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Spontaneous pneumothorax due to primary lung cancers are increasingly reported as of lung cancer incidence increased. We experienced one lung cancer case with pneumothorax as a primary symptom and two who developed pneumothorax after chemotherapy, among 238 cases of primary lung cancer. In the literature, 76 cases of pneumothorax due to primary lung cancers are described. The mechanism of pneumothorax is discussed.
Spontaneous pneumothorax is a rare complication in both primary and metastatic pulmonary neoplasms. Occasionally, pneumothorax is associated with chemotherapy of pulmonary malignancies. Pneumothorax after chemotherapy has been reported only in cases with osteogenic sarcoma, synovial sarcoma, fibrosarcoma, germinal tumors, and lymphoma with lung metastasis. We report a case of a patient with malignant thymoma who suffered from lung metastasis after radiation and adjuvant chemotherapy from lung metastasis after radiation and adjuvant chemotherapy (cyclophosphamide, adriamycin, and cis-platinum). A chest X-ray taken 2 days after chemotherapy showed bilateral pneumothorax, which was resolved with conservative treatment. The pneumothorax in this patient is believed to have been caused by the rupturing of the tumor into the pleural cavity and the bronchi.
In the present study the aims were to analyse the difference in various treatment, complications and recurrence rates between patients with spontaneous pneumothorax and those associated with chronic obstructive lung disease (COLD). We made a retrospective analysis with regard to the therapy of all patients with spontaneous pneumothorax who were treated in the district lung hospital Lostau from 1. Jan 1986 to 31. Dec 1988 (171 patients, men: 136, women: 35). 45 patients suffered from a COLD (men: 42, women: 3). 3 methods of the treatment were set in: 1. conservative management by expectant observation, 2. the aspiration once or repeatedly with the pneumothorax apparatus and 3. the rubber-tube drainage. We consider the aspiration of spontaneous pneumothorax with pneumothorax apparatus as an effective method, which is not very burdensome for the patients. It is our opinion that the practice in patients with a COLD is more active than this in other patients, in form of the rubber-tube drainage.
We have previously shown that in dogs with normal lungs, dependent placement of the puncture site reduced and/or stopped pneumothorax formation while breathing spontaneously. This experiment is now repeated in an acute injury model in dogs receiving either intermittent positive pressure ventilation (IPPV) or continuous positive pressure ventilation (CPPV). Pneumothorax was induced by percutaneous transthoracic insertion of a 20-gauge needle into the right lung. After a constant rate of pneumothorax formation was established (measured by evacuation of right pleural gas by chest tube), the dogs were alternated between 3 min with the puncture site up (left decubitus) or down (right decubitus). Only when the puncture was placed down did the rate of pneumothorax formation decrease (in every case), and this maneuver caused the leak to seal in 21 and 30% of the times with IPPV and CPPV, respectively. These results are consistent with the hypothesis that dependent placement of the puncture site allows reduction of both the alveolar size and alveolar to pleural pressure difference in the region surrounding the leak, thereby reducing and possibly stopping pneumothorax formation.
We made a retrospective analysis with regard to the therapy of all patients with spontaneous pneumothorax who were treated in the district lung hospital Lostau from 1. 1. 1983 to 30. 6. 1985. We waited for the spontaneous regression at 10 patients with a partial pneumothorax, the relapse rate was 30% in these cases. Sixty three patients were aspirated once or repeatedly with the pneumothorax apparatus. Our own success rate was 78% with this therapy, the relapse rate 26%. We treated 18 patients by rubber-tube drain. It was successful in 94%, the relapse rate was 19%. A thoracoscopy with pleurodesis was necessary in one patient who was generally inoperable. Five patients were treated primarily surgically. The same therapy was carried out in 6 patients with bullous emphysema in the free period. We consider the aspiration of spontaneous pneumothorax with pneumothorax apparatus as an effective method, which is not very burden some for the patients. The continuous suction drainage was very important too in the differential therapy of our patients.
