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PubMed1996

Demand valve ventilation in a swine pneumothorax model.

Bag-valve-mask (BVM) and oxygen-powered demand valve (OPDV) are two available adjuncts for artificial ventilation. Use of OPVDs has been limited by concern for causing or worsening pneumothorax. This study examined the effect of OPDV and BVM ventilation in swine with pneumothorax. This was a randomized, crossover design. Five female swine (16 to 23 kg) were sedated (ketamine/xylazine), anesthetized (alpha chloralose), and intubated. Right chest injury was induced, through an incision, using a 14-gauge needle to produce disruption of underlying lung parenchyma. An 18F Foley catheter was inserted and sealed in the right pleural space at the cut-down site. For each trial, a pneumothorax was induced by instilling 300 mL of air. Each subject underwent 10-minute ventilation trials with OPDV and with BVM by the same investigator, blinded to instrumentation. Post-trial pneumothorax volume, heart rate, blood pressure, end-tidal CO2 (ETCO2), and arterial blood gases were measured. There was no significant difference in pneumothorax volume after OPDV ventilation (310.8 mL) versus BVM ventilation (315.4 mL) (P = .821). There were no significant differences between heart rates, blood pressures, or arterial blood gases, although ETCO2 showed statistically significant decreases from baseline in both OPDV (33.0 to 28.6) and BVM (33.8 to 30.2) trials. However, multiple comparisons showed no significant differences between OPDV and BVM at any time points. In this model, OPDV and BVM ventilation did not differ in their effects on pneumothorax volume or hemodynamic variables. No animal showed signs of tension pneumothorax.

Animals↗
PubMed1995

Risk factors for pneumothorax during percutaneous Hickman line insertion in patients with solid and haematological tumours.

The purpose of this study was to identify risk factors for pneumothorax during percutaneous subclavian Hickman line insertion in patients with haematological (HT) or solid tumours (ST). One hundred and twelve patients (55 HT, 57 ST) had 132 subclavian Hickman lines inserted under fluoroscopic control. Lines were inserted on the left on 116 occasions and the right in 16. Thirty-five single, 29 double and 68 triple lumen catheters were inserted. Variables included in the analysis were age, sex, side of insertion, catheter gauge and nutritional status as indicated by the body mass index (BMI kg/m2). Both univariate and logistic regression analyses were performed. There were ten pneumothoraces, all occurring in patients with STs. Univariate analysis revealed that patients with STs were older (median age 59 versus 36 years; P = 0.0001) and more cachectic (median BMI 21.9 versus 24.2 kg/m2; P = 0.03) than those with HTs, and the patients experiencing pneumothorax were older (median age 57 versus 44 years; P < 0.01) and more cachectic (median BMI 19.6 versus 24.0 kg/m2; P = 0.004) than those undergoing uncomplicated procedures. For patients with a BMI < 19 kg/m2 versus those with a BMI > 19 kg/m2, the pneumothorax rate was 5/8 versus 5/124 (P < 0.00001). Logistic regression analysis confirmed the significantly older age of the patients with STs (P < 0.001) and of those experiencing pneumothorax (P = 0.02). This analysis also confirmed the lower BMI of patients experiencing pneumothorax (P = 0.002). The patients' sex, the side of line insertion and the catheter gauge were not associated with pneumothorax on either the univariate or logistic regression analyses. From these data we conclude that pneumothorax complicating a subclavian Hickman line is significantly more likely in elderly patients with a low BMI. Such patients are more likely to have STs than HTs. In patients with a BMI < 19 kg/m2, the subclavian route should be used with caution.

Adult↗
PubMed2006

[Effectiveness and complications of video-assisted surgery for primary spontaneous pneumothorax].

