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PubMed2006

Patient perspectives on management of pneumothorax in lymphangioleiomyomatosis.

STUDY OBJECTIVES: The American College of Chest Physicians Delphi Consensus Statement on management of spontaneous pneumothorax recommended pleurodesis after the first secondary spontaneous pneumothorax to prevent recurrence, and evaluation of patients' perspectives regarding pneumothorax treatment was identified as a future research priority. Patients with lymphangioleiomyomatosis (LAM) are an ideal population for performing these studies, since pneumothorax occurs and recurs more commonly in LAM than in any other chronic pulmonary disorder. STUDY DESIGN AND PARTICIPANTS: A 23-item questionnaire evaluating opinions of pneumothorax treatment was distributed to 615 patients in the LAM Foundation patient database, with a response rate of 52%. RESULTS: Of respondents, 69% (216 of 314 patients) reported a history of radiographically documented pneumothorax, and 181 patients (84%) reported at least one pleurodesis procedure. Neither a history of pneumothorax nor surgical management of pneumothorax affected reported oxygen use or perception of overall lung function, yet 41% thought that their pneumothorax had contributed to a decline in lung function. Few patients (12%) worried frequently about a pneumothorax developing, but one third made lifestyle modifications due to fear of pneumothorax. Extensive pain associated with chest tube placement and inadequate pain management throughout treatment for pneumothorax were frequent concerns. Only 25% of respondents thought that pleurodesis was appropriate for a first pneumothorax, while 60% favored pleurodesis for a second pneumothorax. Despite the apparent reluctance to undergo pleurodesis, most patients agreed that pleurodesis helps prevent pneumothorax recurrence. One third of patients believed that their physicians did not consider their preferences regarding pneumothorax management. CONCLUSIONS: LAM patients and physicians may have different views about the significance of pneumothorax, in that most patients appear to favor a conservative initial approach to pneumothorax management. In conjunction with appropriate pain management, a better understanding of patients' perspectives will facilitate cooperative decision making and may ultimately improve clinical outcomes in LAM related to pneumothorax.

Chest Tubes↗
PubMed2003

Pneumothorax during laparoscopy.

BACKGROUND: Pneumothorax is a known complication of laparoscopy, with most pneumothoraces diagnosed postoperatively with conventional chest x-ray. Electrocardiogram (ECG) conduction changes are associated with pneumothorax. In a sheep model, ECG changes were evaluated as a potential indicator of intraoperative pneumothorax. Additionally, resolution rates of helium (He) and carbon dioxide (CO2) pneumothorax were also evaluated in this model. METHODS: Under general anesthesia, 10 sheep had known volumes (20-100 cc) of either He or CO2 introduced into the left hemithorax. A 12-lead ECG recorded changes associated with the induced pneumothorax. After changes in the ECG plateaued, the gas volume in the hemithorax was increased to 2 L and the resultant pneumothorax was followed for a 2-h period using fluoroscopy to determine resolution rates for the different gas pneumothoraces. Gas volumes were aspirated after 2 h and ECGs were again recorded. RESULTS: Pneumothorax volumes as low as 20 cc produced consistent ECG changes. The amplitude of the precordial QRS complex was seen to diminish, and this lowering of the QRS amplitude continued as pneumothorax volume increased up to 100 cc. The ECG returned to prepneumothorax patterns with aspiration of the left chest. For different gas pneumothoraces, CO(2) pneumothorax showed almost complete resolution in the 2-h period, whereas He pneumothorax was unchanged. CONCLUSIONS: Precordial ECG changes appear to be a very sensitive indicator of pneumothorax, with very small pneumothorax (<100 cc) consistently being detected by reduction of the QRS complex amplitude. Intraoperative use of precordial ECG leads could result in rapid identification of pneumothorax during laparoscopic surgery. Carbon dioxide pneumothorax shows near 100% resolution in a 2-h period. This supports recommendations of expectant management in asymptomatic patients with CO(2) pneumothorax. However, He pneumothorax does not resolve spontaneously quickly and may require aspiration even in asymptomatic patients.

Absorption↗
PubMed1991

Risk factors for the misdiagnosis of pneumothorax in the intensive care unit.

