Spontaneous Pneumothorax

Ahmer A. Karimuddin
August 10th, 2001

Definitions
Primary Spontaneous Pneumothorax (PSP)

No underlying lung disease

Secondary Spontaneous Pneumothorax (SSP)

Complication of underlying lung disease

Definitions
Iatrogenic Pneumothorax
Complication of diagnostic or therapeutic intervention

Traumatic Pneumothorax
Caused by penetrating and or blunt trauma

PSP - Epidemiology
Fairly common 10 cases per 100,000 in men 3 cases per 100,000 in women Typically in tall, thin males between ages of 10 and 30 Risk increases with smoking in dose dependent manner

PSP - Pathology
Patients have no clinical lung disease
On thoracoscopy, 75 to 100 percent have sub-pleural Bullae

Increased numbers in smokers (89%) vs. non smokers (81%)

PSP - Pathophysiology
Air leak due to increased alveolar pressure, secondary to inflammation Air leaks into lung interstitium then into hila, causing pneumomediastinum Mediastinal pressure rises, mediastinal parietal pleura ruptures No defect seen in visceral pleura or evidence of bullous rupture

PSP - Pathophysiology
Due to air in pleural space, decrease in vital capacity Hypoxemia results decreased ventilation perfusion ratio Hypercapnia occurs only rarely

PSP Clinical Presentation

History of chest pain while resting. Physical findings are minimal.

Tachycardia. If large pneumothorax.

Hyper resonance on percussion. Decreased fremitus. Decreased or absent breath sounds.

PSP Clinical Presentation

Clinical clearance of symptoms

Usually within 24-48 hours, even if air in pleural cavity is not evacuated

If HR > 135 or hypotension or cyanosis TENSION PNEUMOTHORAX

PSP Diagnosis
History
Chest x-ray

PA is only one of significance Expiration & inspiration views were found to have no clinical significance

PSP Recurrence
Average rate of recurrence is 30% Most recurrences within six months to two years Increased risk with:

Tall, thin habitus Pulmonary fibrosis History of smoking Young age

No increased risk with number of Bullae

SSP
Potentially life threatening, as limited reserve Most often associated with COPD and PCP pneumonia in HIV Risk in COPD increases with worsening disease 6% of HIV patients will suffer from PCP associated pneumothorax

(30-40% mortality)

SSP
Also seen in:

Langerhans granulomatosis Lymphangioleiomyomatosis Interstitial lung disease Catamenial Pneumothorax

Seen in women, within 72 hours of menses

SSP - Epidemiology
Same rates as PSP Peak is later in life

60 to 65 years

26 per 100,000 patients per year with COPD Occasionally seen as first presenting symptom of pleural and lung CA

SSP Mechanism
Two hypothesis

Same as PSP Ruptured alvelous leaks air directly into pleural space secondary to necrosis evidence seen in PCP associated pneumothorax

SSP Clinical Presentation

Dyspnea, usually severe Chest pain Hypoxemia and hypotension Hypercapnia Must exclude in patient with Chest pain and COPD

SSP Diagnosis
Clinical Presentation Radiological assessment

Bullae may mask presence of air within the pleural cavity Only in patients with previous pulmonary disease, consider CT scan to rule out presence of Pneumothorax

SSP Recurrence
Similar to PSP Various studies show a range in between 39% to 47% Increased rate of recurrence in patients with complicated COPD Smoking most potent risk factor

Pneumothorax - Treatment
Principles:

Evacuate air from the pleural space Prevent recurrences

Pneumothorax - Treatment
Air evacuation is to bring about reexpansion of lung If air within pleural cavity is less than 15% of hemithorax (< 2 ribs) and minimal symptoms:

Consider supplemental oxygen and observation over 6 to 8 hours Approximately 2% reabsorption per day on room air

Pneumothorax - Treatment
If air within pleural cavity is greater than 15% or growing:

Simple intravenous catheter or thoracentesis catheter Chest tube

Simple aspiration successful in 70%

Increased success with age < 50 and < 2.5 L of air aspirated

Pneumothorax - Treatment
Surgical Options

Video Assisted Thoracoscopic Surgery (VATS) with wedge resection & pleurodesis Limited Axillary Thoracotomy Thoracotomy

Pneumothorax - Treatment
VATS is felt to be superior to other options

Decreased time to discharge Small incisions Decreased intra-operative stress Earlier return to function Decreased post-operative pain

Pneumothorax - Treatment
If VATS is superior, then when do we use it?

After second episode High-risk profession Persistent air-leak at 7 days

Yes & No

Pneumothorax - Treatment
Cole et al. (Ann. Thor. Surg., 1985)

Cohort study 89 treated conventionally

50% were operated on

30 treated with VATS on presentation LOS was 6 days in VATS group, while average LOS in conventional group was 8 days Recommended early intervention with VATS, if persistent air leak at 3 days

Pneumothorax - Treatment
Passlick et al. (Ann. Thor. Surg., 1998)

Cohort study (retrospective) 99 patients treated with VATS, 100 patients treated with lateral thoracotomy VATS
Shorter hospital stay Shorter CT drainage Decreased use of narcotics

Pneumothorax - Treatment
Falcoz et al. (Ann. Thor. Surg. 2003)

Using Decision Analysis methodology, attempted to arrive at best decision for second episode of pneumothorax Conventional Management entailed intercosta drainage, followed by VATS/Thoracotomy for persistent air-leak

Pneumothorax - Treatment

Pneumothorax - Treatment
For second episode,

VATS is cost-effective Shorter stay by 5 days Slightly less effective than CM

Pneumothorax - Treatment
For second episode,

VATS is cost-effective Shorter stay by 5 days Slightly less effective than CM

Pneumothorax - Treatment
If it works so well for the second episode, what about the first? Torresini et al. (EJ Card. Thor. Surg., 2003)

RCT 35 patients treated with CT 35 patients treated with VATS

Pneumothorax - Treatment
35 patients treated with CT

4 air-leaks 8 recurrences $3,000 per patient

2 air leaks 1 recurrence $2,000 per patient

35 patients treated with VATS

Pneumothorax - Treatment
VATS

Decreased cost Decreased LOS Decreased recurrence ? Psychological effect

Decreased concern of recurrence Satisfaction with definitive management

Pneumothorax - Treatment
What are the recommendations?

British Thoracics Society, 2002

Pneumothorax - Treatment

Pneumothorax - Treatment
BTS Guidelines

Do not discuss second or third episode Only statement

Refer to Thoracic Surgeon all cases of difficult pneumothorax and persistent air leaks

Pneumothorax - Treatment
American Society of Chest Physicians

Guidelines from 2001

Pneumothorax - Treatment
PSP

SSP

1st episode simple drainage/aspiration If no air-leak, reserve definitive treatment till second episode VATS is preferred treatment

1st episode necessitates definitive treatment VATS is preferred treatment

Pneumothorax
Sclerosing Agents?

Talc (85-92% effective) Tetracycline/Monocycline May be used in patients who will not tolerate an operation High risk of ARDS

Areas of Research
Clinical trial in role of VATS Better sclerosing agents Better utilization of CT for patient section for surgical intervention

Any Questions?