OBJECTIVE: To assess the effectiveness and describe the complications of video-assisted thoracoscopic surgery (VATS) for the treatment of primary spontaneous pneumothorax. PATIENTS AND METHODS: Between May 1997 and September 2003, our department scheduled 147 VATS procedures for spontaneous pneumothorax in 127 patients (102 men [80.5%]). The mean (SD) age for the series was 28.3 (11.6) years. Bullae and blebs were resected by endostapler and vigorous pleural abrasion was carried out. Vanderschueren staging was as follows: stage I, 10 (6.8%); stage II, 22 (15%); stage III, 71 (48.3%); and stage IV, 44 (29.9%). The procedure was indicated for the following reasons: third episode, 56 (38.1%); persistent air leak, 47 (32%); elective, 16 (10.9%); simultaneous bilateral pneumothorax, 28 (19%). VATS was performed on the right side only in 85 patients (57.8%), on the left in 62 (42.2%), and on both sides in 16 (11.6%). RESULTS: A total of 137 of the 147 VATS procedures scheduled (93.2%) were performed, and there were no deaths. The rate of conversion to thoracotomy was 6.8%, and the overall rate of complications was 13.7%. Postoperative complications were due to bleeding in 5 cases (3.6%), air leak (>5 days) in 10 (7.2%), wound infection in 2 (1.4%), residual pneumothorax in 4 (2.9%), need to insert a new pleural drain in 3 (2.1%), and pleural empyema in 1 (0.7%). Two patients took oral analgesics for more than 30 days after the procedure. Pneumothorax recurred during follow-up in 7 patients (5.1%). No significant correlation was found between recurrence of pneumothorax after VATS and Vandeschueren stage, age, bilaterality of the procedure, indication, or days of postoperative drainage (P>.05). CONCLUSIONS: VATS for resection of pleural lesions plus pleural abrasion is an efficacious and simple treatment for primary spontaneous pneumothorax regardless of intraoperative findings.

Adult↗
PubMed2000

Supplemental oxygen improves resolution of injury-induced pneumothorax.

BACKGROUND/PURPOSE: Traditionally, supplemental oxygen is administered to patients with asymptomatic pneumothorax to accelerate spontaneous resolution. However, this practice is based on models that did not include injury to the visceral pleura and ongoing pleural air leak. This study evaluated the effects of increased inspired oxygen concentration on pneumothorax resolution in a visceral pleural injury model. METHODS: A total of 27 New Zealand white rabbits were divided randomly into 3 groups: room air (RA), 40% FIO2 (40%), and 60% FIO2 (60%). A complete unilateral pneumothorax was created in each animal by a thoracoscopically guided visceral pleural puncture. The animals were then housed in designated oxygen chambers, and observers were blinded to the inspired oxygen concentration. Cross table anteroposterior chest x-rays were obtained preoperatively, postoperatively, and twice a day until the pneumothorax resolved. Time to resolution between the 3 groups was analyzed with 1-way analysis of variance (ANOVA). RESULTS: Twenty of 27 (74%) of the animals completed the study successfully. Mean time to resolution in the RA group (n = 7; 111.2 +/- 30.8 hours) was longer than in the 40% group (n = 6; 71.8 +/- 22.3 hours) and the 60% group (n = 7; 39.4 +/- 14.2 hours). The time to resolution also was longer in the 40% group than in the 60% group. Seven rabbits died before completion of the study of tension pneumothorax (3 of 7) or anesthetic complications (4 of 7). CONCLUSIONS: Supplemental oxygen improves resolution of injury-induced pneumothorax. The tradition of administering supplemental oxygen to patients with asymptomatic pneumothorax should be continued even if there is ongoing pleural air leak.

Animals↗
PubMed2003

Pediatric spontaneous pneumothorax.

The aim of this study was to review pediatric spontaneous pneumothorax and describe diagnostic and therapeutic approaches and to review our institutional experience with spontaneous pneumothorax. A medline search using keywords pneumothorax and pediatric in both French and English from 1988 through May 2002 was performed, and pertinent papers regarding the natural history, diagnosis, imaging, and therapy were reviewed. A 10-year chart review of spontaneous pneumothorax recording data on demographics, diagnostic imaging, therapeutic approach, and outcomes was performed. Only 4 case series and one review article were produced by the medline search involving exclusively pediatric spontaneous pneumothrax. One hundred ninety-six other articles involved adult series with a minority of patients under 18 years of age. A subset of articles from this adult-based group were examined to assist in formulating recommendations for diagnosis, imaging, treatment, and surgical management of pediatric spontaneous pneumothorax. Few articles on this topic report randomized studies in the adult literature and none in the pediatric literature. The chart review yielded 53 cases of spontaneous pneumothorax in 40 patients with important data presented in the current review. Although few articles are able to provide best-evidence information, the diagnosis, imaging, treatment, and surgical management of patients with primary spontaneous pneumothorax is achieved with good results. Stronger data specific to pediatric patients are needed.

