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SPONTANEOUS PNEUMOTHORAX
Neal G. Moores • Karl G. Reyes • Siva Raja • David P. Mason
CHAPTER OUTLINE
EPIDEMIOLOGY Aspiration
CAUSES Tube Thoracostomy
Pleurodesis
CLINICAL PRESENTATION Surgery
IMAGING SPECIAL CONSIDERATIONS
MANAGEMENT Secondary Spontaneous Pneumothorax
Observation Catamenial Pneumothorax
The term pneumothorax was first coined by Jean Marc SSP develops as a complication of underlying lung
Gaspard Itard1 in 1803, when he called attention to five disease, most commonly chronic obstructive pulmonary
cases in which free air was found in the thorax after disease (COPD).7 The annual incidence of SSP is approx-
trauma. Derived from the Greek words pneuma (air) and imately 6.3 cases per 100,000 population among men
thorakos (breastplate or chest), it is an apt description for and 2 cases per 100,000 population among women.4 The
the accumulation of air in the pleural space that leads to peak incidence occurs between the ages of 60 and 65
partial or total collapse of the affected lung. The clinical years.5
features of pneumothorax were first described in 1819 by
René Laennec,2 who postulated the relationship to pre-
existing blebs and unprovoked rupture and, hence, the CAUSES
term spontaneous pneumothorax. This pathophysiologic
mechanism was confirmed by Kjærgaard3 in later decades. PSP manifests without forewarning signs or symptoms
Today, the classification of pneumothoraces is based on and is most likely caused by rupture of a subpleural
clinical presentation and underlying lung disease. Mul- bleb. This premise is based on cumulative results of
tiple management strategies range from simple evacua- patients undergoing computed tomography (CT), which
tion of air from the pleural space to potential prevention demonstrated subpleural blebs in as many as 80%.8,9
of future pneumothoraces. Surgical experience confirmed the presence of bullae in
more than 75% of patients who underwent video-assisted
thoracoscopic surgery (VATS) and thoracotomy.10-12
EPIDEMIOLOGY Recent research may indicate a more diffuse pathologic
etiology than simple bleb rupture. Fluorescein-enhanced
Spontaneous pneumothorax (SP) may be termed either a pathologic assay of resected lung tissue in PSP patients
primary or secondary event, dependent on underlying reveals significant inflammatory changes and potential
lung disease. Primary spontaneous pneumothorax (PSP) air-leak sites remote from blebs and other visible
typically occurs in young patients with localized blebs but abnormalities.13
otherwise normal lungs. Secondary spontaneous pneu- After the first episode of PSP, recurrence varies,
mothorax (SSP) occurs in patients with marked structural ranging from 16% to 54%. Most studies indicate an
lung disease and directly contributes to SP. Approxi- average of 30%.14,15 Recent research indicates that the
mately 20,000 new cases of PSP are diagnosed annually presence of subpleural blebs on high-resolution CT
in the United States,4 with an estimated economic impact confers a recurrence risk of up to 68.1%, whereas the
of $130 million per year in lost wages. The annual esti- absence of blebs carries a recurrence risk of only 6.1%.16
mated incidence of PSP is between 7.4 and 18 cases per Most recurrences develop between 6 months and 2 years
100,000 population among men and between 1.2 and 6 after the initial episode.15 Men who are tall and have a
cases per 100,000 population among women.4 Patients history of smoking are at the greatest risk of recurrence.
prone to PSP are usually tall and thin and between 10 Counseling for smoking cessation should be strongly
and 30 years of age.5 A significant factor is cigarette encouraged.15 After the second episode of PSP, the likeli-
smoking, which can increase the risk of PSP by a factor hood of recurrence increases markedly and can reach as
as high as 20.6 high as 83%.7,14
462
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27 SPONTANEOUS PNEUMOTHORAX 463
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464 SECTION 1 THORACIC SURGERY
recurrence is possible. If chest radiography reveals that 5 g.39,40 In theory, talc has the potential to induce malig-
the SP is enlarging, immediate intervention is crucial. nant transformation after decades of use, but thus far, this
has not been demonstrated in humans.41 Nonetheless,
our agent of preference is doxycycline to sclerose benign
Aspiration pleural processes. A total of 500 mg of doxycycline com-
Aspiration allows evacuation of pleural air and complete bined with lidocaine is infused through the chest tube,
reexpansion of the lung. This technique can be applied and the patient’s position is shifted from side to side to
even for larger pneumothoraces if the patient is stable. distribute the sclerosant. Suction is then placed for 48
We prefer the Seldinger technique,30,31 which uses a hours. Recurrence of SP in patients treated with bedside
small, single-lumen central line placed over the superior pleurodesis is high, ranging from 8% to 40%.40,42,43 In our
rib edge in the second interspace in the midclavicular institution, this treatment is reserved for patients who are
line. A three-way stopcock and large syringe are used to not considered good operative candidates, most com-
aspirate until resistance is felt, usually signifying full lung monly patients with SSP.
