Spontaneous Pneumothorax

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Spontaneous Pneumothorax

• Ahmer A. Karimuddin
• August 10th, 2001

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Definitions

• Primary Spontaneous Pneumothorax (PSP)
• No underlying lung disease
• Secondary Spontaneous Pneumothorax (SSP)
• Complication of underlying lung disease

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Definitions

• Iatrogenic Pneumothorax
• Complication of diagnostic or therapeutic
  intervention
• Traumatic Pneumothorax
• Caused by penetrating and or blunt trauma

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PSP - Epidemiology

• Fairly common
• 10 cases per 100,000 in men
• 3 cases per 100,000 in women
• Typically in tall, thin males between ages of 10
  and 30
• Risk increases with smoking in dose dependent
  manner

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PSP - Pathology

• Patients have no clinical lung disease
• On thoracoscopy, 75 to 100 percent have
  sub-pleural Bullae
• Increased numbers in smokers (89) vs. non
  smokers (81)

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PSP - Pathophysiology

• Air leak due to increased alveolar pressure,
  secondary to inflammation
• Air leaks into lung interstitium then into hila,
  causing pneumomediastinum
• Mediastinal pressure rises, mediastinal parietal
  pleura ruptures
• No defect seen in visceral pleura or evidence of
  bullous rupture

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PSP - Pathophysiology

• Due to air in pleural space, decrease in vital
  capacity
• Hypoxemia results decreased ventilation
  perfusion ratio
• Hypercapnia occurs only rarely

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PSP Clinical Presentation

• History of chest pain while resting.
• Physical findings are minimal.
• Tachycardia.
• If large pneumothorax.
• Hyper resonance on percussion.
• Decreased fremitus.
• Decreased or absent breath sounds.

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PSP Clinical Presentation

• Clinical clearance of symptoms
• Usually within 24-48 hours, even if air in
  pleural cavity is not evacuated
• If HR gt 135 or hypotension or cyanosis
• TENSION PNEUMOTHORAX

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PSP Diagnosis

• History
• Chest x-ray
• PA is only one of significance
• Expiration inspiration views were found to have
  no clinical significance

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PSP Recurrence

• Average rate of recurrence is 30
• Most recurrences within six months to two years
• Increased risk with
• Tall, thin habitus
• Pulmonary fibrosis
• History of smoking
• Young age
• No increased risk with number of Bullae

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SSP

• Potentially life threatening, as limited reserve
• Most often associated with COPD and PCP pneumonia
  in HIV
• Risk in COPD increases with worsening disease
• 6 of HIV patients will suffer from PCP
  associated pneumothorax
• (30-40 mortality)

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SSP

• Also seen in
• Langerhans granulomatosis
• Lymphangioleiomyomatosis
• Interstitial lung disease
• Catamenial Pneumothorax
• Seen in women, within 72 hours of menses

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SSP - Epidemiology

• Same rates as PSP
• Peak is later in life
• 60 to 65 years
• 26 per 100,000 patients per year with COPD
• Occasionally seen as first presenting symptom of
  pleural and lung CA

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SSP Mechanism

• Two hypothesis
• Same as PSP
• Ruptured alvelous leaks air directly into pleural
  space secondary to necrosis evidence seen in
  PCP associated pneumothorax

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SSP Clinical Presentation

• Dyspnea, usually severe
• Chest pain
• Hypoxemia and hypotension
• Hypercapnia
• Must exclude in patient with Chest pain and COPD

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SSP Diagnosis

• Clinical Presentation
• Radiological assessment
• Bullae may mask presence of air within the
  pleural cavity
• Only in patients with previous pulmonary disease,
  consider CT scan to rule out presence of
  Pneumothorax

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SSP Recurrence

• Similar to PSP
• Various studies show a range in between 39 to
  47
• Increased rate of recurrence in patients with
  complicated COPD
• Smoking most potent risk factor

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Pneumothorax - Treatment

• Principles
• Evacuate air from the pleural space
• Prevent recurrences

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Pneumothorax - Treatment

• Air evacuation is to bring about re-expansion of
  lung
• If air within pleural cavity is less than 15 of
  hemithorax (lt 2 ribs) and minimal symptoms
• Consider supplemental oxygen and observation over
  6 to 8 hours
• Approximately 2 reabsorption per day on room air

