Management of spontaneous pneumothorax: state of the art.

Spontaneous pneumothorax remains a significant health problem. However, with time, there have been improvements in pathogenesis, diagnostic procedures and both medical and surgical approaches to treatment. Owing to better imaging techniques, it is now clear that there is almost no normal visceral pleura in the case of spontaneous pneumothorax, and that blebs and bullae are not always the cause of pneumothorax. In first episodes of primary spontaneous pneumothorax, observation and simple aspiration are established first-line therapies, as proven by randomised controlled trials. Aspiration should be better promoted in daily medical practice. In the case of recurrent or persistent pneumothorax, simple talc poudrage under thoracoscopy has been shown to be safe, cost-effective and no more painful than a conservative treatment using a chest tube. There are also new experimental data showing that talc poudrage, as used in Europe, does not lead to serious side-effects and is currently the best available pleural sclerosing agent. Alternatively, surgical techniques have considerably improved, and are now less invasive, especially due to the development of video-assisted thoracoscopic surgery. Studies suggest that video-assisted thoracoscopic surgery may be more cost-effective than chest tube drainage in spontaneous pneumothorax requiring chest tube drainage, although it is more expensive than simple thoracoscopy and requires general anaesthesia, double-lumen tube intubation and ventilation. Recommendations are made regarding the treatment of pneumothorax. In secondary or complicated primary pneumothorax, i.e. recurrent or persistent pneumothorax, some diffuse treatment of the visceral pleura should be offered, either by talc poudrage under thoracoscopy or by video-assisted thoracoscopic surgery. Moreover, all of these new techniques should be better standardised to permit comparison in randomised controlled studies.     

Pneumothorax: experience with 1,199 patients

OBJECTIVE: To study the outcome of pneumothorax managed in a university-affiliated metropolitan medical center. DESIGN: A retrospective review. SETTING: Busy metropolitan medical center. PATIENTS AND METHODS: Records of 1,199 patients with pneumothorax were reviewed and analyzed. RESULTS: Primary spontaneous pneumothorax occurred in 218 patients, secondary spontaneous pneumothorax occurred in 505, traumatic in 403, and iatrogenic in 73. Ninety-six patients with small pneumothorax (8%) were managed by observation, and 1,103 patients (92%) were managed by tube thoracostomy. Drainage of the pleural cavity was continued for 1 to 7 days in 893 patients (81%), 8 to 10 days in 176 patients (16%), and > 10 days in 34 patients (3%). Drainage for > 10 days was classified as persistent pneumothorax. In these 34 patients and in 132 others with a second ipsilateral recurrence (a total of 166 patients), direct pleuroscopy was performed. The pleuroscopy findings and further management are outlined in the algorithm. CONCLUSIONS: Pneumothorax is a common condition affecting all age groups. If the volume of the pneumothorax is > 20% of the pleural space, pleural drainage is indicated. For management of persistent or recurrent pneumothorax, the use of pleuroscopy (direct or video-assisted) is of great value and should be part of routine management.     

Válvulas endobronquiales para el tratamiento de la fuga aérea persistente,una alternativa al tratamiento quirúrgico

IntroductionPersistent air leak is frustrating for both patients and physicians, above all leaks with a high risk of surgery. Insertion of endobronchial valves could be an alternative to surgery. The aim of this study is to describe our experience in these valves and analyse their efficacy in a series of patients with persistent air leaks.Material and methodsThe valves are inserted by means of flexible bronchoscopy under conscious sedation and local anesthesia. A preliminary bronchoscopy identifies the air leak by bronchial occlusion using a balloon catheter. A successful outcome is defined as complete disappearance of the leak following removal of the chest drain, without the need for further surgery.ResultsFrom November 2010 to December 2013, 8 patients with persistent air leaks were treated with endobronchial valves. The number of valves used ranged from 1 to 4 (median 2), with a median duration of air leak prior to placement of 15.5 days. There were no complications and the resolution of the leak was complete in 6 of 8 patients (75%). The median duration of drainage after insertion of the valves was 13 days and the median time to removal of 52.5 days.ConclusionsInsertion of endobronchial valves is a safe and effective method for treating persistent air leaks, and a valid alternative to surgery.     

