Spontaneous Spontaneous PneumothoraxPneumothorax

DefinitionsDefinitions

Primary Spontaneous Pneumothorax Primary Spontaneous Pneumothorax (PSP)(PSP)No underlying lung diseaseNo underlying lung disease

Secondary Spontaneous Pneumothorax Secondary Spontaneous Pneumothorax (SSP)(SSP)Complication of underlying lung diseaseComplication of underlying lung disease

DefinitionsDefinitions

Iatrogenic PneumothoraxIatrogenic PneumothoraxComplication of diagnostic or therapeutic Complication of diagnostic or therapeutic

interventionintervention

Traumatic PneumothoraxTraumatic PneumothoraxCaused by penetrating and or blunt traumaCaused by penetrating and or blunt trauma

PSP - EpidemiologyPSP - Epidemiology

Fairly commonFairly common

10 cases per 100,000 in men10 cases per 100,000 in men

3 cases per 100,000 in women3 cases per 100,000 in women

Typically in tall, thin males between Typically in tall, thin males between ages of 10 and 30ages of 10 and 30

Risk increases with smoking in dose Risk increases with smoking in dose dependent mannerdependent manner

PSP - PathologyPSP - Pathology

Patients have no clinical lung diseasePatients have no clinical lung disease

On thoracoscopy, 75 to 100 percent On thoracoscopy, 75 to 100 percent have sub-pleural Bullaehave sub-pleural Bullae

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

PSP - PathophysiologyPSP - Pathophysiology

Air leak due to increased alveolar Air leak due to increased alveolar pressure, secondary to inflammationpressure, secondary to inflammationAir leaks into lung interstitium then into Air leaks into lung interstitium then into hila, causing pneumomediastinumhila, causing pneumomediastinumMediastinal pressure rises, mediastinal Mediastinal pressure rises, mediastinal parietal pleura rupturesparietal pleura rupturesNo defect seen in visceral pleura or No defect seen in visceral pleura or evidence of bullous ruptureevidence of bullous rupture

PSP - PathophysiologyPSP - Pathophysiology

Due to air in pleural space, decrease in Due to air in pleural space, decrease in vital capacityvital capacity

Hypoxemia results – decreased Hypoxemia results – decreased ventilation perfusion ratioventilation perfusion ratio

Hypercapnia occurs only rarelyHypercapnia occurs only rarely

PSP – Clinical PresentationPSP – Clinical Presentation

History of chest pain while resting.History of chest pain while resting.Physical findings are minimal.Physical findings are minimal.Tachycardia.Tachycardia.If large pneumothorax.If large pneumothorax.

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

PSP – Clinical PresentationPSP – Clinical Presentation

Clinical clearance of symptomsClinical clearance of symptomsUsually within 24-48 hours, even if air in Usually within 24-48 hours, even if air in pleural cavity is not evacuatedpleural cavity is not evacuated

If HR > 135 or hypotension or cyanosisIf HR > 135 or hypotension or cyanosisTENSION PNEUMOTHORAXTENSION PNEUMOTHORAX

PSP – Diagnosis PSP – Diagnosis

HistoryHistory

Chest x-rayChest x-rayPA is only one of significancePA is only one of significanceExpiration & inspiration views were found to Expiration & inspiration views were found to

have no clinical significancehave no clinical significance

PSP – RecurrencePSP – Recurrence

Average rate of recurrence is 30%Average rate of recurrence is 30%Most recurrences within six months to two Most recurrences within six months to two yearsyearsIncreased risk with:Increased risk with:Tall, thin habitusTall, thin habitusPulmonary fibrosisPulmonary fibrosisHistory of smokingHistory of smokingYoung ageYoung age

No increased risk with number of BullaeNo increased risk with number of Bullae

SSPSSP

Potentially life threatening, as limited Potentially life threatening, as limited reservereserveMost often associated with COPD and Most often associated with COPD and PCP pneumonia in HIVPCP pneumonia in HIVRisk in COPD increases with worsening Risk in COPD increases with worsening diseasedisease6% of HIV patients will suffer from PCP 6% of HIV patients will suffer from PCP associated pneumothorax associated pneumothorax (30-40% mortality)(30-40% mortality)

SSPSSP

Also seen in:Also seen in:Langerhan’s granulomatosisLangerhan’s granulomatosisLymphangioleiomyomatosisLymphangioleiomyomatosisInterstitial lung diseaseInterstitial lung diseaseCatamenial PneumothoraxCatamenial Pneumothorax

