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PubMed2003

Comparison of large- and small-bore intercostal catheters in the management of spontaneous pneumothorax.

BACKGROUND: Spontaneous pneumothoraces (SP) are a common cause of presentation to emergency departments and subsequent hospitalization. In recent years there has been an increasing trend towards the use of small-bore pleural catheters (PC) rather than conventional large-bore intercostal catheters (ICC) in their initial management. AIMS: To compare the effectiveness and complication rate of ICC and PC in the treatment of SP. METHODS: A retrospective chart audit was conducted of 67 cases of SP admitted to the Royal Prince Alfred Hospital, Sydney, Australia, between 1 July 1997 and 30 June 2000. Demographic data were recorded, including: (i) patient age, (ii) smoking status, (iii) pneumothorax size, (iv) pneumothorax type and (v) aetiology. Outcome data relating to length of hospital stay (LOS) and treatment failure rates and complications of treatment devices were also recorded. RESULTS: Successful pneumothorax resolution was achieved (P = 0.72) in 20 of the 31 (65%) patients initially treated with a ICC, and in 26 of the 36 (72%) patients treated with a PC. The mean LOS in the ICC and PC group was 7 days and 5 days, respectively (P = 0.11). The complication rates in the PC and ICC group were 25% and 10%, respectively (P = 0.13), and the recurrence rates for each group were 17% and 6% (P = 0.20), respectively. However, the combined rate of complications and pneumothorax recurrence within 2 months was 42% in those initially treated with PC, compared with 16% in those treated with ICC (P = 0.04). CONCLUSIONS: PC were as effective as ICC in treating SP in terms of initial pneumothorax resolution and LOS. There were trends towards higher complication and recurrence rates in those treated with PC, but individually these results did not reach statistical significance. However, the combined rate of complications and pneumo-thorax recurrence was significantly higher in those patients treated with the PC than in those treated with ICC.

Adult↗
PubMed2004

Bilateral video-assisted thoracoscopic surgery in the supine position for primary spontaneous pneumothorax.

On the basis of the bilateral nature of bullous lesions of the lung, the authors have performed single-stage bilateral video-assisted thoracoscopic surgery (VATS) in the supine position for primary spontaneous pneumothorax in five patients since October 1999. All five patients were males with a mean age of 23 years (range 19 to 29 years). The presenting pneumothorax was ipsilateral (right-sided) in four patients and simultaneous bilateral in the one remaining patient. Apart from the one case of simultaneous bilateral spontaneous pneumothorax (SBSP), all patients had a history of at least one pneumothorax episode requiring tube thoracotomy. Bilateral bullae were confirmed in all patients on preoperative chest computed tomography (CT). Bilateral bullectomy was performed by endo-stapler with no difficulties. Mean operating time was 111 minutes (range 85 to 140 minutes). All patients were returned to the surgical ward in good condition from the operating room immediately after extubation. No complications were observed, and duration of postoperative hospital stay was two to four days. All patients were alive without recurrence of pneumothorax after a mean follow-up period of 25 months (range, 9 to 43 months). Single-stage bilateral VATS in the supine position has shown itself to be an excellent approach for the treatment of bilateral bullous lesions, combining both efficacy and low morbidity.

Adult↗
PubMed2005

Prevention of overlooked bullae during video-assisted thoracic surgery (VATS) with a combination of high frequency jet ventilation (HFJV) and positive end-expiratory pressure (PEEP) for spontaneous pneumothorax.

BACKGROUND: Overlooked bullae have been reported to contribute to the higher incidence of recurrence of pneumothorax following video-assisted thoracic surgery (VATS). In this study, we investigated whether high frequency jet ventilation (HFJV) + positive end-expiratory pressure (PEEP) prevented overlooking of bullae by blowing up the bullae and inflating the lungs moderately during VATS for spontaneous pneumothorax patients. METHODS: A total of 31 patients with spontaneous pneumothorax who underwent VATS were enrolled in this study. We examined the number, size, and location of bullae with and without HFJV+PEEP during VATS. RESULTS: More bullae were found with HFJV + PEEP than without HFJV + PEEP in 15 of the 31 patients. Significantly more bullae smaller than 2 cm in diameter were detected with HFJV + PEEP than without HFJV + PEEP. In the patients with 1 - 3 bullae, the detection rate was significantly higher with HFJV + PEEP than without HFJV + PEEP. All bullae confirmed with VATS were detected only in one case (3.2 %) on preoperative chest X-ray, and in two cases (6.5 %) on chest CT. The recurrence rate of pneumothorax following VATS with HFJV + PEEP was 3.3 % (1/31). CONCLUSION: Our results suggested that VATS combined with HFJV and PEEP might prevent the overlooking of bullae and reduce the postoperative recurrence of spontaneous pneumothorax.