Autologous blood pleurodesis for pneumothorax complicating graft-versus-host disease-related bronchiolitis obliterans

Bronchiolitis obliterans (BO) is a manifestation of chronic graft-versus-host disease (GVHD) after allogeneic haemopoietic stem cell transplantation. Complications associated with this include persistent air-leak syndromes such as pneumothorax. Many methods have been described for treating this condition, both surgical and nonsurgical. We describe an 8-year-old boy with acute lymphoblastic leukaemia complicated by chronic GVHD-related BO, and subsequent pneumothorax with persistent air leak, who was treated successfully with autologous blood pleurodesis.     

Pneumothorax in patients with respiratory failure in ICU

Pneumothorax is not an uncommon occurrence in ICU patients. Barotrauma and iatrogenesis remain the most common causes for pneumothorax in critically ill patients. Patients with underlying lung disease are more prone to develop pneumothorax, especially if they require positive pressure ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension physiology. Most occurrences of pneumothoraces are readily diagnosed with a chest X-ray. Tension pneumothorax is a medical emergency, and managed with immediate needle decompression followed by tube thoracostomy. A computed tomography (CT) scan of the chest remains the gold standard for diagnosis; however, getting a CT scan of the chest in a critically ill patient can be challenging. The use of thoracic ultrasound has been emerging and is proven to be superior to chest X-ray in making a diagnosis. The possibility of occult pneumothorax in patients with thoracoabdominal blunt trauma should be kept in mind. Patients with pneumothorax in the ICU should be managed with a tube thoracostomy if they are symptomatic or on mechanical ventilation. The current guidelines recommend a small-bore chest tube as the first line management of pneumothorax. In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended. In non-surgical candidates, bronchoscopic interventions or autologous blood patch are other options.     

Beware the ‘raised right hemidiaphragm’ in a female patient with previous pneumothorax surgery: liver herniation through a massive endometrosis-related diaphragmatic fenestration

A 44-year-old non-smoking woman presented with recurrent right spontaneous pneumothorax 9 years after a right-side surgical pleurodesis via a video-assisted thoracic surgery (VATS) approach for suspected primary pneumothorax in another center. Histological examination of tissue excised during the earlier operation confirmed catamenial pneumothorax, but no further treatment was given. During the 9 years since, she had had persistent right lower chest pain and chest X-ray (CXR) had shown a “persistently elevated right diaphragm”, but these had been treated as iatrogenic neuropathic pain and phrenic nerve palsy respectively. A redo right surgical exploration was performed for the current recurrence. Intra-operatively, the right half of the liver was found to have herniated into the chest via a massive fenestration (10 cm × 9 cm) in the right hemidiaphragm. The defect was repaired via a combined thoracotomy and laparotomy approach. This case serves as an advisory that in patients with persistent ipsilateral chest pain and a raised hemidiaphragm following surgery for catamenial pneumothorax, diaphragmatic fenestration and abdominal visceral herniation should be suspected amongst the differential diagnoses.     

Spontaneous tension pneumothorax: what is it and does it exist?

Tension pneumothorax is variously defined but is generally thought of as a pneumothorax in which the pressure of intrapleural gas exceeds atmospheric pressure, producing adverse effects, including mediastinal shift associated with cardiovascular collapse, often attributed to reduced venous return and kinking of the great vessels. The mechanism of tension pneumothorax is said to be a valvular defect in the visceral pleura such that air enters the pleural space in inspiration but cannot exit in expiration, leading to a progressive increase in pressure. However, as the driving pressure forcing air into the pleura in inspiration is atmospheric pressure, the pleural pressure can never exceed 1 atm during inspiration in a spontaneously breathing subject. Furthermore, all pneumothoraces must have pressures greater than atmospheric during expiration, or conventional treatment with intercostal tube drainage would not work. Pilot experiments have failed to show any re‐entry of pleural gas into the lung in patients with persistent air leaks but no evidence of tension, suggesting these behave as valvular pneumothoraces. Case reports of tension pneumothorax in spontaneously breathing patients are rare, and most patients have other explanations for clinical deterioration. Although a large and rapidly expanding pneumothorax may require urgent intervention, it is unlikely that the effects are mediated by high intrapleural pressures. The term tension pneumothorax in spontaneously breathing patients should be reconsidered.     

