Pneumothorax and chest drain insertion

A pneumothorax is caused by air or gas in the pleural space. This causes lung collapse and a variable degree of impairment of both oxygenation and ventilation. Depending on the degree of lung collapse (determined by the size of the pneumothorax) and the underlying respiratory reserve and co-morbidities of the patient the clinical picture can vary from asymptomatic to life-threatening. The initial management varies with the clinical picture as well as the aetiology and size of the pneumothorax. It ranges from observation only (for small primary spontaneous pneumothorax), to needle aspiration or chest drain insertion. Chest drain insertion is a common procedure used routinely to not only drain the chest cavity of air as is the case with a pneumothorax but is also used to drain blood (haemothorax), chyle (chylothorax), pleural fluid or pus (empyema) from the chest cavity. It is the most common procedure in thoracic trauma and both Seldinger and open surgical chest drain insertion are discussed.     

Intractable pneumothorax with empyema in a patient with interstitial pneumonia

Secondary pneumothorax occurring in interstitial lung disease cases is a refractory and life-threatening condition, because of compromised lung function. A 70-year-old woman with interstitial pneumonia was referred to our hospital after treatment failure for pneumothorax associated with empyema. An open window thoracostomy was created, and mechanical irrigation and dressing changes of the pleural cavity were performed. Then, the lung was widely covered with the latissimus dorsi and serratus anterior muscles because there were multiple fistulae on the lung surface. After the covering muscles were completely adhered to the lung surface and stopped air leaking, the chest was successfully closed. The wide covering technique of the lung with chest wall muscles is effective for intractable pneumothorax with multiple fistulae.     

Pneumothorax as a presenting manifestation of early sarcoidosis

Pneumothorax rarely develops sarcoidosis. A 21-year-old man with early sarcoidosis presenting as pneumothorax is reported. The patient came to our institute with severe chest pain and dyspnea. Plain chest roentgenograms revealed pneumothorax in the left lung. A chest tube was inserted to inflate the lung. Subsequent computed tomography demonstrated subpleural blebs in the upper lobe of the left lung. Continuous treatment with tube drainage was performed. However, surgical intervention was needed since long-term tube drainage turned out to be unsuccessful. Thoracoscopic partial extirpation on the left upper lobe was performed. The histology of the obtained lung tissue showed non-caseating granulomas composed of epithelioid cells and occasional giant cells. A diagnosis of sarcoidosis was made on the basis of the histological report. Although early sarcoidosis presenting as pneumothorax is rare in young patients, the possibility of a sarcoidosis should be considered.     

Lung ultrasound in acute and critical care medicine

The development of modern critical care lung ultrasound is based on the classical representation of anatomical structures and the need for the assessment of specific sonography artefacts and phenomena. The air and fluid content of the lungs is interpreted using few typical artefacts and phenomena, with which the most important differential diagnoses can be made. According to a recent international consensus conference these include lung sliding, lung pulse, B-lines, lung point, reverberation artefacts, subpleural consolidations and intrapleural fluid collections. An increased number of B-lines is an unspecific sign for an increased quantity of fluid in the lungs resembling interstitial syndromes, for example in the case of cardiogenic pulmonary edema or lung contusion. In the diagnosis of interstitial syndromes lung ultrasound provides higher diagnostic accuracy (95%) than auscultation (55%) and chest radiography (72%). Diagnosis of pneumonia and pulmonary embolism can be achieved at the bedside by evaluating subpleural lung consolidations. Detection of lung sliding can help to detect asymmetrical ventilation and allows the exclusion of a pneumothorax. Ultrasound-based diagnosis of pneumothorax is superior to supine anterior chest radiography: for ultrasound the sensitivity is 92-100% and the specificity 91-100%. For the diagnosis of pneumothorax a simple algorithm was therefore designed: in the presence of lung sliding, lung pulse or B-lines, pneumothorax can be ruled out, in contrast a positive lung point is a highly specific sign of the presence of pneumothorax. Furthermore, lung ultrasound allows not only diagnosis of pleural effusion with significantly higher sensitivity than chest x-ray but also visual control in ultrasound-guided thoracocentesis.     