Adolescent↗
PubMed1984

Surgical management of spontaneous pneumothorax.

Spontaneous pneumothorax is a common surgical problem. Although the general principles of drainage of the pleural space and of prevention of recurrence seem well known, the literature shows differences in success rates concerning the treatment of a first pneumothorax and of the eventual recurrences. This is probably due to some technical factors and different views on the therapeutical strategy. In this retrospective review of 62 patients with spontaneous pneumothorax, 8 were treated by bed rest for their not enlarging and less than 20% pneumothorax, and 54 were treated by closed chest tube thoracostomy with an early success rate of 93.5% at the first admission. The simultaneous use of scarifying agents and closed chest drainage appears useful for the treatment of immediate or first recurrence. Sixteen patients were readmitted later for ipsilateral recurrence. According to the magnitude of their pneumothorax, they were treated by bed rest or tube thoracostomy with scarifying agents. Four of these patients needed thoracotomy with oversuturing of subpleural blebs and pleurodesis. The total thoracotomy rate of the initial patient population was 12.9% after an average follow up period of 24.8 months.

Adolescent↗
PubMed1990

[Spontaneous pneumothorax in AIDS. Observations in 10 patients].

Ten of our AIDS patients developed a unilateral or bilateral spontaneous pneumothorax. Four patients previously had pneumocystis carinii pneumonia and one had pulmonary tuberculosis. In six patients the pneumothorax occurred during the acute period of pneumocystis carinii pneumonia. Five patients were admitted to hospital because of the pneumothorax. The radiological findings varied from a small pneumothorax to almost total pulmonary collapse. Five of the ten patients were discharged after successful treatment of the pneumothorax but, in two, cystic lung segments had to be removed surgically.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Thoracoscopic talc pleurodesis for the treatment of spontaneous pneumothorax.

BACKGROUND: During the Belgian Surgical Week in May 2004 some controversy existed on the optimal treatment of spontaneous pneumothorax. Doubts raised about the safety of talc in performing pleurodesis because of reported complications. METHODS: A retrospective analysis of a consecutive series of thoracoscopic pleurodesis with talc was performed. Patients operated for spontaneous pneumothorax were analysed focusing on complications and freedom of recurrence. A literature search was performed on complications from the use of talc to treat pleural disease. RESULTS: From September 1999 till August 2004 forty-one patients had a thoracoscopic pleurodesis with talc. In 21 patients this was performed for recurrent malignant pleural effusion and in 20 for spontaneous pneumothorax. In 5 of these 20 patients we faced a secondary spontaneous pneumothorax. In seven patients an apical pulmonary wedge resection of bullae was performed. No intra-operative or serious postoperative complications were seen in these patients. All drains were removed after 4 to 6 days. No episodes of respiratory insufficiency occurred. No recurrence was encountered during a mean follow-up of 22.7 months. CONCLUSION: Thoracoscopic talc pleurodesis for spontaneous pneumothorax was effective and safe in our experience. In the literature no convincing evidence against the use of talc to treat pleural disease was found. Although some cases of ARDS are attributed to the pleural administration of talc, the incidence of complications after talc poudrage appears to be low.

Adolescent↗
PubMed2004

Pneumothorax and the value of chest radiography after ultrasound-guided thoracocentesis.

PURPOSE: To determine the incidence, the operator's experience, and other variables that may influence the development of pneumothorax or re-expansion edema after ultrasound (US)-guided thoracocentesis. MATERIAL AND METHODS: The medical records of 264 procedures in 212 patients who had undergone US-guided thoracocentesis in our radiology department or intensive care unit during the period 1996-2001 were retrospectively reviewed. RESULTS: Post-thoracocentesis pneumothorax occurred in 11 cases, the incidence being 4.2% (11/264). None of the pneumothoraces occurred in the 10 mechanically ventilated patients. All but one patient with pneumothorax were asymptomatic or had only minor symptoms. Chest tube drainage was needed in one patient with a large pneumothorax. No re-expansion edema was recorded, although 1500 ml or more pleural fluid was aspirated in 29 patients. The operator's experience had no effect on the complication rate. Needle size was the only significant variable that contributed to the pneumothorax rate. CONCLUSION: US-guided thoracocentesis can be done equally as safely by residents as by senior radiologists. The safety and feasibility of the method are evident among mechanically ventilated intensive care patients. Our results do not support the routine use of post-thoracocentesis chest radiography.

Adolescent↗
PubMed2005

Spontaneous pneumothorax associated with ankylosing spondylitis.