红霉素治疗持续漏气的自发性气胸疗效观察

目的观察红霉素胸膜腔内注入治疗持续漏气的自发性气胸的作用及安全性。方法选择肋间闭式引流7～10d，继以持续负压吸引72h以上，仍持续漏气的自发性气胸61例，胸膜腔内注入红霉素1g＋50％葡萄糖60ml，并与32例单用50％葡萄糖60ml者作为对照。结果红霉素组治愈率为（49／61）80．3％，明显高于对照组（11／31）35．5％。治疗组不良反应中胸痛发生率仅为19．2％，发热发生率为20．1％。结论红霉素胸膜腔内注入是治疗持续漏气的自发性气胸的有效方法。     

Emergency Use of an Endobronchial One-Way Valve in the Management of Severe Air Leak and Massive Subcutaneous Emphysema

Bronchopleural (BPF) and alveolar-pleural (APF) fistulas are frequently encountered in clinical practice with persistent air leaks that can lead to significant morbidity, prolonged hospital stay, and potentially increased mortality. BPF and APF are commonly related to pulmonary resections. Other etiologies include minimally invasive procedures (thoracentesis and image-guided biopsies), and spontaneous fistulas related to an underlying structural lung disease (e.g., emphysema) or a necrotizing pulmonary process (e.g., infection or malignancy). Radiofrequency ablation for pulmonary malignancies is an effective modality that can rarely lead to APF with persistent air leak. Surgical intervention remains the standard treatment option for BPF and APF. A variety of minimally invasive bronchoscopic approaches can be considered for selected nonsurgical candidates. The use of one-way endobronchial valves to manage severe and persistent air leaks can be considered a minimally invasive option in selected patients. The valves selectively block inspiratory airflow to a specific segmental or subsegmental airway but allow expiratory flow with drainage of air and secretions from the corresponding distal airways and lung parenchyma.     

Late presentation of posterior urethral valves

Late presenting posterior urethral valves are very rare and often present ambiguously. The consequence of late detection can be profoundly detrimental, resulting in persistent voiding dysfunction and/or renal failure. We present an unusual case of a patient with posterior urethral valves who presented at the age of 28 years. We review the literature and discuss the clinical features, diagnosis, and treatment of this condition.     

Pneumothorax associated with lymphoma

Pneumothorax in patients with lymphoma has rarely been reported. We have encountered 8 patients with lymphoma with 17 episodes of pneumothorax; these episodes occurred 3 months to 8 yr in 7 patients after the diagnosis of Hodgkin's disease (HD) and in 1 patient with non-Hodgkin's lymphoma (NHL). The observed incidence of pneumothorax among 1,977 patients with lymphoma was 10-fold higher than expected; this included a significantly higher incidence in patients younger than 30 versus those older than 30 yr of age (1:552 versus 1:5,788 patient-years, p less than 0.001), and a higher incidence in patients with HD than in those with NHL (1:708 versus 1:5,072 patient-years, p less than 0.005). There was a strong suggestion of increased risk for pneumothorax in patients treated with radiotherapy as compared with patients treated without irradiation (1:1,016 versus 0:1,963 patient-years, p = 0.065). Apparent additional contributing factors in 6 patients were lung involvement with lymphoma (n = 2), radiation fibrosis (n = 3), and infection (n = 1). Pneumothorax was persistent in 5 patients, bilateral in 4, and recurrent in 2. The occurrence of pneumothorax in 2 patients heralded death. Management commonly required placement of chest tube (n = 9) or major surgical procedures (n = 5). We conclude that pneumothorax may be more common among patients with lymphoma than previously appreciated. Young age, HD, and probably radiotherapy are predisposing factors. The pneumothoraces associated with lymphoma are more complex and ominous and more difficult to manage than the usual spontaneous pneumothorax. In patients with lymphoma, pneumothorax is likely to be secondary to underlying abnormality of the lung.     

胸腔镜治疗多发胸膜下肺大疱自发性气胸简

目的 探讨在自发性气胸电视胸腔镜手术治疗过程中以结扎速处理多发胸膜下肺大疱的可行性及疗效.方法 103例在电视胸腔镜手术中探查发现多发胸膜下肺大疱的自发性气胸患者分为两组,其中Ⅰ组采用低能量电凝治疗,Ⅱ组采用结扎速处理.结果 与Ⅰ组相比,Ⅱ组术后胸管留置时间显著缩短（P〈0.05）,两组患者手术时间、使用直线切割缝合器钉仓数目、术中出血、术后持续性肺漏气、术后住院时间以及术后复发,无明显差异（P〉0.05）.结论 在自发性气胸术中以结扎速处理多发散在胸膜下肺大疱疗效满意,值得推广.     

Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures

The aim of this prospective study was to evaluate video-assisted thoracoscopic surgery (VATS) in primary and secondary spontaneous pneumothoraces. Over a 37-month period, 107 videothoracoscopic interventions were performed to treat spontaneous pneumothorax in 105 patients, 78 men and 27 women, whose average age was 28 years.Indications for surgery included recurrent ipsilateral pneumothorax (47 cases), persistent air leak (23 cases), hypertensive pneumothorax (14 cases), history of contralateral pneumothorax (13 cases), and elective surgery (10 cases). All of these patients were treated by endoscopic resection of the bullae (or apical zone in cases where the suspected abnormalities, or bullae, could not be visualized) plus physical pleurodesis. There were no perioperative deaths. Complications occurred in 6% of the cases of primary spontaneous pneumothorax and in 45% of the cases of secondary spontaneous pneumothorax. The complications among the secondary pneumothorax patients ranged widely from postoperative subcutaneous emphysema (resolved through simple, unassisted observation) to the need for an accessory minithoracotomy. Two patients (1.8%) suffered a recurrence of pneumothorax 4 and 8 months, respectively, after VATS treatment.     

Reexpansion hypotension. A complication of rapid evacuation of prolonged pneumothorax

Three cases of hypotension are described that followed rapid evacuation of persistent unilateral pneumothorax. Common features included the presence of a pneumothorax for approximately one week before treatment commenced and profuse unilateral reexpansion edema, a rising hematocrit reading, hypotension, and anuria after evacuation of the pneumothorax in spite of a relatively normal pulmonary capillary wedge pressure. In one case, cardiac output was measured and found to be low (1.54 and 1.65 L/min/sq m), with a pulmonary capillary wedge pressure of 10 to 14 mm Hg. Death due to cardiovascular collapse occurred in one patient; ischemic colitis, acute renal failure, disseminated intravascular coagulation, and ischemic necrosis of both humeral heads occurred in another. The cases presented and the literature reviewed suggest that cardiovascular compromise was the end result of the combined effects of intravascular volume depletion and myocardial depression.     

Recurrence of catamenial pneumothorax after surgical treatment]

We reported a case of catamenial pneumothorax that was recurrent after surgical treatment. A 43-year-old woman had sudden chest pain and dyspnea during menstruation. Right pneumothorax and pleural effusion were pointed out on chest X-ray films. When the patient was 31 years old, she received a diagnosis of catamenial pneumothorax and underwent thoracotomy for resection of diaphragmatic endometriosis. However, after surgery she experienced recurrence of right pneumothorax, and was accordingly treated with danazol. The patient decided to terminate medication by herself because her symptoms had disappeared. Several years after the cessation of medication, she experienced chest pain frequently during menstruation, but did not seek a medical check-up. She visited our department because of persistent chest pain in 1997. After the patient was hospitalized, pneumothorax was diagnosed and continuous drainage was performed. Although pneumothorax was alleviated by drainage, it recurred during the patient's next menstrual period. Open lung surgery was performed. Diaphragmatic endometriosis with a small hole and inflammatory thickened lesions on the visceral pleura of the lower lobe (S 6) were found and excised. Microscopic examination of the excised specimens showed endometriosis. Visceral pleural endometriosis has been histologically demonstrated in very few cases. After surgery, hormonal therapy was started. The patient has been well for 12 months without recurrence of pneumothorax. Both surgical and hormonal treatment were considered necessary for the treatment of catamenial pneumothorax in this case.     

Rapid and irreversible cystic change of pulmonary tuberculosis in an immunocompetent adult

This case report illustrates rapid and irreversible cystic change associated with disseminated pulmonary tuberculosis in an immunocompetent adult. In this patient, cystic lesions persisted after successful treatment of Mycobacterium tuberculosis and resulted in spontaneous pneumothorax with persistent air leak.     

Radiotherapy: a novel treatment for pneumothorax.

Pneumothorax is a relatively common condition that is usually managed either conservatively, by chest tube drainage or, if a refractory air leak persists, then with cardiothoracic intervention. However, there is a small group of patients with a persistent air leak in whom surgical intervention is felt to be inappropriate. This study looks at a novel management strategy in a patient presenting with this scenario. A male with underlying bullous lung disease presented with a right pneumothorax. Complete re-expansion was not achieved, despite chest tube drainage and suction. Cardiothoracic intervention was felt to be inappropriate and the air leak persisted despite prolonged conservative management. Ventilation scintigraphy was therefore used to localise the air leak prior to targeted radiotherapy in an attempt to seal the leak via radiation-induced fibrosis. Three weeks after the first fraction of radiotherapy, the air leak ceased. In complex cases of pneumothorax with persistent air leak where cardiothoracic intervention is deemed inappropriate, identification of the air leak site and localised radiotherapy could be considered.     

