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PubMed1997

Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia.

BACKGROUND: Complicated (recurring or persistent) spontaneous pneumothorax requires treatment either by talc pleurodesis with bullae electrocoagulation or, more aggressively, by thoracotomy or video-assisted thoracoscopic surgery. However, the relative merits of bullectomy, pleurectomy, and pleurodesis have not yet been established in the treatment of spontaneous pneumothorax. METHODS: The complications, duration of drainage, length of hospital stay, and immediate and long term success rate of treating complicated spontaneous pneumothorax with talc pleurodesis under local anaesthesia supplemented with nitrous oxide were studied. RESULTS: Talc pleurodesis was performed in 93 patients without serious complication (two benign arrhythmias, two subcutaneous emphysema, two pneumonia, one bronchospasm). The procedure was immediately successful in 90 patients (97%) with a median duration of drainage of five days (range 2-40) and a median length of hospital stay of 5.2 days (range 3-40). After a mean follow up duration of 5.1 (range 1-9.4) years in 84 cases the long term success rate was 95%, although six cases developed a small localised recurrence of spontaneous pneumothorax which did not require further surgery. Macroscopic staging at thoracoscopy was only carried out in the last 59 cases of whom 10 (17%) had bullae with a diameter of > 2 cm. In this group of patients the risk of definitive failure requiring surgery was significantly higher than in those patients without such bullae (odds ratio 7; confidence interval 3.7 to 13.3; p = 0.03), although eight of these patients did not require thoracotomy. Total lung capacity was reduced immediately after talc pleurodesis (mean (SD) 75 (23)% predicted at 10 days) but had improved to 95 (14)% predicted at 12 months. CONCLUSIONS: This study shows that simple thoracoscopic talc pleurodesis under local anaesthesia is a safe and effective treatment for complicated spontaneous pneumothorax. However, patients with bullae of > 2 cm in diameter have a greater risk of treatment failure.

Adolescent↗
PubMed1997

Recurrence of primary spontaneous pneumothorax.

BACKGROUND: Primary spontaneous pneumothorax (PSP) is a common clinical problem and its incidence is thought to be increasing. The risk of recurrence is high and various studies quote rates of 20-60%. Factors which may or may not predispose to recurrence have not yet been established. METHODS: In a study period of four years 291 cases with a diagnosis of pneumothorax were reviewed; 153 patients with PSP were included in the study. Their risk of recurrence was analysed with particular reference to the following variables: age, sex, height and body mass index (BMI) of the patient, the initial size of pneumothorax, the smoking status of the patient, and the primary form of treatment employed. Univariate analysis was carried out by chi 2 testing and multivariate analysis was calculated by a logistic regression model. RESULTS: A retrospective study of 275 episodes of PSP in 153 patients over a four year period confirmed a high incidence of recurrence (54.2%). PSP was twice as common in men as in women, though women were significantly more likely to develop a recurrence (chi 2 = 7.58, df = 1, p < 0.01). Male height was the second most important factor, and smoking cessation the only other variable which significantly influenced the risk of recurrence. CONCLUSIONS: Analysis of several potential risk factors revealed that recurrence was not related to the BMI of the patient, the initial treatment of the pneumothorax, nor to its size. Recurrence was more common in taller men and in women. Smoking cessation appeared to reduce the risk of recurrence. These findings are discussed in the context of the possible aetiology of spontaneous pneumothorax, recurrences, and the management thereof.

Adolescent↗
PubMed2005

New suction guide needle designed to reduce the incidence of biopsy-related pneumothorax: experimental evaluation in canine model.