Seen in women, within 72 hours of mensesSeen in women, within 72 hours of menses

SSP - EpidemiologySSP - Epidemiology

Same rates as PSPSame rates as PSP

Peak is later in lifePeak is later in life60 to 65 years60 to 65 years

26 per 100,000 patients per year with 26 per 100,000 patients per year with COPDCOPD

Occasionally seen as first presenting Occasionally seen as first presenting symptom of pleural and lung CAsymptom of pleural and lung CA

SSP – MechanismSSP – Mechanism

Two hypothesisTwo hypothesisSame as PSPSame as PSP

Ruptured alvelous leaks air directly Ruptured alvelous leaks air directly into pleural space secondary to into pleural space secondary to necrosis – evidence seen in PCP necrosis – evidence seen in PCP associated pneumothoraxassociated pneumothorax

SSP – Clinical PresentationSSP – Clinical Presentation

Dyspnea, usually severeDyspnea, usually severeChest painChest painHypoxemia and hypotensionHypoxemia and hypotensionHypercapniaHypercapniaMust exclude in patient with Chest Must exclude in patient with Chest pain and COPDpain and COPD

SSP – DiagnosisSSP – Diagnosis

Clinical PresentationClinical PresentationRadiological assessmentRadiological assessmentBullae may mask presence of air Bullae may mask presence of air

within the pleural cavitywithin the pleural cavityOnly in patients with previous Only in patients with previous

pulmonary disease, consider CT scan pulmonary disease, consider CT scan to rule out presence of Pneumothoraxto rule out presence of Pneumothorax

SSP – RecurrenceSSP – Recurrence

Similar to PSPSimilar to PSPVarious studies show a range in Various studies show a range in between 39% to 47%between 39% to 47%Increased rate of recurrence in Increased rate of recurrence in patients with complicated COPDpatients with complicated COPDSmoking most potent risk factorSmoking most potent risk factor

Pneumothorax - TreatmentPneumothorax - Treatment

Principles:Principles:

Evacuate air from the pleural spaceEvacuate air from the pleural space

Prevent recurrencesPrevent recurrences

Pneumothorax - TreatmentPneumothorax - Treatment

Air evacuation is to bring about re-Air evacuation is to bring about re-expansion of lungexpansion of lungIf air within pleural cavity is less than If air within pleural cavity is less than 15% of hemithorax (< 2 ribs) and 15% of hemithorax (< 2 ribs) and minimal symptoms:minimal symptoms:Consider supplemental oxygen and Consider supplemental oxygen and

observation over 6 to 8 hoursobservation over 6 to 8 hoursApproximately 2% reabsorption per day on Approximately 2% reabsorption per day on

room airroom air

Pneumothorax - TreatmentPneumothorax - Treatment

If air within pleural cavity is greater If air within pleural cavity is greater than 15% or growing:than 15% or growing:Simple intravenous catheter or Simple intravenous catheter or

thoracentesis catheterthoracentesis catheterChest tubeChest tubeSimple aspiration successful in 70%Simple aspiration successful in 70%Increased success with age < 50 and < Increased success with age < 50 and <

2.5 L of air aspirated2.5 L of air aspirated

Pneumothorax - TreatmentPneumothorax - Treatment

Surgical OptionsSurgical OptionsVideo Assisted Thoracoscopic Surgery (VATS) Video Assisted Thoracoscopic Surgery (VATS)

with wedge resection & pleurodesiswith wedge resection & pleurodesisLimited Axillary ThoracotomyLimited Axillary ThoracotomyThoracotomyThoracotomy

Pneumothorax - TreatmentPneumothorax - Treatment

VATS is felt to be superior to other optionsVATS is felt to be superior to other optionsDecreased time to dischargeDecreased time to dischargeSmall incisionsSmall incisionsDecreased intra-operative stressDecreased intra-operative stressEarlier return to functionEarlier return to functionDecreased post-operative painDecreased post-operative pain

Pneumothorax - TreatmentPneumothorax - Treatment

If VATS is superior, then when do we use If VATS is superior, then when do we use it?it?After second episodeAfter second episodeHigh-risk professionHigh-risk professionPersistent air-leak at 7 daysPersistent air-leak at 7 days

Yes & NoYes & No

Pneumothorax - TreatmentPneumothorax - Treatment

Cole et al. (Ann. Thor. Surg., 1985)Cole et al. (Ann. Thor. Surg., 1985)Cohort studyCohort study89 treated conventionally89 treated conventionally