Adolescent↗
PubMed1978

Pneumothorax in a large autopsy population. A study of 77 cases.

Postmortem chest roentgenograms in approximately 3,500 cases of a random autopsy population were reviewed. Pneumothorax was found in 77 cases (2.2%). Simple pneumothorax was present in 38 cases, and tension pneumothorax or combined simple and tension pneumothorax was present in 39 cases. Only 40 of the 77 patients had been clinically diagnosed as having pneumothorax. Pulmonary conditions most often present in cadavers with pneumothorax were bacterial pneumonia, pulmonary emphysema, and pulmonary embolism, with or without infarcts and infarct abscesses. Procedures most frequently associated with pneumothorax were mechanical ventilation and attempts at cardiorespiratory resuscitation. Rib fractures (iatrogenic and noniatrogenic) were found in 23 of the 77 cases.

Adult↗
PubMedDate not supplied

Spontaneous pneumothorax complicating pulmonary mycetoma in patients with acute leukemia.

Pneumothorax caused by the rupture of a mycetoma into the pleural space is rarely reported in patients undergoing intensive cytotoxic therapy for hematologic malignancies. We reviewed 46 episodes of mycetoma that developed in 43 patients undergoing antineoplastic therapy; six (13%) of these episodes were further complicated by the occurrence of pneumothorax that developed after bone marrow recovery with return to normal granulocyte count. Etiologic agents included Aspergillus fumigatus, Aspergillus fumigatus plus Blastoschizomyces capitatus, and Mucor (one case each). No pathogen was detected in the remaining three cases of pneumothorax. Four of the six patients died (7, 10, 27, and 50 days after the onset of pneumothorax). Two of the six patients with pneumothorax died of massive hemoptysis, whereas only one of the 40 patients who did not develop pneumothorax died of hemoptysis. This suggests that both pneumothorax and hemoptysis may represent the clinical expression of a more destructive course of invasive fungal diseases.

Adult↗
PubMedDate not supplied

Pneumothorax and nasal continuous positive airway pressure ventilation in premature neonates: a note of caution.

The nasal continuous positive airway pressure (NCPAP) ElectroMedical Equipment (EME) system has recently gained wide use in premature infants. However, occasional impingement of the expiratory tubing exit by mattress, coverings, or walls of infant warmers is of concern because of risk for obstruction and pneumothorax. The purpose of this study was to verify whether the use of NCPAP, namely Aladdin-1 (EME, Brighton, England), increases the risk for pneumothorax. The study included premature infants with respiratory distress who necessitated one or more of the following modes: oxygen via head box, NCPAP, synchronized intermittent mandatory ventilation (SIMV), or high frequency oscillatory ventilation (HFOV). For every patient, we recorded the modes of respiratory support, duration of use, and the occurrence of pneumothorax during every mode (number of pneumothorax cases/100 days of support). Among 163 sick premature neonates, pneumothorax developed in 0.17, 1.77, 0.3, and 6 cases per 100 days of oxygen via head box, NCPAP, SIMV, and HFOV, respectively. Pneumothorax developed more often during NCPAP than with SIMV. Pneumothorax in premature infants might be increased with the use of the newly developed NCPAP system. In these circumstances, possible accidental obstruction of the exit of its expiratory tubing could be contributory to this complication.

Humans↗
PubMed2006

Familial spontaneous pneumothorax.

PURPOSE OF REVIEW: Over 10% of patients with primary spontaneous pneumothorax report a positive family history of the disease. While some cases can be attributed to rare inherited connective tissue diseases, several families with familial spontaneous pneumothorax have been described that do not show clinical evidence of these monogenic disorders. Until recently the molecular underpinning of this disease was unknown. RECENT FINDINGS: In the last 18 months, mutations in the gene encoding folliculin (FLCN) have been identified in individuals with familial spontaneous pneumothorax. Mutations in this gene were known previously to cause a rare skin disease, Birt-Hogg-Dubé syndrome, an autosomal dominantly inherited disease characterized by benign skin tumors, diverse types of renal cancer, pulmonary cysts, and spontaneous pneumothorax. Two animal models and studies of renal cancers support a tumor-suppressor function for folliculin. The presence of thin-walled cysts in basilar and subpleural locations of the lung is a feature of this disease. Most families display reduced penetrance of the pneumothorax phenotype. Several individuals with a family history of spontaneous pneumothorax have a mutation in the folliculin gene. SUMMARY: A significant fraction of families with familial spontaneous pneumothorax have mutations in the folliculin gene and should be considered a forme fruste of Birt-Hogg-Dubé syndrome.