In an attempt to remove air that enters the pleural space during computed tomography (CT)-guided coaxial transthoracic needle biopsy, the authors fashioned an 18-gauge experimental suction guide needle and evaluated the incidence of pneumothorax with this needle in comparison to the incidence of pneumothorax with a standard 18-gauge guide needle in a canine model. This experiment had animal care and use committee approval. Ten dogs underwent a biopsy of each lung, for a total of 20 lung biopsies. Half of the biopsies were performed by using the experimental needle (five right lungs, five left lungs), and half were performed by using a standard guide needle. CT revealed pneumothorax during the procedure and was performed to reveal pneumothorax 1 and 3 hours after the procedure. A significant reduction (P < .016) in intraprocedural lung biopsy-associated pneumothorax was found when the experimental guide needle was used.

Animals↗
PubMed1988

Pneumothorax: radiologic treatment with small catheters.

In many institutions, the standard treatment of symptomatic and large pneumothoraxes has been with surgically placed large-bore (22-32-F) chest tubes. During the past 3-4 years, the authors used small catheters (7, 8.2, and 9.4 F) to decompress 30 pneumothoraxes (15 under tension) resulting from percutaneous lung biopsy. The catheters were inserted under computed tomographic or fluoroscopic guidance for the treatment of large (greater than 35%) or symptomatic pneumothoraxes. Twenty-eight of 30 patients were treated successfully with the small catheters alone; two patients underwent surgical placement of 32-F tubes (4 and 12 hours later) because of incomplete resolution of the pneumothoraxes. This series demonstrates that small-caliber catheters effectively decompress pneumothoraxes and that they can be inserted expeditiously by radiologists in the radiology department.

Adult↗
PubMed1988

Pneumothorax and other lung diseases: effect of altered resolution and edge enhancement on diagnosis with digitized radiographs.

Prior studies have shown that pneumothorax is one of the more difficult entities to diagnose with digitized radiography. This study was designed to test whether increasing resolution from 1.25 to 2.5 line pairs per millimeter (lp/mm) and image processing (edge enhancement from unsharp masking) would increase accuracy and confidence in the diagnosis of pneumothorax, as well as normal cases and other forms of lung disease. Conventional radiographs were digitized with use of a laser reader and then reformatted as film hard copy. Eleven observers read 35 cases reformatted in three different ways (1.25 lp/mm, 2.5 lp/mm, 1.25 lp/mm unsharp mask). The images with finer resolution (2.5 lp/mm) and unsharp mask images were superior to those with coarser resolution (1.25 lp/mm) for the diagnosis of pneumothorax. There was no difference in diagnostic accuracy for normal patients. For abnormalities other than pneumothorax, the unsharp mask images were significantly worse. Confidence in the diagnosis of pneumothorax and other abnormalities was highest with the finest resolution (2.5 lp/mm).

Humans↗
PubMed1992

Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers: implications for detection in patients.

Pneumothorax was induced in cadavers to determine the effects of patient positioning and imaging modality (conventional screen-film and computed radiography) on radiographic findings. Chest radiography, with cadavers in the supine frontal, erect frontal, and left lateral decubitus positions, was performed at baseline and after injection of incremental quantities of air into the pleural space. Five radiologists independently interpreted each radiograph. The ability of the radiologists to diagnose pneumothorax varied by cadaver position and depended on volume of air. Overall, the left lateral decubitus view was most sensitive (88%) for diagnosis of pneumothorax, followed by the erect (59%) and supine (37%) views. Receiver operating characteristic curves and multiple repeated measures analysis of variance revealed no statistically significant difference between diagnostic proficiency with conventional screen-film radiography and that with computed radiography. The authors conclude that the lateral decubitus view is superior to the erect and supine views for pneumothorax detection and that conventional and computed radiography perform similarly in pneumothorax detection.

Cadaver↗
PubMed2000

Autologous blood clot seal to prevent pneumothorax at CT-guided lung biopsy.