expansion. Chest radiography is then performed to
confirm the findings, and the catheter is removed.27,28,32-36 Surgery
Commercially prepared kits with one-way valves (Heim-
lich valve)7 allow air to exit but prevent air entry. These Surgical indications for PSP are recurrence, large or per-
valves can be left in place until full lung expansion is sistent air leaks, and incomplete lung expansion after tube
achieved. For more rapid resolution, however, it is our thoracostomy. Other surgical indications include patients
preference to perform tube thoracostomy with a small with a history of bilateral SP and patients in occupations
chest tube. Complications of aspiration, although rare, that would place them at high risk if a pneumothorax
may include bleeding and possible lung injury. Reported recurred, such as commercial pilots and professional
success is higher in resolving PSP (66% to 83%) than for scuba divers.19,26,37,38 Although some thoracic surgeons
SSP (37%).27,35 SP that does not respond successfully to recommend surgery in patients with a first-time PSP if
aspiration requires tube thoracostomy. bullae are detected on CT scan,22 we think that this strat-
egy is highly aggressive, unnecessary, and unproven; thus
we do not incorporate this practice into our treatment
Tube Thoracostomy strategies.
Tube thoracostomy is recommended for patients with VATS is the surgical procedure of choice for SP,
large or symptomatic SP and for most patients with SSPs. replacing the previous procedure, axillary thoracot-
Patients with signs of a tension pneumothorax should be omy.44,45 The goals of surgery are resection of the offend-
treated without hesitation, even before chest radiography ing bulla, complete lung expansion, and pleurodesis to
is performed. Tube placement is through the fifth inter- prevent recurrence. A standard three-port VATS tech-
costal space in the midaxillary line. In our experience, as nique is used with lung isolation through a double-lumen
with chest tubes placed through port sites following endotracheal tube. The entire lung is carefully inspected,
VATS, there is no need to tunnel chest tubes placed at with particular attention to the apex and superior seg-
bedside. ments, because these are typical bullae locations. Saline
A small chest tube can be difficult to direct to the apex flooding of the hemithorax during gentle lung inflation
of the chest, so a 28 Fr is preferable. The chest tube is can help locate a ruptured bleb. Some surgeons resect the
left in place for 24 to 48 hours. Our practice is to place apex of the lung even if no bleb is located, although our
the chest tube on water seal once lung expansion has been practice is to perform lung resection only when a bleb is
confirmed. If an air leak persists and nonoperative man- identified (Fig. 27-1). Buttressed staple lines are not nec-
agement is preferred, a Heimlich valve can be placed. essary with otherwise normal lung parenchyma.
The patient can then be discharged for outpatient Intraoperative pleurodesis should be performed in
management. The efficacy of suction is debated, but addition to blebectomy. Mechanical pleurodesis is our
there is no evidence that it speeds the resolution of SP. most common method and is performed with use of a
If it is used, it should be used judiciously.37 Tube thora- Bovie scratch pad with aggressive abrasion of the parietal
costomy successfully resolves PSP in approximately 90% pleura (Fig. 27-2). It is our practice to infuse doxycycline
of patients for the first occurrence, 50% for the first as an additional chemical sclerosant, although some sur-
recurrence, and 15% after a second recurrence.38 For geons choose to infuse talc at the time of surgery with
this reason, definitive management of SP recurrences good results and minimal impairment of pulmonary func-
will require either surgical intervention or chemical tion over time.46,47 This is in spite of a recent study out
pleurodesis. of Korea suggesting that there is no difference in recur-
rence with mechanical pleurodesis following bleb
resection.48
Pleurodesis Another effective method of obtaining pleural sym-
After tube thoracostomy, chemical pleurodesis may help physis is parietal pleurectomy, by either VATS or open
prevent SP recurrence. Sclerosing agents are instilled to techniques. Results are similar to those of mechanical
create pleural symphysis. The most commonly used abrasion.49,50 Surgeons should make every effort to control
agents are sterile talc slurry and doxycycline solution. air leak before leaving the operating room. Apical chest
Because adult respiratory distress syndrome may be trig- tube placement is crucial to full lung expansion. Postop-
gered by high doses of talc, use should be limited to eratively, chest tubes are placed to water seal as soon as
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27 SPONTANEOUS PNEUMOTHORAX 465
REFERENCES
a chest x-ray demonstrates full expansion, and no air leak
1. Myers JA: Simple spontaneous pneumothorax. Dis Chest 26:420–
is present. VATS successfully resolves SP and prevents 441, 1954.