An integrated macro/micro approach to evaluating pivot flow within the Medtronic ADVANTAGE bileaflet mechanical heart valve

BACKGROUND AND AIM OF THE STUDY: An integrated macro/micro approach was used to evaluate flow within the pivots of the Medtronic ADVANTAGE bileaflet heart valve. Results were compared with those obtained with the St. Jude Medical bileaflet heart valve. METHODS: The integrated macro/micro approach consists of both a macroscopic hydrodynamic performance assessment and a three-part microscopic flow analysis. The hydrodynamic performance assesses the basic dynamic functions of the valves, while the microscopic flow analysis uses pivot flow visualization, computational fluid dynamics and laser Doppler velocimetry to determine pivot flow characteristics. Pivot flow visualization captures two-dimensional images of the pivot flow, defines the computational fluid dynamics boundary conditions, and validates the computational result. Three-dimensional unsteady computational fluid dynamics simulation reconstructs pivot flow structures. Laser Doppler velocimetry maps pivot velocity field and provides velocity validation for the computational simulation. RESULTS: The macroscopic hydrodynamic performance assessment showed the ADVANTAGE and St. Jude Medical valves to be comparable under identical flow conditions. The three techniques in the microscopic analysis mutually confirmed that the pivot design of the ADVANTAGE valve permits continuous-flow washing in the pivot recess, the pivots of both valves are completely wiped twice in a cardiac cycle, and no persistent pivot flow stases are observed. CONCLUSION: The integrated macro/micro approach represents a powerful systematic method for determining detailed microscopic flow structures inside the pivots of bileaflet mechanical valves. The use of this technique during the design process of a bileaflet valve can eliminate the persistent flow stases that lead to thrombus formation.     

Effectiveness and failure factors of manual aspiration using a small needle for large pneumothorax in stable patients

BackgroundManual aspiration as the initial management of a large pneumothorax in a clinically stable patient has been reported to be safe and effective. However, the effect with smaller needles, the number of aspiration, the indication other than spontaneous pneumothorax and failure factors are unknown. We assessed the effectiveness and failure risk factors of manual aspiration up to three using a 20- or 22-gauge (G) needle in patients with a large, clinically stable pneumothorax.MethodsWe included 107 clinically stable patients with large pneumothorax. Patients who were unstable, required a ventilator, underwent chest tube drainage or had an observed small pneumothorax, bilateral pneumothorax, hemopneumothorax, or postoperative pneumothorax were excluded. Up to three aspirations were performed using 20- or 22-G intravenous needles. When the aspiration volume was ≥2,500 mL or lung expansion did not occur, a chest tube was placed.ResultsThe first aspiration was successful in 57 patients (53.3%), the second in 16 patients (59.3%), and the third in eight patients (80.0%). No patient experienced any obvious complications or required emergent hospitalization or surgery after aspiration. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum [odds ratio (OR): 4.93; 95% confidence interval (CI): 1.49–22.71; P=0.0075], spontaneous secondary pneumothorax (OR: 3.11; 95% CI: 1.14–8.76; P=0.027), and ≤24 h from onset to presentation (OR: 2.95; 95% CI: 1.12–8.26; P=0.028). There were no significant differences in intrathoracic pressure after aspiration or plasma factor XIII levels between patients with resolved and persistent pneumothorax.ConclusionsManual aspiration up to three times using a small needle might be one of a treatment option in clinically stable patients with any large pneumothorax. Aspiration failure was correlated with an inter-pleural distance >20 mm at the level of the hilum, spontaneous secondary pneumothorax, and ≤24 h from onset to presentation.     

Recurrent hydropneumothorax as a presenting feature of malignant mesothelioma

A 73-year-old former smoker with previous occupational exposure to asbestos presented with a pneumothorax that was initially managed by simple aspiration. Despite this, it re-accumulated and a bronchopleural fistula was suspected. A video-assisted thoracoscopic procedure was performed and revealed an abnormally thickened pleura that turned out to be a mesothelioma. All persistent pneumothoraces should be investigated.