PURPOSE: To determine whether the use of autologous blood clot seal (ABCS) after biopsy of lung lesions can reduce or prevent pneumothorax. MATERIALS AND METHODS: The authors evaluated 100 patients (63 men, 37 women; age range, 27-78 years) with pleural (n = 23) or deep (n = 77) lesions. Thirty-eight patients had emphysema. Patients were randomly assigned to one of two groups: those in whom the biopsy track was sealed with autologous blood clot (n = 50) and those who did not receive autologous blood clot (n = 50). Biopsy was performed with computed tomographic (CT) guidance and a 19-gauge coaxial system. The autologous blood clot, which ranged from 0.5 to 4.5 mL, was injected while the sheath was being withdrawn. RESULTS: Pneumothorax developed in four of the 23 patients (17%) with pleural lesions and 19 of the 77 patients (24%) with deep lesions. Pneumothorax occurred in four of the 45 patients (9%) who had deep lesions and received autologous blood clot and in 15 of the 32 patients (47%) who had deep lesions and did not receive autologous blood clot (P <.001). In patients with emphysema, pneumothorax occurred in three of the 20 patients (15%) who received autologous blood clot and 10 of the 14 (71%) who did not (P <.001). There were seven large pneumothoraces necessitating treatment; all occurred in patients who did not receive autologous blood clot. CONCLUSION: Plugging of biopsy tracks with ABCS, particularly after biopsy of deep lung lesions, significantly reduced the frequency of pneumothorax-particularly of large pneumothoraces-and, therefore, the need for treatment and the attendant cost.

Adult↗
PubMed2001

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

BACKGROUND: Although manual aspiration is used for treating pneumothorax, the post-aspiration radiograph may not be a reliable indicator of whether the pleural leak remains. We have previously shown that marker gas can identify an air leak in patients with spontaneous pneumothoraces. OBJECTIVE: This study examines whether a marker gas technique can be safely used to manage patients with iatrogenic pneumothoraces. METHODS: 10 patients with iatrogenic pneumothorax were identified among a cohort referred for manual aspiration of pneumothorax, using a marker gas technique, in which inspired metered-dose inhaler propellant gas is detectable in pneumothorax aspirate using a portable flame ioniser. The presence of marker gas was taken to imply a persistent air leak. RESULTS: Marker gas was detected in the aspirate from 3 out of 10 pneumothoraces. 2 required intercostal tube drainage because of lung collapse following initial aspiration and 1 was treated conservatively. Marker gas was not detected in 7 cases (2 post-pacemaker insertion, 5 pleural aspiration +/- biopsy), and in all these cases, manual aspiration resulted in sustained re-expansion of the lung. There was a trend towards a significant relationship between the presence or absence of marker gas and the need for a further intervention (p = 0.055). CONCLUSION: The presence or absence of a pleural leak during manual aspiration of iatrogenic pneumothorax can be demonstrated by this technique. The absence of marker gas in the aspirate implies that manual aspiration will be successful, whereas its presence, in most cases, predicts either failure of manual aspiration to expand the lung or early re-collapse of the lung.

Aged↗
PubMed1979

Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950 to 1974.

Between 1950 and 1974, 318 cases of initial pneumothorax were diagnosed among the residents of Olmsted County, Minn. Seventy-five cases were due to trauma, and 102 were iatrogenic. One hundred forty-one cases were spontaneous in onset, of which 77 were primary and 64 secondary to a specific underlying pulmonary disease. The age-adjusted incidence of primary spontaneous pneumothorax was 7.4/100,000/yr for males and 1.2/100,000/yr for females. For secondary spontaneous pneumothorax, the incidence was 6.3 and 2.0/100,000/yr for males and females, respectively. The ratio of male-to-female incidence was 6.2:1 for primary and 3.2:1 for secondary spontaneous pneumothorax. The differences between the incidence rates for primary and secondary pneumothorax by sex or in total were not significantly different.

Female↗
PubMed2005

Additional minocycline pleurodesis after thoracoscopic surgery for primary spontaneous pneumothorax.