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Pneumothorax - Treatment

• If air within pleural cavity is greater than 15
  or growing
• Simple intravenous catheter or thoracentesis
  catheter
• Chest tube
• Simple aspiration successful in 70
• Increased success with age lt 50 and lt 2.5 L of
  air aspirated

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Pneumothorax - Treatment

• Surgical Options
• Video Assisted Thoracoscopic Surgery (VATS) with
  wedge resection pleurodesis
• Limited Axillary Thoracotomy
• Thoracotomy

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Pneumothorax - Treatment

• VATS is felt to be superior to other options
• Decreased time to discharge
• Small incisions
• Decreased intra-operative stress
• Earlier return to function
• Decreased post-operative pain

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Pneumothorax - Treatment

• If VATS is superior, then when do we use it?
• After second episode
• High-risk profession
• Persistent air-leak at 7 days
• Yes No

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Pneumothorax - Treatment

• Cole et al. (Ann. Thor. Surg., 1985)
• Cohort study
• 89 treated conventionally
• 50 were operated on
• 30 treated with VATS on presentation
• LOS was 6 days in VATS group, while average LOS
  in conventional group was 8 days
• Recommended early intervention with VATS, if
  persistent air leak at 3 days

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Pneumothorax - Treatment

• Passlick et al. (Ann. Thor. Surg., 1998)
• Cohort study (retrospective)
• 99 patients treated with VATS, 100 patients
  treated with lateral thoracotomy
• VATS
• Shorter hospital stay
• Shorter CT drainage
• Decreased use of narcotics

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Pneumothorax - Treatment

• Falcoz et al. (Ann. Thor. Surg. 2003)
• Using Decision Analysis methodology, attempted to
  arrive at best decision for second episode of
  pneumothorax
• Conventional Management entailed intercosta
  drainage, followed by VATS/Thoracotomy for
  persistent air-leak

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Pneumothorax - Treatment
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Pneumothorax - Treatment

• For second episode,
• VATS is cost-effective
• Shorter stay by 5 days
• Slightly less effective than CM

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Pneumothorax - Treatment

• For second episode,
• VATS is cost-effective
• Shorter stay by 5 days
• Slightly less effective than CM

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Pneumothorax - Treatment

• If it works so well for the second episode, what
  about the first?
• Torresini et al. (EJ Card. Thor. Surg., 2003)
• RCT
• 35 patients treated with CT
• 35 patients treated with VATS

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Pneumothorax - Treatment

• 35 patients treated with CT
• 4 air-leaks
• 8 recurrences
• 3,000 per patient
• 35 patients treated with VATS
• 2 air leaks
• 1 recurrence
• 2,000 per patient

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Pneumothorax - Treatment

• VATS
• Decreased cost
• Decreased LOS
• Decreased recurrence
• ? Psychological effect
• Decreased concern of recurrence
• Satisfaction with definitive management

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Pneumothorax - Treatment

• What are the recommendations?
• British Thoracics Society, 2002

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Pneumothorax - Treatment
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Pneumothorax - Treatment

• BTS Guidelines
• Do not discuss second or third episode
• Only statement
• Refer to Thoracic Surgeon all cases of difficult
  pneumothorax and persistent air leaks

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Pneumothorax - Treatment

• American Society of Chest Physicians
• Guidelines from 2001

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Pneumothorax - Treatment

• PSP
• 1st episode simple drainage/aspiration
• If no air-leak, reserve definitive treatment till
  second episode
• VATS is preferred treatment

• SSP
• 1st episode necessitates definitive treatment
• VATS is preferred treatment

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Pneumothorax

• Sclerosing Agents?
• Talc (85-92 effective)
• Tetracycline/Monocycline
• May be used in patients who will not tolerate an
  operation
• High risk of ARDS

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Areas of Research

• Clinical trial in role of VATS
• Better sclerosing agents
• Better utilization of CT for patient section for
  surgical intervention

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Any Questions?