OBJECTIVE: To identify risk factors predisposing to the misdiagnosis of pneumothorax in the ICU. DESIGN: A prospective case series investigation. SETTING: A medical ICU service of a military referral hospital. PATIENTS: All adult medical ICU patients were evaluated during a 12-month period. Of 464 admissions, 28 (6%) were found to have acquired a pneumothorax during their medical ICU stay. INTERVENTIONS: Nineteen (67.9%) patients with pneumothorax were diagnosed correctly on initial presentation of their pneumothorax. The remaining nine (32.1%) patients' pneumothoraces were misdiagnosed at initial presentation. MEASUREMENTS AND MAIN RESULTS: Tension pneumothorax occurred more frequently in patients with an initially misdiagnosed pneumothorax (33.3%) than in patients with pneumothoraces that were correctly diagnosed during their medical ICU stay (5.3%) (p less than .06). Thirteen variables chosen prospectively were examined using a chi-square statistic. The following four variables occurred statistically more often in nine patients with an initially misdiagnosed pneumothorax: a) mechanical ventilation required at the time of the development of pneumothorax (p less than .05); b) an atypical radiographic location of the pneumothorax (p less than .05); c) altered mental status exhibited at the time of pneumothorax presentation (p less than .05); and d) development of pneumothorax after peak physician staffing hours (p less than .02). CONCLUSIONS: Certain medical ICU patients appear to be at higher risk for the initial misdiagnosis of pneumothorax. Familiarity with factors predisposing to this problem should allow for a higher index of suspicion for the diagnosis of pneumothorax in critically ill patients and possibly improve the early detection of pneumothorax.

Causality↗
PubMed2004

Incidence and risk factors of delayed pneumothorax after transthoracic needle biopsy of the lung.

STUDY OBJECTIVES: To evaluate the incidence and clinical significance of delayed pneumothorax, and to analyze the influence of multiple variables on the rate of delayed pneumothorax associated with transthoracic needle biopsy (TTNB) of the lung. STUDY DESIGN: Prospective study. SETTING: Tertiary care university hospital. STUDY SUBJECTS: Adult patients underwent TTNB from June 2001 to June 2002. MEASUREMENTS AND RESULTS: Among the 458 patients included in this study, 280 fluoroscopic-guided, 21 CT-guided, and 157 ultrasonography-guided lung biopsies were performed. A follow-up chest radiograph was obtained immediately, and 3 h, 8 h, and 24 h after the biopsy procedure. Pneumothorax that had not developed up to 3 h but developed later was defined as a delayed pneumothorax. Patients with a symptomatic or enlarged pneumothorax were treated using a pigtail catheter or chest tube. Variables such as age, gender, lesion size, location, presence of an emphysematous change, biopsy guidance methods, and biopsy devices were analyzed. Pneumothorax developed in 100 of the 458 patients (21.8%), and delayed pneumothorax developed in 15 patients (3.3%). Seventeen patients, including 3 patients with delayed pneumothorax, required a pigtail catheter or a chest tube insertion. The pigtail catheter or chest tube insertion rate in delayed pneumothorax was 20% (3 of 15 patients). Female gender and the absence of an emphysematous change correlated with an increased rate of delayed pneumothorax (p < 0.05). Lesion size, location, biopsy guidance methods, devices, and underlying diseases were not correlated with the delayed pneumothorax rate. CONCLUSIONS: The incidence of delayed pneumothorax was 3.3% of all TTNBs. Female gender and the absence of an emphysematous change were identified as risk factors for delayed pneumothorax. Delayed pneumothorax is clinically important because of its considerable incidence and the necessity for pigtail catheterization or chest tube insertion in these patients.

Adult↗
PubMed2000

Pneumothorax in horses: 40 cases (1980-1997).