Genetic Predisposition to Disease↗
PubMed2005

Protective pneumothorax for needle biopsy of mediastinum and pulmonary hilum.

The risk of performing CT-guided transthoracic needle biopsy of some mediastinal and pulmonary hilar masses is increased by the presence of intervening lung. A series of patients is presented in whom a protective pneumothorax provided access for biopsy of masses in the mediastinum and pulmonary hilum. Review of Interventional Radiology records revealed 24 patients who had biopsies of mediastinum or pulmonary hilum, in whom protective pneumothorax was used, or attempted, to provide percutaneous access for biopsy. Characteristics of these patients and their procedures were reviewed. Percutaneous access to the pleural space was gained in 21/24 (88%) of patients. A protective pneumothorax was established in 19 (79%); 2 patients had pleural adhesions that prevented the lung from being displaced. The process of creating the protective pneumothorax added a mean time of 17 minutes to the procedure (range 6-30 minutes). All patients had biopsy using coaxial technique, with either a 20-gauge or 18-gauge core biopsy instrument, in addition to needle aspiration. Air leak requiring tube drainage occurred in 1/19 (5%) of patients who had a protective pneumothorax, and in 2/5 (40%) of patients in whom protective pneumothorax was not established. Percutaneous creation of a protective pneumothorax is a safe method that provides access for needle biopsy of deep lesions in the chest without traversing aerated lung.

Biopsy, Needle↗
PubMedDate not supplied

Image feature analysis and computer-aided diagnosis in digital radiography: automated detection of pneumothorax in chest images.

In order to aid radiologists in the diagnosis of pneumothorax from chest radiographs, an automated method for detection of subtle pneumothorax is being developed. The computerized method is based on the detection of a fine curved-line pattern, which is a unique feature of radiographic findings of pneumothorax. Initially, regions of interest (ROIs) are determined in each upper lung area, where subtle pneumothoraces commonly appear. The pneumothorax pattern is enhanced by the selection of edge gradients within a limited range of orientations. Rib edges included in this edge-enhanced image are removed, based on the locations of posterior ribs that are determined separately. A subtle curved line due to pneumothorax is then detected by means of the Hough transform. The detected pneumothorax pattern is marked on the chest image displayed on a CRT monitor. With the present computer method applied to 50 chest images (28 normals and 22 abnormals with pneumothorax), we were able to detect 77% of pneumothoraces, with 0.44 false-positives per image.

Humans↗
PubMed2003

CT-guided transthoracic needle aspiration biopsy of pulmonary nodules: needle size and pneumothorax rate.

PURPOSE: To evaluate the effect of coaxial needle size on pneumothorax rate and the diagnostic accuracy of computed tomography (CT)-guided transthoracic needle aspiration biopsy (TNAB) of pulmonary nodules. MATERIALS AND METHODS: Retrospective review of 846 consecutive CT-guided TNAB procedures was performed. A coaxial approach was implemented in all patients by using an 18- or 19-gauge outer stabilizing needle through which a smaller aspiration needle or automated biopsy gun was inserted for tissue sampling. Univariate and multivariate regression analyses were used to analyze coaxial needle size, age, sex, smoking history, lesion size, use of an automated core biopsy gun, number of needle passes, and frequency of chest tube placement. Sensitivity, specificity, and diagnostic accuracy were calculated for 676 patients with at least 18 months of clinical follow-up. RESULTS: Pneumothorax occurred in 226 of 846 patients. Coaxial needle size and patient age had a significant effect on pneumothorax rate. Pneumothorax occurred in 124 (38%) of 324 patients who underwent procedures with 18-gauge needles and in 121 (23%) of 522 patients who underwent procedures with 19-gauge needles (P <.001). The overall diagnostic accuracy was 96% for procedures performed with 18-gauge needles and 92% for procedures performed with 19-gauge needles, with a sensitivity of 95% and 89% and a specificity of 100% and 99%, respectively. Pneumothorax occurred in 153 patients older than 60 years, in 99 patients 60 years and younger (P <.02), in 90 patients older than 70 years, and in 162 patients younger than 70 years (P <.01). The relationship between pneumothorax rate and age as a continuous distribution was not significant (P <.07), nor were the 50- or 75-year age cutoffs (P <.06 and P <.9, respectively). CONCLUSION: Use of a smaller coaxial stabilizing needle produces a substantially decreased risk of pneumothorax with comparable diagnostic accuracy, sensitivity, and specificity for histopathologic diagnosis of pulmonary nodules.