Learning Curve for Percutaneous Radiofrequency Ablation of Pulmonary Metastases From Colorectal Carcinoma: A Prospective Study of 70 Consecutive Cases

Background Percutaneous radiofrequency ablation (RFA) for inoperable colorectal pulmonary metastases is associated with a morbidity rate of 30% to 40%. A learning curve in this treatment approach has not been documented before.Methods The clinical and treatment-related data regarding 70 consecutive percutaneous RFA procedures for inoperable colorectal pulmonary metastases were collected prospectively. A comparison between the initial 35 cases (group 1) and the subsequent 35 cases (group 2) was performed. Univariate and multivariate analyses were conducted to identify the significant risk factors for overall morbidity, pneumothorax, and chest drain requirement.Results There was no hospital mortality. The overall morbidity rate was 37%. The rate of pneumothorax was 27%. Twelve patients (17%) required chest drain insertion for pneumothorax. There was a significant decline in the incidence of overall morbidity, pneumothorax, and chest drain requirement in group 2 as compared with group 1. Both the number of lung metastases ablated and the RFA treatment period (group 1 vs. group 2) were independent risk factors for overall morbidity, pneumothorax, and chest drain requirement. Distribution of lung metastases (unilateral vs. bilateral) was an independent risk factor for overall morbidity and pneumothorax, but not for chest drain requirement.Conclusions There is a learning curve for percutaneous lung RFA. With accumulated experience in this procedure, a low morbidity rate can be achieved.     

Contralateral pneumothorax in bullous lung after pneumonectomy: report of two cases

Contralateral pneumothorax after pneumonectomy is potentially fatal. We experienced two cases of right pneumothorax after left pneumonectomy in which the patients had multiple bullae in the right lung. Case 1 involved a 49-year-old man with non-small-cell lung cancer (NSCLC) who underwent left pneumonectomy after induction chemoradiotherapy. Eleven months after surgery, he had pneumothorax and was treated with chest tube drainage and pleurodesis. He was discharged but died of recurrent pneumothorax 1 month later. Case 2 involved a 57-year-old man with NSCLC who had left pneumonectomy. Five months after surgery, he had pneumothorax and was treated with chest tube drainage. Because of prolonged air leak, ligation of the ruptured bulla was performed with a percutaneous cardiopulmonary support system on standby. No pneumothorax recurrence occurred for 2 years. Although management of pneumothorax after pneumonectomy is challenging, surgical intervention may be useful and necessary especially when there is high risk of recurrent pneumothorax.     

Lung cancer incidentally detected at the treatment of pneumothorax ; report of two cases

We report 2 cases of lung cancer incidentally detected following pneumothorax. Case 1:A 40-year-old man complaining of dyspnea was admitted with right pneumothorax. Chest computed tomography (CT) after chest drainage showed a cavitary nodule with pleural indentations in the right lower lobe. It was indicated at surgery that pneumothorax was caused by perforation of the tumor into the pleural cavity. Right lower lobectomy was performed because the pathological diagnosis of the nodule was a large cell carcinoma. The final histopathological diagnosis was stage II A (pT2aN1M0). The patient died of recurrence 14 months after surgery. Case 2:A 47-year-old man who admitted with right pneumothorax was found to have a nodule with pleural indentations closely a bulla at the apex of the right lung by chest CT after chest drainage. Pneumothorax was indicated to be caused by rupture of the bulla at surgery. Right upper lobectomy was performed because the pathological diagnosis of the nodule was a squamous carcinoma. The final histopathological diagnosis was stage I A (pT1bN0M0). The patient is alive at 2 years after the operation without recurrence. Lung cancer detected following pneumothorax which was caused by perforation of the tumor is generally considered to have poor prognosis. Whereas, prognosis of lung cancer incidentally detected following pneumothorax depends on its staging.     

