analysis. The following risk factors for chronic chest pain and chronic paresthesia were assessed by univariable and multivariable Cox regression model: age, gender, cannabis smoking, video thoracoscopy ports number, pleurodesis technique (partial pleurectomy/pleural electrocauterization/pleural abrasion/talc poudrage), chest tube size (24/28 F), postoperative chest tube stay.ResultsBlebs/bullae resection with pleurodesis was performed in 732 (80%) cases; pleurodesis alone in 188 (20%). During a median follow-up of 68 (IQR: 42–95) months, chronic chest pain developed in 8% of patients, chronic chest paresthesia in 22%; 0.5% of patients regularly assumed painkillers. Chronic chest pain was independently associated with partial pleurectomy/pleura abrasion (P<0.001) and postoperative chest tube stay (P=0.019). Chronic chest paresthesia was independently associated with pleurodesis by partial pleurectomy (P<0.001), chest tube stay (P=0.035) and 28 F chest tube (P<0.001).ConclusionsAfter video thoracoscopic surgery for primary spontaneous pneumothorax, the incidence of chronic chest pain and paresthesia was significantly lower when pleurodesis was performed by pleural electrocauterization or talc poudrage, and chest tube was removed early. A 24 F chest tube was associated with lower risk of chronic chest paresthesia.     

Early detection of delayed pneumothorax using lung ultrasound after transthoracic needle lung biopsy: A prospective pilot study

ObjectivesDelayed pneumothorax can cause an emergency room visit and be life‐threatening in case of tension pneumothorax after transthoracic needle biopsy. We hypothesized that most delayed pneumothoraces are diagnosed by later enlargement of occult pneumothorax due to the low diagnostic accuracy of a chest X‐ray. Lung ultrasound is a highly accurate tool for detection of pneumothorax. The aim of this study is to evaluate the diagnostic accuracy of lung ultrasound for prediction of delayed pneumothorax on chest X‐ray.MethodsThis prospective pilot study was performed between April 2020 and July 2020 in Chungnam National University Hospital. The participants underwent chest X‐rays and lung ultrasound before, immediately after, and 3 h after transthoracic needle biopsy, respectively. The presence or absence of lung sliding at each anterior BLUE‐point on an ultrasound and pneumothorax on a chest X‐ray was recorded.ResultsPneumothorax occurred in 17 (35.4%) participants, and three of them underwent chest tube replacement. Of the 17 (35.4%) cases of pneumothorax, five participants (10.4%) were diagnosed with delayed pneumothorax. Three out of five participants showed loss of lung sliding on lung ultrasound before the diagnosis of delayed pneumothorax. Therefore, the sensitivity of lung sliding on lung ultrasound for early detection of delayed pneumothorax was 60%. Two undetected cases were asymptomatic, and the pneumothoraces were exceedingly small and recovered spontaneously. Thus, sensitivity for detection of clinically meaningful delayed pneumothorax requiring chest tube replacement was 100% (2/2).ConclusionLung ultrasound can probably predict clinically meaningful delayed pneumothorax after transthoracic needle lung biopsy.     

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

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

Analysis of factors predicting the application of chemical pleurodesis for pneumothorax: An observational study

Chemical pleurodesis is performed in pneumothorax patients to treat nonresolving air leakage or prevent recurrence. However, factors that might predict the need for chemical pleurodesis remain unknown. Therefore, this study investigated predictive factors for the application of chemical pleurodesis for pneumothorax.We retrospectively analyzed 401 adult pneumothorax patients who underwent chest tube drain insertion during hospitalization at Fukujuji Hospital from January 2016 to December 2020. The patients were divided into 3 groups: the pleurodesis group, comprising 89 patients treated with chemical pleurodesis; the nonpleurodesis group, comprising 206 patients treated without chemical pleurodesis; and the surgical group, comprising 106 patients treated surgically. Data for patients in the pleurodesis group were compared to those in the nonpleurodesis or surgical group, and a predictive score of the application of chemical pleurodesis for pneumothorax was developed.Compared with the nonpleurodesis group, in the pleurodesis group, patient age was higher (P < .001), emphysema (n = 33 (37.1%) vs 70 (34.0%), P = .045), and interstitial pneumonitis (n = 19 (21.3%) vs 19 (9.2%), P = .022) were more common causes, and chest tube suction was more common (n = 78 (87.96%) vs n = 123 (59.7%), P < .001). Similar results were found between the pleurodesis and surgical groups. We developed a score for predicting the application of chemical pleurodesis for pneumothorax, including the following factors: age ≥55 years; presence of emphysema and/or interstitial pneumonitis; and use of chest tube suction. The score for the pleurodesis group showed a high area under the receiver operating characteristic curve compared with that for the nonpleurodesis group (0.776 [95% confidence interval]: 0.725–0.827). With a score of 2 as the cutoff value, the sensitivity was 91.0% and the specificity was 52.4%. In a comparison between the pleurodesis and surgical groups, the predicting score showed the high AUC of 0.904 (95% confidence interval: 0.863–0.945).This study reveals predictive factors for the application of chemical pleurodesis and provides a predictive score including 3 factors.     