Adolescent↗
PubMed1987

Hemodynamic effects of rapidly evacuating prolonged pneumothorax in rabbits.

Clinical observations suggest that systemic hypotension may be caused by rapid evacuation of persistent pneumothorax. This observation has not been substantiated experimentally and the mechanism(s) are unknown. In this study, we measured systemic hemodynamic parameters in rabbits before and for 2 h during negative pressure evacuation of a right-sided pneumothorax of 7-9 days duration. Three groups of animals were studied: 10 rabbits breathed room air and were hypoxemic during pneumothorax (hypoxemic pneumothorax = HP); 10 rabbits breathed 40% O2-60% N2, which prevented arterial hypoxemia during pneumothorax (supraoxemic pneumothorax = SP); seven normal control animals were untreated during this time period (NC). Pneumothoraces in HP and SP were evacuated by negative pressure applied to the right pleural space for 2 h while animals were anesthetized and mechanically ventilated. The NC group was anesthetized and ventilated without prior pneumothorax. Serial hemodynamic measurements were made before and during pleural suction.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1982

Position may stop pneumothorax progression in dogs.

We attempted to see what the effect of position was on the rate of pneumothorax formation. In 6 anesthetized spontaneously breathing dogs in the left decubitus position, a chest tube was inserted into the right hemithorax. A right-sided pneumothorax was induced by percutaneous transthoracic insertion of a 20-gauge needle into the lung. Once a constant rate of pneumothorax formation occurred, the dogs were alternated between 3 min of no evacuation by the chest tube with the puncture site up (left decubitus) or down (right decubitus). The pneumothorax that accumulated was always evacuated immediately thereafter with the chest tube in the highest position (left decubitus). In every case, the rate of pneumothorax formation decreased with the puncture site down rather than with it up. Furthermore, this maneuver caused the site of leak to completely seal 11 of 21 times in which the puncture site was placed dependent. There was, however, no significant change in the rate of pneumothorax formation with the puncture site kept in the nondependent position. These results are consistent with the hypothesis that placing the site of pleural gas leak in the most dependent position causes a reduction in alveolar size as well as the alveolar to pleural pressure gradient in the region surrounding the leak. Both of these factors would tend to slow the rate of pneumothorax formation and allow sealing of the puncture site.

Animals↗
PubMedDate not supplied

How to avoid and manage a pneumothorax.

Pneumothorax is one of the most frequent complications during percutaneous central vascular cannulation. When choosing a site for central vascular access, the internal jugular vein is preferable to other vessels, for the lower frequency of related complications, including pneumothorax. This review intends to summarize the current state of the art on how to avoid and, if it occurs, to manage this rare but relevant complication. In order to prevent pneumothorax, as well as other relevant complications of central vein cannulation, it is advisable to use ultrasound guidance whenever possible. If pneumothorax occurs, it is important to recognize its signs and symptoms. To exclude the presence of asymptomatic pneumothorax, in the normal clinical routine a chest X-ray should be obtained within 4 hours from the procedure of central vein cannulation of subclavian and internal jugular veins. If promptly recognized, pneumothorax can be managed quickly and in a relatively easy way. Depending on its size and symptoms, and in particular when a tension pneumothorax is suspected, treatment can vary from simple observation to a chest tube insertion or, in the latter case, to an emergency thoracentesis needle insertion in the pleural space.

Catheterization, Central Venous↗
PubMed1997

Pneumothorax in HIV-infected patients: role of Pneumocystis carinii pneumonia and pulmonary tuberculosis.