A case of pneumothorax which was operated with the axillary longitudinal small incision

A pneumothorax usually occurs in young men. From the cosmetic point of view, the size of the skin incision should be considered to be minimal if surgery is applied for young pneumothorax patients. We reported a case of pneumothorax which was operated with a small longitudinal axillary skin incision, the size of which was 3.5 cm long. The patient was a 18-year-old high school student. He was admitted to our hospital with the diagnosis of spontaneous pneumothorax. His chest X-ray showed a moderate collapse of his left lung and bullae in his left apex. Tube drainage was performed and the collapsed lung re-expanded completely. Chest CT scan demonstrated that he had bullae in the apex of his left lung. No other lesions were found in the other part of both lungs. Surgery was indicated socially. Bullectomy was successfully performed with a small (3.5 cm) longitudinal axillary skin incision. We recommend this skin incision for young patients with pneumothorax if the chest CT scan confirms that the bullae or blebs are localized to the apex of superior segment of the lower lobe.     

Neumotórax primario espontáneo durante el embarazo: reporte de un caso y revisión de la literatura

Spontaneous pneumothorax in pregnancy is an extremely rare cause of dyspnea with less than 100 cases reported in the literature. A 28-year-old primigravida at 39⁺⁴ weeks of gestation presented to the emergency department with sudden onset of dyspnea and pleuritic chest pain. A chest radiograph revealed a large, left-sided pneumothorax with a collapsed lung. A chest tube was placed with incomplete re-expansion of the lung. A cesarean section under epidural anesthesia was performed for suspected macrosomia. The postpartum was uneventful. Despite its rarity, spontaneous pneumothorax should be excluded in every pregnant woman presenting with sudden onset of dyspnea and chest pain. A heightened index of suspicion is essential for prompt management of this condition, avoiding adverse fetal and maternal outcomes. For a correct diagnosis and management, more solid recommendations and a multidisciplinary approach are needed.     

Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous pneumothorax

BACKGROUND: There is no technique in general use that reliably predicts the outcome of manual aspiration of spontaneous pneumothorax. We have hypothesised that the absence of a pleural leak at the time of aspiration will identify a group of patients in whom immediate discharge is unlikely to be complicated by early lung re-collapse and have tested this hypothesis by using a simple bedside tracer gas technique. METHODS: Eighty four episodes of primary spontaneous pneumothorax and 35 episodes of secondary spontaneous pneumothorax were studied prospectively. Patients breathed air containing a tracer (propellant gas from a pressurised metered dose inhaler) while the pneumothorax was aspirated percutaneously. Tracer gas in the aspirate was detected at the bedside using a portable flame ioniser and episodes were categorised as tracer gas positive (>1 part per million of tracer gas) or negative. The presence of tracer gas was taken to imply a persistent pleural leak. Failure of manual aspiration and the need for a further intervention was based on chest radiographic appearances showing either failure of the lung to re-expand or re-collapse following initial re-expansion. RESULTS: A negative tracer gas test alone implied that manual aspiration would be successful in the treatment of 93% of episodes of primary spontaneous pneumothorax (p<0.001) and in 86% of episodes of secondary spontaneous pneumothorax (p=0.01). A positive test implied that manual aspiration would either fail to re-expand the lung or that early re-collapse would occur despite initial re-expansion in 66% of episodes of primary spontaneous pneumothorax and 71% of episodes of secondary spontaneous pneumothorax. Lung re-inflation on the chest radiograph taken immediately after aspiration was a poor predictor of successful aspiration, with lung re-collapse occurring in 34% of episodes by the following day such that a further intervention was required. CONCLUSIONS: National guidelines currently recommend immediate discharge of patients with primary spontaneous pneumothorax based primarily on the outcome of the post-aspiration chest radiograph which we have shown to be a poor predictor of early lung re-collapse. Using a simple bedside test in combination with the post-aspiration chest radiograph, we can predict with high accuracy the success of aspiration in achieving sustained lung re-inflation, thereby identifying patients with primary spontaneous pneumothorax who can be safely and immediately discharged home and those who should be observed overnight because of a significant risk of re-collapse, with an estimated re-admission rate of 1%.     

An early case of pulmonary lymphangioleiomyomatosis diagnosed by video-assisted thoracoscopic surgery.