OBJECTIVE: To review the incidence and clinical characteristics of spontaneous pneumothorax in patients with ankylosing spondylitis (AS). METHODS: This is a retrospective observational cohort study. Chest radiographs and medical records of patients with a diagnosis of AS from 1993 to 2003 in a tertiary referral centre were reviewed. RESULTS: A total of 1028 patients with a diagnosis of AS were identified from July 1993 to July 2003. Twenty-two patients had typical apical lung fibrotic changes in the chest radiographs (22/1028, 2.1%). Three of these patients (3/22, 13.6%) with lung disease had pneumothorax. Two patients had recurrences and received video-assisted thoracoscopic surgery (VATS) on the second attack. The third patient received talc pleurodesis on the first attack and did not have a recurrence. The incidence of spontaneous pneumothorax in patients with AS was 0.29% (3/1028) with an incidence density of 64.85/100,000 patient-yr (95% confidence interval: 66.17-63.57/100,000). CONCLUSION: Spontaneous pneumothorax appears to be exceedingly rare in AS unless there is an underlying fibrocystic lung disease, in which case its occurrence is not uncommon. Cigarette smoking may be an important co-factor. Once developed, recurrences are common even after treatment. Prophylactic procedures should thus be considered for the first attack of spontaneous pneumothorax.

Adult↗
PubMed1995

Unrecognized pneumothorax as a cause of intraspinal air.

STUDY DESIGN: This is a case report. OBJECTIVE: A case of intraspinal air in a polytraumatized patient with unrecognized pneumothorax after blunt chest trauma is reported. SUMMARY OF BACKGROUND DATA: In most cases, intraspinal air is associated with degenerative disc disease, epidural abscess, or synovial cyst, or it follows iatrogenic manipulation. Scialdone and Wagle first reported a case of intraspinal air due to a laceration of the right main bronchus. No previous case of intraspinal air after a simple unsuspected pneumothorax following blunt chest trauma has been reported. METHODS: During routine x-ray and computed tomography examination of a polytraumatized patient, an unsuspected pneumothorax due to a rib fracture was detected in a thorax computed tomography scan. Computed tomography scans of the cervical spine showed a collection of intraspinal air. RESULTS: The computed tomography examination of a polytraumatized patient with an unsuspected pneumothorax after blunt chest trauma showed the embolization of air in the paravertebral vein plexus and in the intraspinal canal. CONCLUSION: These observations suggest a wider indication for computed tomography scans of the thorax in blunt chest trauma. Also, whenever intraspinal air is found in the diagnostic course of a traumatized patient, a hidden pneumothorax should be suspected and ruled out.

Adult↗
PubMed2005

Pneumothorax as a complication of breast augmentation.

BACKGROUND: Pneumothorax is a recognized complication of breast augmentation which, until now, was thought to be rare. The authors hypothesize that it is more common than generally appreciated. METHODS: A fax survey was sent to 363 members of the California Society of Plastic Surgeons in 2001, questioning their experience with this complication. RESULTS: The survey response rate was 50 percent, revealing that one in three members of the California Society of Plastic Surgeons had at least one patient who experienced a pneumothorax, and one in 10 had experienced two or more complications of pneumothorax while performing breast augmentation. Sixty-two members reported a total of 83 separate pneumothoraces in their career. No local or hypodermic needle injections were used in 24 percent of these patients. Fifty-five percent of patients were hospitalized, with 71 percent of the cases paid for by insurance companies. Treatment consisted of observation and repeated chest radiograph in 33 percent, needle aspiration alone in 16 percent, and chest tube insertion in 47 percent. CONCLUSIONS: The cause is difficult to determine, but causes suspected by respondents included intraoperative laceration of the pleura (43 percent), needle puncture at the time of local injection (37 percent), ruptured pulmonary blebs during or after the procedure (16 percent), and high anesthetic ventilation pressures (3 percent). The authors believe the complication of pneumothorax is more common than generally appreciated and is not necessarily caused by negligence. The authors now include this complication in their consent form and recommend keeping an intracatheter, pigtail catheter, or Heimlich valve in surgical facilities for treatment of a possible tension pneumothorax.

California↗
PubMed2005

Diagnosis of pneumothorax on F-18 FDG PET after transbronchial biopsy.

Transbronchial lung biopsy (TBLB) is associated with pneumothorax, 12% occurring 1 to 4 hours postprocedure (delayed pneumothorax). We report a case of a delayed pneumothorax first diagnosed on a positron emission tomography (PET) scan performed 5 days after TBLB. An early post-TBLB chest radiograph (after 1 hour) had not demonstrated any pneumothorax. The delayed pneumothorax was later confirmed with a repeat radiograph after the PET scan. Often, PET is performed to diagnose or stage pulmonary lesions after TBLB rather than before. Therefore, nuclear physicians must remain vigilant to recognize subtle pneumothoraces on PET scans.