RATIONALE: Ipsilateral recurrence rates of spontaneous pneumothorax after video-assisted thoracoscopic surgery are higher than rates after open thoracotomy. OBJECTIVES: This study was conducted to determine whether additional minocycline pleurodesis would be effective in diminishing recurrence after video-assisted thoracoscopic surgery treatment of primary spontaneous pneumothorax. METHODS: Between June 2001 and February 2004, 202 patients with primary spontaneous pneumothorax were treated by conventional or needlescopic video-assisted thoracoscopic surgery. The procedures included resection of blebs and mechanical pleurodesis by scrubbing the parietal pleura. After the operation, patients were randomly assigned to additional minocycline pleurodesis (103 patients) or to observation (99 patients). MAIN RESULTS: Patients in the minocycline group had higher intensity chest pain and required a higher accumulated dose of meperidine. Short-term results showed that the two groups had comparable chest drainage duration, postoperative hospital stay, and complication rates. Patients in the minocycline group demonstrated a trend of decreased rate of prolonged air leaks (1.9 vs. 6.1%, p = 0.100). After a mean follow-up of 29 mo (12-47 mo), recurrent ipsilateral pneumothorax was noted in two patients in the minocycline group and eight patients in the observation group (p = 0.044 by the Kaplan-Meier method and log-rank test). Postoperative long-term residual chest pain and pulmonary function were comparable in both groups. CONCLUSIONS: Although associated with intense immediate chest pain, additional minocycline pleurodesis is a safe and convenient procedure that can reduce the rate of ipsilateral recurrence after thoracoscopic treatment for primary spontaneous pneumothorax.

Adult↗
PubMedDate not supplied

Mechanisms of pneumothorax following tracheal intubation.

To investigate the mechanism by which pneumothorax may occur as a complication of tracheal intubation, we submitted four cats to tracheotomy and three to tracheal intubation. To simulate the dissection of air along fascial planes following tracheotomy, we placed catheters in either the pretracheal or subcutaneous plane and applied positive pressure to the catheters. The cats undergoing tracheal intubation were ventilated with excessive positive pressure. Computed tomography was used to document the progression of pneumothorax. High positive pressures during mechanical ventilation led to pneumothorax and pneumomediastinum, and the mechanism was primarily the dissection of air along the perivascular sheaths of the pulmonary arteries, presumably due to rupture of perivascular alveoli. Dissection of air along the pretracheal fascia following tracheotomy produced pneumomediastinum but not pneumothorax. This suggests that pneumothorax occurring clinically is more likely a complication of assisted ventilation than a complication of tracheotomy surgery.

Animals↗
PubMedDate not supplied

Delayed pneumothorax after subclavian vein catheterization.

One hundred fourteen patients having 121 subclavian venipunctures were studied retrospectively. Eight pneumothoraces occurred (6.6%) and were most frequent after the insertion of large catheters, or when the subclavian area was distorted by previous venipuncture or radiation. Delayed pneumothorax occurred in five patients. This unusual diagnosis was made radiographically 8 to 96 hr postoperatively in response to the appearance of new pulmonary symptoms. Delayed pneumothorax required treatment with tube thoracostomy more frequently than immediate pneumothorax. This study establishes the approximate incidence of delayed pneumothorax for the first time. The relative frequency of this complication may challenge the cost effectiveness of pneumothorax diagnosis by chest films done within 1 or 2 hr of subclavian venipuncture. An alternative diagnostic protocol is considered.

Adolescent↗
PubMed2001

Impaired early neurologic outcome in newborn piglets reoxygenated with 100% oxygen compared with room air after pneumothorax-induced asphyxia.