Pulmonary lymphangioleiomyomatosis (LAM) is a rare and progressive disease of young women that usually causes death from respiratory failure. Here we report an early case that was diagnosed by thoracoscopy. A 28-year-old woman presented to a local clinic with chest pain and her chest X-ray film showed left pneumothorax. After placement of a chest tube, the lung re-expanded fully. Following the recurrence of left pneumothorax, she was referred to our hospital and underwent video-assisted thoracoscopic surgery (VATS). However, left pneumothorax recurred again one month later. She underwent a second thoracoscopic operation, during which a bulla was recognized in the lingular segment of the left lung and was resected. On histological examination of the surgical specimen findings consistent with LAM were obtained. Taking the preoperative imaging findings and the thoracoscopic findings into consideration, a diagnosis of early lymphangioleiomyomatosis was made. Thoracoscopic management of pneumothorax in young women can facilitate the early diagnosis of this condition.     

Spontaneous pneumothorax after traumatic pneumonectomy: a role for talc pleurodesis in secondary prevention?

We report a case of spontaneous contralateral pneumothorax 2 months after a pneumonectomy, with the initial placement of an intercostal chest drain on the side of the pneumothorax. Due to the high risk of a subsequent life-threatening pneumothorax, pleurodesis became an important consideration. Surgical pleurodesis can be complicated by the risks of single lung ventilation; therefore, talc pleurodesis was performed by using the intercostal drain once the lung had fully expanded. The patient remains free of recurrence 14 months after the pneumonectomy. Our case suggests that talc may be an effective alternative method of secondary prevention of a pneumothorax after a pneumonectomy.     

Pneumothorax and insertion of a chest drain

A pneumothorax occurs when the visceral or parietal pleura is breached and air enters the pleural space. This leads to loss of the negative intrapleural pressure and lung collapse. Pneumothoraces may be classified into ‘simple’, ‘tension’ or ‘open’ according to the underlying pathophysiology. A chest radiograph is essential in diagnosis and management. Tension pneumothorax is a medical emergency, relieved initially with needle thoracentesis, but treated definitively with a chest drain. The latter is inserted in all cases where aspiration is unsuccessful in controlling symptoms in a simple pneumothorax. A thoracic surgical opinion should be sought if there is persistent air leak from the drain or the lung fails to re-expand after three days.A chest drain is used to drain air, blood, fluid or pus from the pleural space. Proper attention should be paid to patient preparation, which should include full asepsis, appropriate patient positioning, and application of National Patient Safety Agency recommendations. A chest drain is usually inserted under local anaesthesia in the ‘safe triangle’ in the lateral chest wall using blunt dissection. The drains should not be clamped in cases of pneumothorax, and the drainage bottle should always be kept below the level of the patient’s chest.     

A case of simultaneous bilateral spontaneous pneumothorax after the Nuss procedure

We present a case of simultaneous bilateral spontaneous pneumothorax caused by a pleuro-pleural communication formed from Nuss procedure for pectus excavatum. A 17-year-old man with a history of Nuss operation complained chest pain and dyspnea. A chest roentgenogram demonstrated a tiny bilateral pneumothorax and two metallic bars inserted at the Nuss procedure. Computed tomography revealed furthermore a bulla in the apex of the left lung. The bilateral pneumothorax critically deteriorated after 4 days from onset and urgent bilateral chest drainages were performed. Nevertheless the drainages the full expansion of both lungs was not obtained and air leakage only from left side was continued. A video-assisted left bullectomy was performed 9 days after the tube insertion. The two bars penetrating anterior mediastinal pleura were thought to be a cause of the simultaneous bilateral spontaneous pneumothorax.     

Pneumothorax and chest drain insertion

Chest drain insertion is a common procedure used routinely to drain the chest cavity. It can be used to drain air, as is the case of a pneumothorax, or to drain blood (heamothorax), chyle (chylothorax), fluid (pleural effusion) or pus (empyema) from the chest cavity. It is the commonest procedure performed for thoracic trauma. Seldinger and open surgical chest drain insertion are both discussed, as well as the use of ultrasound guidance to aid insertion/aspiration. Air (or fluid) in the pleural cavity causes the lung to collapse and results in a variable degree of impairment of both oxygenation and ventilation. Depending on the degree of lung collapse (determined by the size of the pneumothorax), the respiratory reserve and the comorbidities of the patient, the clinical picture can vary from asymptomatic to life threatening. The initial patient management depends on the clinical picture as well as the size and aetiology of the pneumothorax. Management ranges from observation only (for small primary spontaneous pneumothoraces), to needle aspiration or chest drain insertion.     