Patients with acquired immune deficiency syndrome (AIDS) are at increased risk for pneumothorax, which usually occurs in the setting of Pneumocystis carinii pneumonia. The rationale of the present study was based on the hypothesis that the increased incidence of pulmonary tuberculosis in human immunodeficiency virus (HIV)-infected patients could favour the development of pneumothorax in such patients. A case-control study was performed comprising 140 HIV-infected patients grouped as follows: 35 patients with pneumothorax and 105 matched controls without pneumothorax. Univariate analysis identified four risk factors for pneumothorax: 1) previous P. carinii pneumonia (p=0.01); 2) current P. carinii pneumonia (p=0.02); 3) pulmonary tuberculosis (p=0.01); and 4) cysts, pneumatoceles or bullae on chest radiographs (p<0.001). Multivariate analysis indicated that current P. carinii pneumonia (p=0.01) and pulmonary tuberculosis (p=0.04) were both independent risk factors for pneumothorax. In conclusion, our findings demonstrate that, in addition to Pneumocystis carinii pneumonia, pulmonary tuberculosis enhances the risk of pneumothorax in patients with acquired immune deficiency syndrome.

AIDS-Related Opportunistic Infections↗
PubMed1993

Chest radiograph--a poor method for determining the size of a pneumothorax.

The ability of chest radiographs to determine the size of a pneumothorax was tested in 16 patients using computed tomographic (CT) scan as a reference method. To determine if CT with a slice thickness of 12 mm could be used, its accuracy was assessed in a lung model experiment. The lung model consisted of a water-filled plastic bag (lung) fitted into a plastic chamber (hemithorax), both of approximately the same size and shape as in man. Water was drawn off in incremental steps and a CT was done after each step. The area of the pneumothorax was calculated by computer and when multiplied by slice thickness and number of slices, the total volume of the pneumothorax could be compared with the extracted amount of water. A good correlation (r = 0.99), with the line of regression close to the line of identity, was found between the CT investigation and the artificial pneumothorax. In the patients, the size of the pneumothorax, judged by radiograph using two different methods of calculation, was correlated to the size obtained by CT. The correlation was poor (r = 0.71) irrespective of method of calculation. The size of the pneumothorax estimated by CT showed a good correlation (r = 0.99) to the initial aspirated air volumes in 12 of the 16 patients treated with drainage. A cautious attitude toward the use of chest radiographs for calculations of the degree of lung collapse in patients with pneumothorax is recommended.

Adult↗
PubMed1997

The clinician's perspective on pneumothorax management.

OBJECTIVE: We sought to determine the current practice habits among clinicians treating spontaneous pneumothorax and bronchopleural fistula. METHODS: Practice habits were determined by a randomized postal survey of 3,000 American College of Chest Physicians members. Group comparisons are performed by chi2 analysis with p<0.05 being significant. RESULTS: Four hundred nine respondents (13.6%) included 176 practicing pulmonologists (43.0%), 67 academic pulmonologists (16.4%), 102 thoracic surgeons (25.0%), and 64 others (15.6%). More than 50% of respondents treat a first small primary spontaneous pneumothorax (PSP) by simple observation, a first small secondary spontaneous pneumothorax (SSP) by chest tube, persistent air leak in both PSP and SSP with chest tube+video-assisted thoracoscopy, and use a 20 to 24F chest tube in mechanically ventilated ARDS-related tension pneumothorax. First recurrences of PSP and SSP were treated by a variety of interventions that included simple observation (PSP=14%, SSP=4%), chest tube (22%/17%), chest tube+sclerosis (20%/16%), chest tube+video-assisted thoracoscopy (36%/48%), and chest tube+thoracotomy (5%/12%). The most popular sclerosing agents are doxycycline (48%), talc slurry (24%), and talc poudrage (19%). More than 75% of physicians intervened in a persistent air leak between 5 and 10 days. Chest tubes are initially placed to suction by 48% of respondents in PSP and removed >24 h after air leak ceases in 79%. Chest tube clamping prior to removal is employed by 67% of respondents. Significant differences exist between thoracic surgeons and pulmonologists with surgeons placing more chest tubes for first-time PSP and performing chest tube+video-assisted thoracoscopy for first recurrences of PSP more often than pulmonologists. Thoracic surgeons seldom use sclerosis in spontaneous pneumothorax compared to pulmonologists. CONCLUSIONS: Marked practice variation exists in clinicians' approaches to the management of spontaneous pneumothorax and bronchopleural fistulas that is partially explained by differences between pulmonologists and thoracic surgeons. A national consensus statement is needed to guide randomized studies in pneumothorax management.

Anti-Bacterial Agents↗