Birth asphyxia is a serious problem worldwide, resulting in 1 million deaths and an equal number of neurologic sequelae annually. It is therefore important to develop new and better ways to treat asphyxia. In the present study we tested the effects of reoxygenation with room air or with 100% oxygen (O2) after experimental pneumothorax-induced asphyxia on the blood oxidative stress indicators, early neurologic outcome, and cerebral histopathology of newborn piglets. Twenty-six animals were studied in three experimental groups: 1) sham-operated animals (SHAM, n = 6), 2) animals reoxygenated with room air after pneumothorax (R21, n = 10), and 3) animals reoxygenated with 100% O2 after pneumothorax (R100, n = 10). In groups R21 and R100, asphyxia was induced under anesthesia with bilateral intrapleural room air insufflation. Gasping, bradyarrhythmia, arterial hypotension, hypoxemia, hypercarbia, and combined acidosis occurred 62 +/- 6 min (R21) or 65 +/- 7 min (R100; mean +/- SD) after the start of the experiments; then pneumothorax was relieved, and a 10-min reoxygenation period was started with mechanical ventilation with room air (R21) or with 100% O2 (R100). The newborn piglets then breathed room air spontaneously during the next 3 h. Blood oxidative stress indicators (oxidized and reduced glutathione, plasma Hb, and malondialdehyde concentrations) were measured at different stages of the experiments. Early neurologic outcome examinations (neurologic score of 20 indicates normal, 5 indicates brain-dead) were performed at the end of the study. The brains were next fixed, and various regions were stained for cerebral histopathology. In the SHAM group, the blood gas and acid-base status differed significantly from those measured in groups R21 and R100. In group R100, arterial PO2 was significantly higher after 5 (13.8 +/- 5.6 kPa) and 10 min (13.2 +/- 6.3 kPa) of reoxygenation than in group R21 (8.7 +/- 2.8 kPa and 9.2 +/- 3.1 kPa). The levels of all oxidative stress indicators remained unchanged in the study groups (SHAM, R21, and R100). The neurologic examination score in the SHAM group was 18 +/- 0, in group R21 it was 13.5 +/- 3.1, and in group R100 it was 9.5 +/- 4.1 (significant differences between SHAM and R21 or R100, and between R21 and R100). Cerebral histopathology revealed marked damage of similar severity in both asphyxiated groups. We conclude that the blood oxidative stress indicators and cerebral histopathology did not differ significantly after a 10-min period of reoxygenation with room air or with 100% O2 after pneumothorax-induced asphyxia, but reoxygenation with 100% O2 might impair the early neurologic outcome of newborn piglets.

Acid-Base Equilibrium↗
PubMed2000

Do bullae indicate a predisposition to recurrent pneumothorax?

A relationship between idiopathic spontaneous pneumothorax (ISP) and visible parenchymal bullae and blebs has been reported. The causal relationship between blebs and bullae and ISP is questionable. Consequently, resection of the involved area is only indicated if it predisposes to recurrence of the pneumothorax. CT studies on 101 cases of ISP were analysed. The presence of bullae and their distribution was then related to the first and recurrent pneumothorax. CT demonstrated bullae in 56% of first ISP and in 64% of recurrent ISP, mostly among older patients. Only eight patients had bullae larger than 2 cm on the side of the pneumothorax. The location of the bullae was not a factor in predicting recurrent pneumothorax.

Adult↗
PubMed1993

Spontaneous pneumothorax following partial resolution of total bronchial obstruction.

Spontaneous pneumothorax following chest irradiation is thought to occur in patients with radiation fibrosis several months or more after the completion of therapy. In the four patients presented herein, spontaneous pneumothorax was seen during or immediately after therapeutic radiation of lung cancer. All patients had bronchoscopic findings of bronchial obstruction by the tumor before treatment and radiographic improvement of atelectasis was observed during therapy. The interval between the improvement of atelectasis and the development of pneumothorax varied by less than three weeks. These common findings suggest that rupture of alveoli or emphysematous bullae and subsequent pneumothorax might be due to overinflation of the affected lung caused by partial bronchial obstruction. We should be aware of the occurrence of spontaneous pneumothorax following partial resolution of total bronchial obstruction.

Aged↗
PubMed1994

Risk of pneumothorax not increased by obstructive lung disease in percutaneous needle biopsy.