Pneumothorax and chest drain insertion

Chest drain insertion is a common procedure used routinely to drain the chest cavity. It can be used to drain air, as is the case of a pneumothorax, or to drain blood (heamothorax), chyle (chylothorax), fluid (pleural effusion) or pus (empyema) from the chest cavity. It is the commonest procedure performed for thoracic trauma. Seldinger and open surgical chest drain insertion are both discussed, as well as the use of ultrasound guidance to aid insertion/aspiration. Air (or fluid) in the pleural cavity causes the lung to collapse and results in a variable degree of impairment of both oxygenation and ventilation. Depending on the degree of lung collapse (determined by the size of the pneumothorax), the respiratory reserve and the comorbidities of the patient the clinical picture can vary from asymptomatic to life threatening. The initial patient management depends on the clinical picture as well as the size and aetiology of the pneumothorax. Management ranges from observation only (for small primary spontaneous pneumothoraces), to needle aspiration or chest drain insertion.     

Pulmonary surgery for pulmonary lesion with pulmonary tuberculosis or of tuberculosis]

Nine patients with pulmonary tuberculosis underwent open chest surgery for pulmonary lesions of tuberculosis or other than tubercolosis. They were 1 case of lung cancer, 4 cases of pneumothorax, 1 case of multi drug resistant pulmonary tuberculosis and 3 cases of tuberculoma. Postoperative complications developed in 3 cases including 2 of pneumothorax and 1 of lung collapse.     

Delayed pneumothorax and hydrothorax with central venous catheter migration

We report a case of delayed pneumothorax, central venous catheter migration and iatrogenic hydrothorax in a 22-year-old female. The left subclavian central venous catheter initially transfixed the lung apex; pneumothorax occurred 24 h later following initiation of positive pressure ventilation. Lung collapse as a result of the pneumothorax caused catheter migration and hydrothorax. Catheter removal and chest drainage led to an uneventful recovery.     

Five cases of contralateral pneumothorax after lung resection

Contralateral pneumothorax is one of severe complications after lung resection. We present our experiences with surgical treatment of 5 cases [case 4 is under the percutaneous cardiopulmonary support (PCPS) assistance] of contralateral pneumothorax after lung resection. All cases were men and not able to stop smoking, the disease caused by lung resection was lung cancer 3 and tuberculosis 2. Operative procedure was lobectomy 4 and pneumonectomy 1. Tracheal intubation was done before radiological confirmation of pneumothorax in 4 cases. Immediately after diagnosis all patients underwent chest drainage. Because the contralateral pneumothorax after lung resection is severe complication, we thought that surgical treatment is necessary. Though the thoracoscopic surgery under the PCPS assistance is also possible, it seems that a small thoracotomy with adjusting ventilation by anesthetist are more favorable. Accurate diagnosis and treatment is the key for success of treatment. The patient who receives lung resection due to lung cancer often has emphysema, and the risk of contralateral pneumothorax after the operation should also be explained.     

Intrathoracic tracheobronchial injuries in childhood

Trauma to the intrathoracic tracheobronchial tree is a rare but usually fatal injury. Patients with pneumothorax, subcutaneous emphysema, and a history of blunt or penetrating injury to the lower neck or chest must undergo early bronchoscopy to evaluate the lower airway. Thoracotomy should be performed as soon as the patient's condition allows an attempt at primary repair. The diagnosis is frequently missed because it is so uncommon and its symptoms may resolve after chest tube drainage of the pneumothorax. Airway stenosis or occlusion usually follows. Still, local resection of the stricture and reanastomosis frequently result in recovery of lung function. Neglected cases complicated by infection usually require lung resection.