Severe re-expansion pulmonary edema after chest tube insertion for the treatment of spontaneous pneumothorax: A case report

Rationale:Re-expansion pulmonary edema (REPE) is a rare complication after chest tube insertion for the treatment of spontaneous pneumothorax. However, this complication can be life threatening when it occurs. Therefore, it is necessary to recognize REPE early and treat it appropriately. In the present study, we report a severe REPE case occurring after chest tube insertion in a patient with spontaneous pneumothorax.Patient concerns:A 27-year-old male patient visited out hospital with chest pain on the left, which had started a week ago. After diagnosed with pneumothorax and having chest tube insertion, the patient complained of sudden shortness of breath, persistent cough, foamy sputum, and vomiting.Diagnosis:Based on the symptoms and imaging findings, the patient was diagnosed as REPE.Interventions:After the condition of the patient deteriorated rapidly, he was transferred to intensive care unit and then mechanical ventilation and conservative treatment were performed after endotracheal intubation.Outcomes:After mechanical ventilation and conservative treatment in the intensive care unit, the symptoms and radiological findings improved, and then mechanical ventilation was weaned and the chest tube was removed from the patient. However, due to recurrent pneumothorax after removal of the chest tube, video assisted thoracoscopic surgery (VATS) wedge resection was performed. At 6 months post-operative follow up, he was well with normal radiological findings.Lessons:REPE occurs rarely, but once it does, it causes a serious condition that can be life-threatening. Therefore, patients with the risk factors related to it should receive a closed observation after chest tube insertion. Moreover, if REPE occurs, appropriate treatments should be carried out by recognizing it early.     

老年自发性气胸75例临床特点分析

目的探讨老年自发性气胸中继发性气胸与原发性气胸的临床特点。方法回顾我院2001年2月至2006年2月收治的75例老年自发性气胸患者的临床资料,其中继发性气胸48例,为A组,原发性气胸27例,为B组,将两组的临床特点进行分析比较。结果（1）临床表现：A组出现气急、心悸、呼吸衰竭和不稳定型气胸的比例分别为66.7%（32/48）、56.3%（27/48）、43.8%（21/48）和70.8%（34/48）,B组分别为11.1%（3/27）、18.5%（5/27）、7.4%（2/27）和18.95%（5/27）。A组较B组明显增加,差异有显著性。（2）A组气胸类型以交通性气胸为主,B组以闭合性气胸为主,两组在气胸压缩面积、复发率等方面相比无显著性差异,但A组的误诊率为16.8%（8/48）,较B组的0（0/27）明显增高,差异有显著性。（3）治疗与归转：A组平均治愈时间为24.2±2.1天较B组11.4±3.5天明显增加,差异有显著性。A组多采用胸腔闭式引流治疗,而B组多采用胸穿抽气治疗。两组病人经积极治疗后其治愈率和死亡率无差别。结论老年继发性气胸较原发性气胸症状重,临床表现不典型,易误诊,须及时诊断和治疗。     