50% were operated on50% were operated on30 treated with VATS on presentation30 treated with VATS on presentationLOS was 6 days in VATS group, while average LOS was 6 days in VATS group, while average

LOS in conventional group was 8 daysLOS in conventional group was 8 daysRecommended early intervention with VATS, if Recommended early intervention with VATS, if

persistent air leak at 3 dayspersistent air leak at 3 days

Pneumothorax - TreatmentPneumothorax - Treatment

Passlick et al. (Ann. Thor. Surg., 1998)Passlick et al. (Ann. Thor. Surg., 1998)Cohort study (retrospective)Cohort study (retrospective)99 patients treated with VATS, 100 patients 99 patients treated with VATS, 100 patients

treated with lateral thoracotomytreated with lateral thoracotomyVATSVATS

Shorter hospital stayShorter hospital stayShorter CT drainageShorter CT drainageDecreased use of narcoticsDecreased use of narcotics

Pneumothorax - TreatmentPneumothorax - Treatment

Falcoz et al. (Ann. Thor. Surg. 2003)Falcoz et al. (Ann. Thor. Surg. 2003)Using Decision Analysis methodology, Using Decision Analysis methodology,

attempted to arrive at best decision for second attempted to arrive at best decision for second episode of pneumothoraxepisode of pneumothorax

Conventional Management entailed intercosta Conventional Management entailed intercosta drainage, followed by VATS/Thoracotomy for drainage, followed by VATS/Thoracotomy for persistent air-leakpersistent air-leak

Pneumothorax - TreatmentPneumothorax - Treatment

Pneumothorax - TreatmentPneumothorax - Treatment

For second episode,For second episode,VATS is cost-effectiveVATS is cost-effectiveShorter stay by 5 daysShorter stay by 5 daysSlightly less effective than CMSlightly less effective than CM

Pneumothorax - TreatmentPneumothorax - Treatment

For second episode,For second episode,VATS is cost-effectiveVATS is cost-effectiveShorter stay by 5 daysShorter stay by 5 daysSlightly less effective than CMSlightly less effective than CM

Pneumothorax - TreatmentPneumothorax - Treatment

If it works so well for the second episode, If it works so well for the second episode, what about the first? what about the first?

Torresini et al. (EJ Card. Thor. Surg., Torresini et al. (EJ Card. Thor. Surg., 2003)2003)RCTRCT35 patients treated with CT35 patients treated with CT35 patients treated with VATS35 patients treated with VATS

Pneumothorax - TreatmentPneumothorax - Treatment

35 patients treated with CT35 patients treated with CT4 air-leaks4 air-leaks8 recurrences8 recurrences$3,000 per patient$3,000 per patient

35 patients treated with VATS35 patients treated with VATS2 air leaks2 air leaks1 recurrence1 recurrence$2,000 per patient$2,000 per patient

Pneumothorax - TreatmentPneumothorax - Treatment

VATSVATSDecreased costDecreased costDecreased LOSDecreased LOSDecreased recurrenceDecreased recurrence? Psychological effect? Psychological effect

Decreased concern of recurrenceDecreased concern of recurrenceSatisfaction with definitive managementSatisfaction with definitive management

Pneumothorax - TreatmentPneumothorax - Treatment

What are the recommendations?What are the recommendations?British Thoracics Society, 2002British Thoracics Society, 2002

Pneumothorax - TreatmentPneumothorax - Treatment

Pneumothorax - TreatmentPneumothorax - Treatment

BTS GuidelinesBTS GuidelinesDo not discuss second or third episodeDo not discuss second or third episodeOnly statementOnly statement

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

Pneumothorax - TreatmentPneumothorax - Treatment

American Society of Chest PhysiciansAmerican Society of Chest PhysiciansGuidelines from 2001Guidelines from 2001

Pneumothorax - TreatmentPneumothorax - Treatment

PSPPSP11stst episode – simple episode – simple

drainage/aspirationdrainage/aspirationIf no air-leak, reserve If no air-leak, reserve

definitive treatment till definitive treatment till second episodesecond episode

VATS is preferred VATS is preferred treatmenttreatment

SSPSSP 11stst episode necessitates episode necessitates

definitive treatmentdefinitive treatment VATS is preferred VATS is preferred

treatmenttreatment

PneumothoraxPneumothorax

Sclerosing Agents?Sclerosing Agents?Talc (85-92% effective)Talc (85-92% effective)Tetracycline/MonocyclineTetracycline/MonocyclineMay be used in patients who will not tolerate an May be used in patients who will not tolerate an

operationoperationHigh risk of ARDSHigh risk of ARDS