Essentials in Cardiothoracic Surgery Management of Pneumothorax and Bullous Disease

Punnarerk Thongcharoen, MD Siriaj Hospital Medical School

Management of Pneumothorax
Background Management of primary spontaneous pneumothorax Management of secondary spontaneous pneumothorax Management of iatrogenic pneumothorax

References

Background
Terms
Primary spontaneous pneumothorax (PSP) Secondary spontaneous pneumothorax (SSP) Iatrogenic PTX Tension PTX Catamenial PTX

Recommendations
SSP higher morbidity / mortality than PSP Strong emphasis on smoking cessation, to minimise the risk of recurrence PTX is not usually associated with physical exertion Symptoms in PSP may be minimal or absent Symptoms are greater in SSP, even if PTX is relatively small in size

 The presence of breathlessness influences the management strategy Severe symptoms and signs of respiratory distress suggest the presence of tension PTX

Diagnosis

X-ray
Standard CXR upright in inspiration are recommended, rather than expiratory films It is currently recommended that a diagnostic PACS workstation is available for image review CT scanning is recommended for uncertain or complex cases

 In defining a management strategy, the size of a PTX is less important than the degree of clinical compromise The differentiation of a large/ small PTX CT
Most accurate PTX size calculations Not neceassary

Size of pneumothorax

3 dimension estimation

Volume of Pneumothorax
9.5 cm 12 cm

= (123 9.53) / 123 = 50%

SSSC7
Sizing PTX

ACCP
< or > 3 cm apex-tocupola distance

BTS
< or >2 cm lung margin lateral chest wall

PT
Either ACCP or BTS

Treatment
The distinction between PSP and SSP should be made, to guide appropriate management Breathlessness indicates the need for active intervention The size of PTX
determines the rate of resolution relatively indicates active intervention

PSP
Conservative/ ambulatory care Active interventions
Medical Surgical

Management of pneumothorax
Observation Needle aspiration Small-bore catheter drainage Tube thoracostomy (ICD) for surgery, only Unfit Chemical pleurodesis Surgery

 Observation is the treatment of choice for small PSP, without significant breathlessness

SSSC7
Treatment for Observe asymptomatic small PSP,

ACCP
Observe

BTS
Observe

PT
Observe

PT = Author

 Pt with significant breathlessness, whatever size, should undergo active intervention ICD is required for tension or bilateral PTX A large PSP, but without significant breathlessness, may be managed by observation alone.

2009

Cochrane review
1239 publications 6 studies only one eligible for inclusion No significant between NA and ICD
Immediate success rate Early failure rate Hosp stay One year success rate No of patient requiring pleurodesis in one year

NA reduction in the percent of pt hospitalised

Needle aspiration?
SSSC7
Role of needle Delayed aspiration asymptomatic (NA) PSP, < 30% PSP Fail NA

ACCP
May consider in enlarging PSP after observation

BTS
Initial treatment for non-tension PSP Small bore catheter chest drain. NA should not repeat.

PT
May consider in delayed asymptomatic PSP Small bore catheter chest drain. NA should not repeat.

SSSC7
Significant PSP (>30% PSP) with symptom, initial treatment ICD, 20Fr, with water seal drainage system

ACCP
Small bore catheter (<14Fr) or medium bore tube (1622Fr), Heimlich valve or water seal

BTS
NA is procedure of choice in most cases

PT
Small bore catheter (<14Fr) or medium bore tube (1622Fr), Heimlich valve or water seal Not recommend

Large bore chest drain (24-28 Fr)

Not Not recommend. recommend May use in BPF, or patient with positive pressure ventilation

ICD with suction?

Air might be removed at a rate that exceeds the rate of air leak Promote healing by apposition of the visceral and parietal pleural layers. Optimal suction pressures -10 to -20 cm H2O

 The addition of suction too early

may precipitate reexpansion pulmonary oedema especially in the case of a PSP that may have been present for more than a few days

SSSC7
Suctioned drainage system

ACCP

BTS
Should not be routinely used. May consider if persistent air leak > 48 hr

PT
Should not be routinely used. May consider if persistent air leak or lung is not completely reexpanded after 48 hr

If the lung is If lung fails to not completely reexpand reexpanded. quickly with water seal system

SSSC7
Medical chemical pleurodesis

ACCP
Acceptable in high risk patients or wish to avoid surgery

BTS

PT

Same as ACCP Should only be used o high and BTS risk patients or wish to avoid surgery

BTS 2003
Persistent air leak/failure of the lung to re-expand, early (3-5 days) thoracic surgical opinion Open thoracotomy + pleurectomy lowest recurrence rate Minimally invasive procedures, VATS, pleural abrasion, and surgical talc pleurodesis - effective alternative strategies

ACCP 2001
Patients with air leaks persisting > 4 days should be evaluated for surgery
Patients should not undergo the placement of an additional chest tube or bronchoscopy to seal endobronchial sites of air leaks.

 Although the relative value of VATS compared to a limited thoracotomy has not been clearly defined, the panel selected VATS as the preferred management.

 VATS is the preferred intervention.

Clinical trials do not demonstrate the superiority of VATS vs limited thoracotomy. The panel s preference for VATS was based on practice preferences.

SSSC7
Persistent air > 5 7 days leak requiring surgical intervention

ACCP
> 3 5 days

BTS
> 5 7 days

PT
> 3 5 days

SSSC7
Surgical approach VATS is preference. Experience with minithoracotomy has been favorable.

ACCP
VATS (based on panel s practice preference)

BTS

PT

Open limited VATS or posterolateral axillary thoracotomy thoracotomy has lowest recurrence rate while VATS is better tolerated.