OBJECTIVE: To characterize pneumothorax in horses and to describe clinical signs, diagnostic testing, and clinical outcome of horses with pneumothorax. DESIGN: Retrospective study. ANIMALS: 40 horses. PROCEDURE: Medical records of horses with pneumothorax were reviewed to obtain information on signalment, history, clinical signs, diagnostic testing, treatment, and clinical outcome. RESULTS: Horses developed pneumothorax secondary to pleuropneumonia (17 horses), open wounds of the thorax (9), closed trauma to the thorax (7), surgery on the upper portion of the respiratory tract (3), and surgery involving the thoracic cavity (1); 3 horses had pneumothorax of unknown cause. Clinical signs included tachypnea, dyspnea, cyanosis, lack of lung sounds on auscultation of the dorsal aspect of the thorax, fever, tachycardia, signs of depression or anxiousness, and cough. Radiography and ultrasonography were useful to definitively diagnose pneumothorax. Pneumothorax was bilateral in 47.5% (19/40) and unilateral in 42.5% (17/40) of horses; designation of unilateral versus bilateral was not recorded in the remaining 4 horses. Horses with pneumothorax secondary to pleuropneumonia more commonly had unilateral pneumothorax (64.7% for unilateral vs 29.4% for bilateral; not specified for 1 horse). Horses with pneumothorax secondary to pleuropneumonia were less likely to survive than horses with pneumothorax secondary to other causes (35.3 vs 69.6% survived, respectively). CONCLUSIONS AND CLINICAL RELEVANCE: Pleuropneumonia is an important cause of pneumothorax in horses. Classic clinical signs of pneumothorax may not be evident. Radiography, ultrasonography, or both may be required for diagnosis. Prognosis for survival is better for horses with pneumothorax not associated with pleuropneumonia.

Animals↗
PubMed1999

Pneumothorax: a review of 146 adult cases admitted at a university teaching hospital in Pakistan.

OBJECTIVE: There is a lack of data on the etiology and outcome of pneumothorax among the Pakistani population. Our aim was to review the etiology, clinical course, management and outcome of patients presenting with pneumothorax. PATIENTS AND METHODS: All adult cases with pneumothorax admitted to a University Teaching Hospital in Karachi, between January 1992 and June 1996, were reviewed and analyzed. RESULTS: A total of 146 patients were reviewed. Their mean age was 46.3 years (SD +/- 17.8 years) with a male to female ratio of 3.7:1. Secondary pneumothorax was the commonest type seen (45%), followed by traumatic (21%), iatrogenic (18%) and primary (16%). Tuberculosis (47%) and COPD (45%) were most common lung diseases associated with secondary pneumothorax. Pneumothorax secondary to TB presented at an earlier age than that with COPD (49.6 vs. 60.1 years). Similarly, patients with primary pneumothorax were significantly younger than patients with secondary pneumothorax (42.3 vs. 51.7 years). Rib fracture was the most common cause of traumatic pneumothorax. Coronary artery bypass grafting, transthoracic fine needle aspiration and neck vein cannulations were the leading iatrogenic causes. The commonest symptoms of pneumothorax were dyspnea (68%) and chest pain (40%). Most cases (81%) were successfully managed by intercostal tube drainage. CONCLUSION: In our study population, secondary pneumothorax was the commonest variety seen. TB was the commonest cause of secondary pneumothorax, closely followed by COPD. Nearly 40% of pneumothorax were either traumatic or iatrogenic. Intercostal tube drainage remains the treatment of choice for pneumothorax.

Adolescent↗
PubMed1986

Epidemiology of spontaneous pneumothorax in women.

An epidemiologic study was done on spontaneous pneumothorax in women. Six hundred sixty-four patients with spontaneous pneumothorax comprising 409 with idiopathic pneumothorax (61.6 percent), and 255 with secondary pneumothorax (38.4 percent) were studied. By age, idiopathic pneumothorax had its peak incidence in the 20s and secondary pneumothorax the 30s. Secondary pneumothorax included iatrogenic pneumothorax resulting from acupuncture treatment. The female patients were not so thin and tall as the male patients. The percentage of positive family history among the female patients was 4.42 percent in the idiopathic type and 0.45 percent in the secondary type. The percentage in the male idiopathic type of pneumothorax was 2.29 percent. Catamenial pneumothorax and pneumothorax with pulmonary hamartoangiomyomatosis are well known as specific in female subjects, but the cases are rare. Nonetheless, attention should be paid to female-specific rare types, for the etiology of idiopathic pneumothorax.