Although intravenous drug abuse is endemic in urban America, only 19 cases of pneumothorax from neck injections have been reported. For this reason, the experience at Detroit Receiving Hospital was reviewed. Data collected included patient demographics, size of pneumothorax, use of antibiotics, and complications related to tube thoracostomy. Of 525 diagnoses of pneumothorax between January 1, 1982 and December 31, 1984, 113 (21.5%) occurred as a result of drug abuse in 84 patients. Average patient age was 32 years (range 20 to 55 years). Thirty-eight (45%) were female. The number of admissions per year has increased, and 11 patients showed multiple admissions over the 3-year study period. Nine patients had bilateral collapse. One hundred six pneumothoraces (94%) were treated with closed thoracostomy with a tube-related hospital stay of 5 days, overall stay averaging 7 days. Only six patients received antibiotics for chest tube prophylaxis, and no in-hospital tube-related infections were identified. Thirteen patients developed residual pneumothorax following tube removal, but only two required a new tube. Pneumothorax in drug abusers is a serious urban problem and one with which physicians need be familiar.
Pneumothorax and haemothorax constitute serious complications of a blunt chest trauma. During 1970-1978 64 persons with pneumothorax and 109 cases of haemothorax were admitted to and treated in the Surgical Unit of the University Hospital, Göttingen. In nearly every case fracture of several ribs had also occurred. The method of choice for treating cases of pneumothorax was by Bülau drainage; surgical closure of the air leakage was rarely necessary. Conservative measures are indicated only if the pneumothorax is narrow or confined to the apical region. It is worth mentioning that in a large number of cases pneumothorax developed during positive pressure ventilation after a chest injury. Complications of Bülau drainage were: damage to the lungs, skin emphysema and bleeding from the intercostal artery. Open application of the Bülau drainage in the 2nd intercostal space is therefore recommended. Treatment of traumatic pleural effusions by Bülau drainage was required in only 14 of 109 cases. Therapy-resistent effusions necessitated thoracotomy and evacuation of the haematoma in 4 persons. If Bülau drainage fails completely to evacuate the haemothorax, it should be promptly followed by thoracotomy to prevent the development of adhesions and the resulting impairment of respiratory function.
Spontaneous pneumothorax is a rare complication of metastatic lesions of the lung. Treatment was given to 111 cases of synovial sarcoma at the Center Clinics in 1975-1981, lung metastases being in 53 cases (47.7%). Spontaneous pneumothorax was registered in 4 patients (3.6%) out of the total number of cases and in 7.55% of those with lung metastases. Three cases of spontaneous pneumothorax and lung metastases of synovial sarcoma revealed no symptoms. Therapeutic effect was obtained by conservative treatment. The risk of spontaneous pneumothorax in cases of lung metastases is increased after chemotherapy, which may be associated with the disintegration of subpleural metastases. Pneumothorax did not interfere with repeated courses of chemotherapy.
We have observed four patients with sarcoidosis who developed pneumothorax. In one of the patients who had a thoracotomy, non-caseating granulomata were seen to be extensively involving the pleura. The patient had five episodes of spontaneous pneumothorax involving both lungs before and after surgery. Such episodes were not observed following insititution of corticosteroid therapy. Whether pneumothorax and sarcoidosis are two independent processes occurring in the same individual or whether the pneumothorax is causally related to the sarcoidosis has not been determined. The fact that the sarcoidosis is usually very extensive before pneumothroax develops would suggest the latter. Rupture of emphysematous blebs or necrosis of subpleural sarcoid tubercles have been proposed as the mechanisms of pneumothorax in sarcoidosis.
During the past 24 years 571 cases of spontaneous pneumothorax were observed in 408 persons. The aetiology of spontaneous pneumothorax is reviewed. Diagnostic thoracoscopy followed by suction drainage is recommended. Bilateral tension pneumothorax and recurrent pneumothorax were treated by surgery. The preferential method was local or partial parietal pleurectomy. In some cases the pneumothorax was sealed by a dura graft. There was no substantial functional impairment and no post-thoracotomy death. The average lenght of treatment was 20 days.