Biopsy, Needle↗
PubMed2006

Pneumothorax secondary to acupuncture therapy.

A 27-year-old medical student seeking acupuncture therapy for a right levator scapular muscle spasm developed acute dyspnea, chest pain, and nonproductive cough within minutes following the treatment. The patient was later diagnosed with a 30% pneumothorax of the right lung. Pneumothorax is a well-known adverse effect of medical procedures such as central line placement, thoracocentesis and transbronchial lung biopsy. This case illustrates another iatrogenic cause of pneumothorax--acupuncture-induced pneumothorax. A review of the literature since 1985 reveals nine case reports of acupuncture-induced pneumothorax.

Acupuncture Therapy↗
PubMed1991

Spontaneous pneumothorax: marker gas technique for predicting outcome of manual aspiration.

OBJECTIVE: To determine whether in a patient with spontaneous pneumothorax the presence or absence of a pleural leak can be shown at the time of manual aspiration by use of a marker gas. Also, to find out if the technique can predict whether manual aspiration will be successful, hence avoiding the need for intercostal tube drainage. DESIGN: Prospective study of 25 episodes of pneumothorax during which patients breathed air from a Douglas bag that contained chlorofluorocarbon gases from a metered dose inhaler while the pneumothorax was aspirated. SETTING: Medical unit of a district general hospital. PATIENTS: 22 patients who presented over nine months with acute pneumothorax. MAIN OUTCOME MEASURES: Presence or absence of chlorofluorocarbon marker gases in the aspirate. Presence or absence of sustained re-expansion of the affected lung in the chest radiograph. RESULTS: Marker gas was detected in the aspirate from 16 out of 25 pneumothoraces. Of these, 13 required intercostal tube drainage because of failure of the lung to re-expand. Marker gas was not detected in nine cases, and in all of these cases manual aspiration resulted in sustained re-expansion of the lung. CONCLUSIONS: The presence or absence of a pleural leak during manual aspiration of spontaneous pneumothorax can be shown by using this technique. The absence of marker gas in the aspirate implies that manual aspiration will be successful, whereas its presence predicts, in most cases, either failure of manual aspiration to expand the lung or early re-collapse of the lung.

Acute Disease↗
PubMed1998

British Thoracic Society guidelines for the management of spontaneous pneumothorax: do we comply with them and do they work?

OBJECTIVES: To determine how British Thoracic Society (BTS) guidelines for the management of spontaneous pneumothorax have been implemented over a four year period in a large district general hospital with a specialised respiratory unit. To assess the validity of the guidelines in the management of spontaneous pneumothorax. METHODS: A retrospective case notes study over a four year period for all patients with spontaneous pneumothoraces attending the accident and emergency (A&E) department of a large district general hospital. RESULTS: 115 episodes of spontaneous pneumothorax were identified. Overall 20.8% of episodes were treated correctly by BTS guidelines. Decisions made by A&E staff were significantly more likely to be correct than decisions made by on call medical teams (39.4% v 13.4%, p = 0.002). There was a non-significant trend towards better compliance with BTS guidelines over the four year period. The management decision was made by A&E staff only in 28.7% of episodes. Patients without chronic lung disease could be safely observed as outpatients. Forty three pneumothoraces were aspirated: 23 (58%) successfully; eight (18.6%) with little or no improvement; and 12 (27.9%) initially successfully but developing increased size of pneumothorax within a period of 72 hours. Three patients had repeat aspirations, two successfully. Age over 50, chronic lung disease, and more than 2.5 litres of air aspirated were significantly associated with failure of aspiration (p < 0.01). There was a 28.6% failure rate of aspiration for patients with moderate pneumothoraces without chronic lung disease. CONCLUSIONS: Patients over the age of 50 should be treated the same as patients with chronic lung disease. A second aspiration should be attempted if the first aspiration is initially successful with subsequent recurrence of pneumothorax. Further research is required to clarify if patients with moderate pneumothoraces under the age of 50 and no chronic lung disease should be aspirated or observed.

Adult↗
PubMed2000

Management of spontaneous pneumothorax-a Welsh survey.