All computed tomography directed lung biopsies from 1987 to 1991 were retrospectively reviewed. Pneumothorax occurred in 33 of 93 (35 percent) patients; 16 of these patients or 17 percent overall required a chest tube. No correlation was found between the presence of obstructive lung disease and the incidence of pneumothorax. Patients with smaller lesions were more likely to incur a pneumothorax. No relation was found with central or peripheral location, patient's age, or the operator and the incidence of pneumothorax. Patients with a pneumothorax were more likely to require a chest tube if they had obstructive lung disease.

Aged↗
PubMed1994

Intrapleural talc for the prevention of recurrent pneumothorax.

The ipsilateral recurrence rate after the first spontaneous pneumothorax treated with tube thoracostomy is reported to be between 23 percent and 52 percent. The incidence of recurrence after the first recurrence is substantially higher. Chemical pleurodesis has been attempted to decrease the recurrence rate. Tetracycline has been widely utilized, but parenteral tetracycline is no longer available. Therefore, alternative sclerosing agents have been used. Talc has been demonstrated to be effective in preventing recurrences and it has minimal long-term effects. This prospective study was designed to determine the efficacy of talc pleurodesis in patients with recurrent spontaneous pneumothorax. Eighteen patients admitted between May 1985 and March 1993 to the Department of Thoracic Surgery underwent thoracoscopy and were treated by tube thoracostomy with chemical pleurodesis. All the patients had had at least two pneumothoraces and six had had at least six pneumothoraces. Sterile asbestos-free talc, 2g, was aerosolized throughout the pleural surface. One or two chest tubes were inserted, left clamped for 2 h, and unclamped after this time. The tubes were removed when no air had escaped for 24 h. Only one (5.6 percent) patient had recurrence of the pneumothorax, and a second insufflation of talc resulted in no new recurrence after a follow-up of 10 months. The remaining 94.4 percent did not have recurrence of pneumothorax within an observation period of 38.5 +/- 28.1 months. The follow-up was more than 2 years for 66.7 percent with no recurrence and was more than 5 years for 33.3 percent. We conclude from these observations that the insufflation of 2 g of talc into the pleural space is a safe effective treatment for control of recurrent spontaneous pneumothorax.

Adult↗
PubMed1999

Evaluation of patient-related and procedure-related factors contributing to pneumothorax following thoracentesis.

OBJECTIVE: To evaluate patient-related and procedure-related risk factors for thoracentesis-related pneumothorax. DESIGN: Prospective, nonrandomized cohort study. SETTING: Pulmonary Special Procedures Unit of a university medical center. METHODS: Thoracentesis using either a 22-gauge, a Boutin, or a Cope needle (depending on availability and operator preference) was performed by the pulmonary faculty or by pulmonary physicians-in-training under faculty supervision. In order to control for effusion size and the presence of loculations, chest radiography and pleural ultrasonography were performed prior to each thoracentesis. Potential patient-related and procedure-related risk factors for pneumothorax were analyzed at the procedure level using the presence or absence of pneumothorax on the postprocedure chest radiograph as the sole outcome variable. RESULTS: Two hundred fifty-five thoracenteses were performed in 205 adult patients (113 men and 92 women; mean age, 58.8+/-18 years) over a 3(1/2)-year period. One hundred fifty procedures were performed for diagnostic purposes, 28 procedures were performed for therapeutic purposes, and 77 procedures were performed for both diagnostic and therapeutic purposes. Based on the radiographic criteria, 152 effusions (60%) were small. Loculations were present in 76 patients (30%). Pneumothoraces occurred in 14 instances (5.4%), and chest tube drainage was required in 2 instances (0.78%). Hospitalization status, critical illness, effusion size or type, presence of loculations, operator, needle type, amount of fluid withdrawn, occurrence of dry tap, and type of thoracentesis were not associated with an increased frequency of pneumothorax. The only predictor variable demonstrating statistical significance was repeated thoracentesis. CONCLUSION: The results of a bivariate analysis suggest that pneumothorax following thoracentesis is a rare event that is not easily predictable when the procedure is performed by experienced operators in a controlled setting.

Chest Tubes↗