Bleb/bullae management
Bullectomy should be performed by staple bullectomy/ hand sewing Options include electrocoagulation, laser ablation
Depending on institutional expertise and experience

Recurrence prevention BTS 2003

There is debate between surgical pleurodesis or pleural abrasion partial or total pleurectomy Pleurectomy s recurrence rate = 0.4, Pleural abrasion s recurrence rate = 2.3%.

Recurrence Prevention ACCP 2001

Same as BTS 15% of panel members, however, would offer patients an intervention to prevent a recurrence after the first pneumothorax.

Recurrence Prevention ACCP 2001

Surgical pleurodesis should be performed with parietal pleural abrasion limited to the upper half of the hemithorax. Parietal pleurectomy is an acceptable alternative.

SSSC7 Recurrence prevention procedure Parietal pleural abrasion or resection

ACCP Pleural abrasion > pleurectomy/ talc insufflation

BTS Combined upper half pleurectomy and pleural abrasion

PT Combined 2/3 -3/4 pleurectomy and pleural abrasion

 Secondary pneumothorax
Open thoracotomy is the recommended approach. VATS procedures should be reserved for those with poor lung function.

Secondary pneumothorax
All patients with SSP should be admitted to hospital for at least 24 hours Most patients will require the insertion of a small-bore chest drain Those with a persistent air leak should be discussed with a thoracic surgeon at 48 hours

 Medical pleurodesis may be appropriate for inoperable patients Patients with SSP can be considered for ambulatory management with a Heimlich valve

ACCP
Most members of the panel recommend an intervention to prevent pneumothorax recurrence after the first occurrence. *** Medical or surgical thoracoscopy is preferred. *** a muscle- sparing (axillary) thoracotomy is an acceptable alternative. A standard thoracotomy is not appropriate therapy for most patients. ***

Recent data on VATS outcome

Recently reported recurrence rates following VATS bullectomy combined with surgical pleurodesis has been 1.7-5.7% Shorter postoperative hospital stay, less postoperative pain, and better pulmonary gas exchange in the postoperative period
RCT ???

 VATS performed under local anaesthetic supplemented by nitrous oxide inhalation

increasing the risk of missing a leaking bleb or bulla.

Conclusion from BTS, ACCP

Indication Surgery for first time PTX ??? Surgical approach
Preferred Open VATS - minithoracotomy Alternative VATS, transaxilary thoracotomy

Recurrence prevention
Pleural abrasion pleurectomy surgical chemical

pleurodesis

Surgery for pneumothorax

Posterolateral thoracotomy Transaxillary thoracotomy Median sternotomy VAT

Muscle incision Skin Incision

Catamenial PTX

Catamenial PTX
Catamenial PTX is underdiagnosed in female PTX patients A combination of
surgical intervention (include diaphragmatic resection or plication of the fenestrations seen) hormonal manipulation - gonadotrophin-releasing hormone analogues

PTX and pregnancy

PTX recurrence is more common in pregnancy Observation/ simple aspiration usually effective Elective assisted delivery and regional anaesthesia at or near term A corrective surgical procedure (VATS) should be considered after delivery

Iatrogenic PTX
The majority observation alone

If intervention is required simple aspiration COPD On ventilator ICD ICD

Traumatic pneumothorax
The indication of VATS included:
Persistent PTX On-going bleeding in stable patients Retained hemothorax/ infected pleural space and collections Evaluation of the diaphragm in penetrating injuries and management

Bullous Lung Disease

Generalised emphysematous or normal lung with large emphysematous bullae

Surgical indication
Symptomatic patients Giant bullae occupying over one third of a hemithorax Mediastinal shift Bullae complications
Pneumothorax, infection, and enlargement with time

Treatment options
Surgery VATS/ thoracotomy
Bullectomy Modified Monaldi technique
opening the bulla, placing a purse-string suture at the neck of the bulla

 Talc is a, natural, hydrated magnesium silicate that has the approximate chemical formula of Mg3(Si2O5)2(OH)2.
aerosol (insufflation) in a suspension (slurry)

Cost analysis of VATS versus thoracotomy : critical review

8 studies specifically looked at cost
Lung biopsy Wedge resection of lung nodules Pneumothorax LVRS Lung cancer
Eur Respir J 2003; 22:735-8

The cost-effectiveness of VATS

Mainly retrospective studies VATS - initially more expensive, but a shorter hospital stay may compensate this. Economically justified as an initial procedure instead of ICD for 1st and recurrent PSP
Less Cx, lower cost ?

Prospective randomized trial VATS vs Open

VATS vs limited m. sparing thoracotomy VATS
Less physiologic deterioration (FEV1, FVC) Longer op time Less early PO analgesics required Shorter LOS PSP > SSP

Prospective trial VATS vs Open

VATS vs transaxillary mini-thoracotomy (nonRT) Op time, early PO analgesics required and duration of chest tube placement
No statistically difference Op time, ICD duration in VATS are longer

Historical series comparison

VATS is better Less PO narcotic required Less op bleeding Cheaper Earlier return to work

Historical series comparison 2

VATS is probably better Shorter or the same ICD duration Shorter or the same LOS, PO stay

Historical series comparison 3

Inconclusive Shorter, longer or the same op time Less, more, or the same PO Cx VATS is probably worse Higher or the same recurrence rate

Surgical approaches to both lungs

Bilateral thoracotomy/ VATS Median sternotomy Bilateral apical stapling & apical pleurectomy through unilateral axillary thoracotomy/ VATS

 The most common approach - bilat VATS lateral decubitus position, with side-changing Or supine position, modify the sites of the trocars,
2 on the anterior axillary line 1 on the midclavicular line/ 2nd ICS