The release of vasopressin (AVP) was assessed by measuring urinary excretion of the hormone in ten neonates who had an acute and symptomatic pneumothorax in the first three days after birth. AVP excretion rose significantly (paired t analysis) after the pneumothorax occurred. When apparent re-expansion of the lungs occurred after treatment, excretion of AVP returned to prepneumothorax levels within eight to 16 hours. If the pneumothorax persisted or worsened. AVP excretion remained elevated. Urine osmolality rose significantly (paired t analysis) after pneumothorax, presumably in response to the increased AVP levels. Two of the ten infants had hyponatremia in the period studied, while in a state of sodium balance. It was concluded that AVP release is increased after a pneumothorax occurs. This increase is apparently not due to osmoregulatory requirements. Fluid intake in these infants may need adjustment to prevent an inappropriate positive water balance.
During recent years, 14 episodes of pneumothorax in 4 children and adolescents with cystic fibrosis of the pancreas (CF) have been treated in the University Department of Pediatrics in Zurich. Treatment with pleural drainage, associated with instillations of sclerosing agents was usually tedious and did not prevent relapses. One patient died after the second episode, another was successfully treated by pleurectomy. The incidence of pneumothorax in adolescent CF patients increases rapidly mostly due to the longer life expectancy of CF patients. Both lungs are equally affected. In more than 50% one or more relapses occur. The prognosis is usually bad. No specific etiologic factors can be incriminated, pneumothorax occurring mostly during periods of physical inactivity. The pathogenesis seems, in the majority of cases, to be the bursting of a subpleural emphysematous bulla or bleb. Such bullae can mostly be recognised radiologically many years prior to the first pneumothorax episode, usually in severely affected lungs in children over 10 years of age. From the reviewed literature as well as from our own experience it seems that pleurectomy is the only efficient treatment, being well tolerated, curing the actual episode of pneumothorax, and preventing relapses.
Spontaneous pneumothorax is infrequently caused by strenuous exertion. To our knowledge there has only been one case of spontaneous pneumothorax associated with weightlifting reported in the medical literature. We describe three consecutive cases of spontaneous pneumothorax associated with weightlifting. We postulate that spontaneous pneumothorax in these patients may be secondary to improper breathing techniques. It is important that physicians and weight trainers be aware of the association between weight lifting and spontaneous pneumothorax and assure that proper instruction is given to athletes who work with weights.
METHODS: From January 1986 to 31 November 1993, 354 cases of AIDS (CDC criteria 1987) were diagnosed. The possible existence of spontaneous pneumothorax at any time during the evolution and its presumed cause were evaluated. RESULTS: During the period studied, 7 (1.9%) of AIDS patients presented pneumothorax. The existence of a pulmonary infection was proven in 6: 3 pneumonia by Pneumocystis carinii, 2 bacterial pneumonia (Streptococcus pneumoniae and Pseudomonas sp.) and 1 tuberculosis. One patient presented a Pneumocystis carinii pneumonia 3 months prior to the pneumothorax. In the study period 88 (22.8%) of the AIDS patients presented pneumonia by Pneumocystis carinii and 181 (51.1%) presented tuberculosis. The rate of pneumothorax in patients with a history or presence of pneumonia by Pneumocystis carinii was of 4.5% and 0.5% in patients with tuberculosis. CONCLUSIONS: The development of pneumothorax is relatively frequent in patients with AIDS in our area. As found in other series, its most frequent cause was Pneumocistis carinii pneumonia, despite the high incidence of tuberculosis.