经胸腔镜手术与开胸手术在治疗自发性气胸的效果

目的探讨胸腔镜手术与开胸手术在治疗自发性气胸的不同效果。方法将我科自发性气胸210例分为两组,其中应用胸腔镜115例为VATS组,同期开胸手术治疗自发性气胸95例为开胸组。比较两组术中切口长度、出血量、手术时间等,术后引流管拔管时间,患者的体温,应用镇静剂情况,住院天数,住院费用等。结果两组除住院费用无统计学意义（P〉0.05）外,其余各项观察指标都有统计学意义。结论从VATS组手术与开胸手术在治疗自发性气胸各个方面效果看,具有切口小、出血量少、手术时间短、恢复快等优点,值得推广。     

Spontaneous pneumothorax as the first manifestation of lung cancer: two case report

Spontaneous pneumothorax (SP), as the first manifestation of lung cancer, is relatively rare, with reported occurrence rate of between 0.03% and 0.05%. The mechanism of concurrent pneumothorax with lung cancer is not clear, however several theories were proposed, including tumor necrosis mechanism and rupture of the bulla which contains tumor. We herein report two cases of lung cancer, in which the initial manifestations was only limited to SP. Without any radiologic abnormalities preoperatively, wedge resection of bullatous lung and subsequent histologic study followed. Pathologic study revealed the presence of bullatous change of the lung and combined lung cancer.     

Utilizing the chest tube insertion site as the site of initial trocar insertion with an optical-access trocar in video-assisted thoracoscopic surgery for spontaneous pneumothorax

BackgroundIn video-assisted thoracoscopic surgery for spontaneous pneumothorax, the initial trocar can be inserted into the pleurocutaneous fistula formed during preoperative chest drain placement. The use of an optical-access trocar to replace the initial trocar and chest tube may have a greater success rate than blind trocar insertion. Therefore, the present study aimed to evaluate the safety and feasibility of the use of an optical-access trocar to replace the initial trocar and chest tube during surgery for spontaneous pneumothorax.MethodsThe present study included 28 patients who underwent video-assisted thoracoscopic surgery for spontaneous pneumothorax following preoperative chest drain placement between April, 2017 and December, 2019. At the start of surgery, the chest drain was removed and the initial trocar was inserted into the pleural cavity. An optical-access trocar with an inner diameter of 5 mm was used as the initial trocar. To use a 0-degree endoscope for the optical-access trocar, this procedure requires the preparation of both, a 0-degree endoscope and a 30-degree endoscope. To evaluate the safety of the optical view method, the lungs and chest wall adjacent to the initial trocar insertion site were observed from the second trocar.ResultsThe initial trocar could be inserted through the chest tube insertion site in 26 out of 28 cases (92.9%). No instances of lung injury or pulsatile bleeding around the initial trocar were observed. No cases of postoperative wound infection or wound dehiscence were observed.ConclusionsThe use an optical-access trocar as the initial trocar when replacing a preoperatively placed chest tube is safe and feasible during video-assisted thoracoscopic surgery for spontaneous pneumothorax.     

老年气胸合并慢阻肺的诊疗临床分析

目的研究老年气胸合并慢性阻塞性肺疾病患者的临床特点及治疗方法。方法对我院2016年1月至2018年12月收治的30例老年自发性气胸患者的临床资料进行回顾性分析。结果30例老年患者中,治愈28例,其中完全肺复张者25例,肺复张达80%~90%者3例,因严重感染或呼吸衰竭而死亡2例。结论合并有慢性阻塞肺疾病病史的老年气胸患者发病较突然,病程进展较快,易误诊且病情凶险,尽早给予胸腔闭式引流等对症治疗有助于疾病的好转。     

慢性阻塞性肺疾病合并自发性气胸的治疗方式探讨

目的探讨和比较胸腔镜手术和传统开胸手术治疗慢阻肺并发自发性气胸患者的临床治疗效果。方法分析在我院胸外科接受治疗的慢阻肺患者临床资料。入组患者根据治疗方案随机分为两组,即胸腔镜治疗组(观察组)和传统开胸治疗组(对照组)。比较两组患者的基线资料、临床状况、肺功能相关指标、并发症。结果本研究共纳入研究对象90例,其中观察组和对照组各45例。观察组患者的手术时间、术后疼痛时间、术中出血量、引流管时间及住院时间均低于对照组,具有统计学差异;治疗前两组患者的MVV、FVC、FEV1均无统计学差异(P均0.05),而治疗2周后观察组患者的MVV(t=6.430,P0.01)、FVC(t=2.173,P=0.032)、FEV1(t=3.033,P=0.003)均显著高于对照组;两组患者的术后并发症均无统计学差异(P均0.05)。结论对于慢阻肺合并有自发性气胸的患者,行胸腔镜手术治疗效果明显优于传统开胸手术。     