The authors sought to determine to what degree current practice by hospital physicians and accident and emergency (A&E) departments in Wales conformed to the British Thoracic Society's guidelines for the management of spontaneous pneumothorax. Questionnaires were posted to all consultants involved in emergency medical admissions in Wales (149 consultant physicians and 23 A&E consultants) of whom 101 (59%) replied. Only 45% used the classification, "small, moderate, or complete" to describe the size of pneumothorax. Just 44% would do as recommended by the British Thoracic Society and discharge an asymptomatic patient with a primary pneumothorax and 34% would discharge a patient with a primary pneumothorax after successful aspiration. Only 20% were prepared to try aspiration initially for a secondary pneumothorax with a complete lung collapse. Thirty four per cent would follow the recommendation to remove a chest drain without prior clamping of the tube 24 hours after bubbling had stopped. In the event of a persistent air leak 69% would refer patients or seek a specialist opinion. Physicians with an interest in respiratory medicine tolerated persistent air leaks for significantly longer than did non-respiratory physicians (median of 7 v 5 days, p=0.001). The survey indicates that fewer than expected consultant physicians and A&E consultants in Wales manage spontaneous pneumothoraces in the way recommended by the guidelines. Physicians with an interest in respiratory medicine tended to comply with these guidelines more than general physicians with interests other than respiratory medicine or A&E consultants but the trend was not significant at the 5% level. It is felt that the guidelines should be disseminated more widely, ensuring that emergency admissions units and A&E departments have copies on display or easily accessible, and that they could be expanded to cover other aspects such as timing for surgery.

Chest Tubes↗
PubMed1985

Effects of pneumothorax or pleural effusion on pulmonary function.

The effects of pneumothorax or pleural effusion on respiratory function as measured by the commonly applied tests were investigated by studying 13 patients (six with pneumothorax, seven with effusion) with and, as far as possible, without air or fluid in the pleural cavity. Measurements included spirometric volumes, carbon monoxide transfer factor (TLCO), and KCO by the single breath method, maximum expiratory flow-volume curves, and subdivisions of lung volume estimated by both inert gas dilution and body plethysmography. In patients with pneumothorax "pleural volume" was estimated as the difference between lung volumes measured by dilution and thoracic gas volume measured by plethysmography. In patients with effusion the change in "pleural volume" was equated with the volume of fluid subsequently aspirated. "Total thoracic capacity" (TTC) was estimated by adding total lung capacity (TLC) measured by dilution and "pleural volume." Both effusion and pneumothorax produced a restrictive ventilatory defect with reductions of vital capacity, functional residual capacity, and TLC. In the patients with effusion TTC fell after aspiration, suggesting that the pleural fluid produced relative expansion of the chest wall as well as compression of the lung. In patients with pneumothorax, however, there was no difference in TTC with and without air in the pleural space. In the presence of pleural air or fluid there was a slight decrease in TLCO and increase in KCO, with a small but significant increase in the rate of lung emptying during forced expiration.

Adolescent↗
PubMed1985

A place for aspiration in the treatment of spontaneous pneumothorax.

In a retrospective survey of 195 patients with spontaneous pneumothorax, 100 had a deep (greater than 20%) air space. Thirty one patients were considered unsuitable for aspiration because of complicating disease. Sixty nine patients were treated by aspiration, and in 45 of these reexpansion was sufficient for the case to be managed as shallow pneumothorax while the patient remained ambulant. The average initial aspiration from the 69 patients was 1 X 1 litres. The intrapleural pressure was subatmospheric in only 22 (49%) of the 45 successfully aspirated patients. A chest radiograph several hours after aspiration is the principal control required for this treatment. The recurrence rate was 11.1%. Of 95 patients with a shallow pneumothorax, 3 were intubated for progressive lung collapse and the remainder were encouraged to lead a normal life. The recurrence rate was 11.6%. Retrospectively, it was concluded that 137 patients (70%) had a closed pneumothorax at diagnosis. Primary intubation of all patients with a deep pneumothorax would have represented overtreatment.

Humans↗
PubMed1991

Pneumothorax and malignant mesothelioma in patients over the age of 40.

Five patients over the age of 40 with malignant mesothelioma of the pleura presented with a spontaneous pneumothorax in the course of five years. The diagnosis of malignant mesothelioma was not suspected at surgery but was made by histological examination of the pleurectomy specimens. During this time 91 pleurectomies for recurrent pneumothorax were performed, 45 in patients over the age of 40; malignant mesothelioma therefore accounted for 11% of spontaneous pneumothorax requiring pleurectomy in this age group. The association of spontaneous pneumothorax and malignant mesothelioma is not emphasised in current publications. These five cases highlight the need for all pleurectomy specimens in cases of spontaneous pneumothorax to be sent for histological examination and for a full occupational history to be taken, especially in older patients.

Adult↗