Tension pneumothorax as a complication of ventilatory support may cause severe cardiac problems. The diagnosis may be difficult. Risk factors predisposing to the misdiagnosis of this condition include atypical location of the pneumothorax. Three patients with adult respiratory distress syndrome who had atypical, localized tension pneumothorax are described. Each had an ipsilateral functioning chest tube in place at the time. Placement of chest tubes into the localized pneumothoraces resulted in immediate improvement in hemodynamic status in two patients, but the third patient died before the chest tube could be placed. A diagnosis of tension pneumothorax should be considered in any patient on a ventilator whose hemodynamic status deteriorates in the presence of high airway pressures. In patients with adult respiratory distress syndrome the pneumothorax can remain localized because the heavy, noncompliant lungs cannot collapse enough for air to dissect diffusely through the pleural space; pleural adhesions may also contribute to this phenomenon.
Pneumothorax in pregnancy raises several problems especially of therapy. In the present study we report a case observed in our Institution and literature data on 15 further cases. Pneumothorax occurred in 9 cases in the course of pregnancy, in 6 cases during delivery and in 1 case in the post-partum period. Immediate treatment was insertion of pleural drain in 13 patients and bed rest in 3 patients. Surgery was required in 8 cases and was performed after delivery in 5 cases and during pregnancy in 3 cases, 6 thoracotomies, 1 bilateral thoracotomy and 1 sternotomy for bilateral pneumothorax were carried out. Actually a videothoracoscopic treatment, requiring general anaesthesia, is also possible. In all observed cases pneumothorax didn't represent a serious risk for both mother and foetus, for the timely therapeutic measures. Pneumothorax represents an uncommon pathology, usually underestimated in literature, that must be taken into account whenever during pregnancy or the post-partum period a progressive respiratory failure arises.
The results of treatment of 226 patients with unspecific spontaneous pneumothorax in 1980-1990 are discussed. Poor efficacy of punctures of the pleural cavity (32.4%) is noted. Pleural cavity drainage proved to be effective in 79.7% of cases, both in primary and in recurrent pneumothorax. Chemical pleurodesis with tetracycline and 4% sodium bicarbonate solution was conducted in patients with complicated forms of pneumothorax (bronchopleural fistulas, hydropneumothorax). The advantage of 4% sodium bicarbonate solution over the tetracycline solution was obvious. To prevent the development of encapsulated hydrothorax the authors improved the method of pleural cavity drainage. The described method of instrumental treatment of spontaneous pneumothorax allowed injurious surgical intervention and recurrent pneumothorax to be avoided in 100% of cases.
OBJECTIVE: To determine whether the frequency of pneumothorax is increased after thoracentesis in chronic obstructive pulmonary disease patients. DESIGN: Prospective. SETTING: Northeastern community hospital. PATIENTS: One-hundred-six patients underwent multiple thoracentesis; 36 patients had co-existent chronic obstructive pulmonary disease (mean age, 68.2 years). Chronic obstructive pulmonary disease was identified by radiologic findings consistent with chronic obstructive pulmonary disease and as forced expiratory volume in one second less than 70% of predicted. OUTCOME MEASURES: Identification of pneumothorax on chest roentgenogram after thoracentesis. INTERVENTION: Patients had diagnostic or therapeutic thoracentesis with follow-up chest radiography within 2 hours, or sooner if clinically indicated. RESULTS: Patients with chronic obstructive pulmonary disease had a higher incidence of pneumothorax (15 of 36 patients; 41.7%) than those patients without underlying chronic obstructive pulmonary disease (13 of 70 patients; 18.5%; p = 0.005). The frequency of pneumothorax was no different according to who performed the procedure (house staff or pulmonologist), whether it was for diagnostic or therapeutic reasons, and whether a small (< 500 ml) or large (> 500 ml) amount of fluid is removed. CONCLUSION: Pneumothorax may frequently occur in patients with chronic obstructive pulmonary disease undergoing thoracentesis. The reason may be related to the altered architecture of the lung parenchyma and the change in mechanical forces in chronic obstructive pulmonary disease. Sonography-guided thoracentesis may offer a safer means of performing thoracentesis in patients with chronic obstructive pulmonary disease.