电视胸腔镜治疗自发性气胸62例分析

目的总结电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）治疗自发性气胸的优越性。方法 2005年8月～2010年2月对62例自发性气胸行VATS,肺大疱用切割缝合器切除,部分肺大疱用丝线结扎。结果术后平均住院7.4d,胸腔引流管放置平均3.6d。术后并发症2例（均为部分肺不张）。全部病例治愈,随访5个月～4年,无复发。结论 VATS是彻底治疗自发性气胸的最佳方法,其疗效确切,具有创伤小、恢复快等优点。     

高龄肺癌患者术后化疗方案的可行性分析

目的分析高龄肺癌患者术后化疗方案的可行性,并对于不同化疗方案进行对比。方法采取前瞻性研究法,选取我科2011年1月至2013年1月300例非小细胞肺癌(NSCLC)术后接受化疗的高龄患者,随机分为实验组和对照组,实验组予以GP方案进行化疗,对照组予以NP方案,所有患者均化疗4个疗程。对比两组患者化疗前后治疗情况。结果两组患者化疗4个周期后的CD+4和CD+4/CD+8均显著高于治疗前,P0.01;实验组化疗4个周期后各指标均优于对照组P0.05。两组患者化疗不良反应发生率无显著差异,P0.05。结论对于高龄肺癌患者予以术后采取GP方案化疗,优于NP方案。     

Reticulum-cell sarcoma with intracardiac metastases. Case with angiocardiographic improvement after chemotherapy.

A prospective, multiple observer auscultatory and phonocardiographic study of 100 patients with pericardial friction confirmed the dominant prevalence of triphasic pericardial rubs (56 percent of patients with sinus rhythm). In 9 of 33 patients with various biphasic rub patterns there was summation of the ventricular diastolic rub with the atrial systolic rub, concealing an additional 10 percent of potential triphasic friction. Fourteen of 15 monophasic rubs were audible or recordable only during ventricular systole. Rubs were best heard along the left sternal border in 84 percent of cases and tended to be louder during inspiration than during expiration; in 35 cases there was no respiratory predilection. Twenty-three rubs were palpable. Ten rubs occurred in patients with pericardial effusion, five of whom had tamponade. Extension of the neck did not have a dependable effect on rub intensity.     

Cytoreductive surgery and intraperitoneal chemotherapy for colorectal peritoneal metastases

AIM: To systematically review the available evidence regarding cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) for colorectal peritoneal metastases (CPM).METHODS: An electronic literature search was carried out to identify publications reporting oncological outcome data (overall survival and/or disease free survival and/or recurrence rates) following CRS and IPC for treatment of CPM. Studies reporting outcomes following CRS and IPC for cancer subtypes other than colorectal were only included if data were reported independently for colorectal cancer-associated cases; in addition studies reporting outcomes for peritoneal carcinomatosis of appendiceal origin were excluded.RESULTS: Twenty seven studies, published between 1999 and 2013 with a combined population of 2838 patients met the predefined inclusion criteria. Included studies comprised 21 case series, 5 case-control studies and 1 randomised controlled trial. Four studies provided comparative oncological outcome data for patients undergoing CRS in combination with IPC vs systemic chemotherapy alone. The primary indication for treatment was CPM in 96% of cases (2714/2838) and recurrent CPM (rCPM) in the remaining 4% (124/2838). In the majority of included studies (20/27) CRS was combined with hyperthermic intraperitoneal chemotherapy (HIPEC). In 3 studies HIPEC was used in combination with early post-operative intraperitoneal chemotherapy (EPIC), and 2 studies used EPIC only, following CRS. Two studies evaluated comparative outcomes with CRS + HIPEC vs CRS + EPIC for treatment of CPM. The delivery of IPC was performed using an “open” or “closed” abdomen approach in the included studies.CONCLUSION: The available evidence presented in this review indicates that enhanced survival times can be achieved for CPM after combined treatment with CRS and IPC.