Adolescent↗
PubMed2007

Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography.

OBJECTIVE: The purpose of this study was to prospectively evaluate the accuracy of transthoracic sonography in the detection of pneumothorax after transthoracic sonographically guided lung biopsy. SUBJECTS AND METHODS: Transthoracic sonography was performed on 285 patients after transthoracic sonographically guided lung biopsy. Disappearance of the sliding lung and comettail artifacts and appearance of reverberation artifacts were considered evidence of pneumothorax. Upright chest radiography was performed within 30 minutes of transthoracic sonography. If a discrepancy between transthoracic sonographic and chest radiographic findings occurred, CT was performed. When it was diagnosed, pneumothorax was sonographically monitored. After visualization of resolution of pneumothorax, chest radiography was performed to confirm the resolution. RESULTS: Pneumothorax occurred in eight (2.8%) of the patients. Transthoracic sonography depicted all cases of pneumothorax and excluded pneumothorax in the other cases. Chest radiography did not depict one case of pneumothorax, which was confirmed on CT. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were all 100% for transthoracic sonography and 87.5%, 100%, 100%, 99.6%, and 99.6%, respectively, for chest radiography. The 95% confidence intervals (CI) of the differences in sensitivity, negative predictive value, and overall accuracy were -10% to 35%, -0.1 to 0.9%, and -0.1 to 0.9%. Transthoracic sonographic visualization of resolution of pneumothorax was always confirmed with chest radiography. CONCLUSION: These preliminary results suggest that transthoracic sonography is as effective as chest radiography in the detection of pneumothorax after transthoracic sonographically guided lung biopsy and may become the method of choice for excluding, diagnosing, and monitoring pneumothorax after transthoracic sonographically guided biopsy. Chest radiography may be needed only for assessment of the extent of pulmonary collapse after transthoracic sonographic diagnosis of pneumothorax or in the presence of discrepancy between transthoracic sonographic findings and clinical presentation.

Adult↗
PubMed1996

Pneumothorax after small-bore catheter placement for malignant pleural effusions.

OBJECTIVE: The objective of this study was to evaluate the incidence and significance of pneumothorax after small-bore chest tube placement for symptomatic malignant pleural effusions. SUBJECTS AND METHODS: Over a 2-year period, 90 patients with a known primary malignant tumor and symptomatic pleural effusion were referred to the radiology service at Duke University Medical Center. All patients underwent placement of a small-bore chest tube with fluid drainage in preparation for intrapleural sclerotherapy. Two of these patients were excluded because of coexisting empyema (n=1) and thoracentesis (n=1). The remaining 88 patients (30 men and 58 women; 26-86 years old [mean, 60 years old], who had 90 chest tubes placed, formed our study group. The incidence, duration, and clinical significance of their pneumothoraces and the amount of pleural effusion drained were recorded. RESULTS: Among the 88 patients with 90 chest tubes, 27 patients with 28 chest tubes (31%) were found to have pneumothorax after the procedure. For 23 patients with 24 chest tubes, pneumothorax was evident on chest radiographs taken immediately after tube insertion and fluid drainage. Four patients with four chest tubes were found to have pneumothorax on chest radiographs taken the next day. No significant difference in the amount of fluid drained during the procedure was noted for patients with or without pneumothorax (831 ml versus 853 ml). No relationship between the size of each pneumothorax and the size of each drainage catheter was seen. The duration of pneumothorax ranged from 2 hr to 18 days (average, 3.5 days). Resolution of pneumothorax was seen in 22 (79%) of 28 cases; the remaining six cases of pneumothorax (21%) were stable, and the patients showed eventual fluid reaccumulation after chest tube removal and no sclerotherapy. No patient developed tension pneumothorax, respiratory distress, or other complications. CONCLUSION: Pneumothorax should be recognized as a common finding after chest tube placement and immediate fluid drainage for malignant pleural effusions. We suggest that this finding is related to rapid removal of fluid from a relatively stiff, noncompliant lung. Patients whose lungs do not fully re-expand in several days will probably not benefit from sclerotherapy. Their tubes may be removed without risk of an enlarging tension pneumothorax.

Adult↗