recurrence in more than 90% of patients.51 Whereas 2. Driscoll PJ, Aronstam EM: Experiences in the management of
some studies show that recurrence of SP is slightly higher recurrent spontaneous pneumothorax. J Thorac Cardiovasc Surg
with VATS compared with thoracotomy, this small incre- 42:174–178, 1961.
ment does not justify the discomfort and lost work days 3. Kjærgaard H, Anderson H: Spontaneous pneumothorax in the appar-
ently healthy, Copenhagen, 1932, Levin & Munksgaard, p 159.
in this generally young population.52 Thoracotomy is 4. Melton LJ, 3rd, Hepper NG, Offord KP: Incidence of spontaneous
reserved for VATS failures and complex giant bleb resec- pneumothorax in Olmsted County, Minnesota: 1950 to 1974. Am
tions not amenable to VATS. Rev Respir Dis 120:1379–1382, 1979.
5. Primrose WR: Spontaneous pneumothorax: a retrospective review
of aetiology, pathogenesis and management. Scott Med J 29:15–20,
1984.
SPECIAL CONSIDERATIONS 6. Bense L, Eklund G, Wiman LG: Smoking and the increased risk
of contracting spontaneous pneumothorax. Chest 92:1009–1012,
1987.
Secondary Spontaneous Pneumothorax 7. Baumann MH, Strange C: Treatment of spontaneous pneumotho-
rax: a more aggressive approach? Chest 112:789–804, 1997.
Clinical presentation of SSP is similar to that of PSP; 8. Lesur O, Delorme N, Fromaget JM, et al: Computed tomography
however, dyspnea and respiratory compromise are often in the etiologic assessment of idiopathic spontaneous pneumotho-
more profound, given the presence of underlying lung rax. Chest 98:341–347, 1990.
Descargado para Daniela Muñoz (danii.munozr@gmail.com) en Universidad de Santiago de Chile de ClinicalKey.es por Elsevier en marzo 20, 2018.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2018. Elsevier Inc. Todos los derechos reservados.
466 SECTION 1 THORACIC SURGERY
9. Mitlehner W, Friedrich M, Dissmann W: Value of computer 33. Archer GJ, Hamilton AA, Upadhyay R, et al: Results of
tomography in the detection of bullae and blebs in patients with simple aspiration of pneumothoraces. Br J Dis Chest 79:177–182,
primary spontaneous pneumothorax. Respiration 59:221–227, 1992. 1985.
10. Donahue DM, Wright CD, Viale G, et al: Resection of pulmonary 34. Delius RE, Obeid FN, Horst HM, et al: Catheter aspiration for
blebs and pleurodesis for spontaneous pneumothorax. Chest simple pneumothorax. Experience with 114 patients. Arch Surg
104:1767–1769, 1993. 124:833–836, 1989.
11. Inderbitzi RG, Leiser A, Furrer M, et al: Three years’ experience 35. Hamilton AA, Archer GJ: Treatment of pneumothorax by simple
in video-assisted thoracic surgery (VATS) for spontaneous pneu- aspiration. Thorax 38:934–936, 1983.
mothorax. J Thorac Cardiovasc Surg 107:1410–1415, 1994. 36. Vallee P, Sullivan M, Richardson H, et al: Sequential treatment of
12. Sahn SA, Heffner JE: Spontaneous pneumothorax. N Engl J Med a simple pneumothorax. Ann Emerg Med 17:936–942, 1988.
342:868–874, 2000. 37. So SY, Yu DY: Catheter drainage of spontaneous pneumothorax:
13. Noppen M, Dekeukeleire T, Hanon S, et al: Fluorescein-enhanced suction or no suction, early or late removal? Thorax 37:46–48,
autofluorescence thoracoscopy in patients with primary spontane- 1982.
ous pneumothorax and normal subjects. Am J Respir Crit Care Med 38. Jain SK, Al-Kattan KM, Hamdy MG: Spontaneous pneumothorax:
174:26–30, 2006. determinants of surgical intervention. J Cardiovasc Surg (Torino)
14. Light RW: Pleural diseases, ed 5, Philadelphia, 2007, Lippincott 39:107–111, 1998.
Williams & Wilkins, p xiii. 39. Kennedy L, Rusch VW, Strange C, et al: Pleurodesis using talc
15. Lippert HL, Lund O, Blegvad S, et al: Independent risk factors for slurry. Chest 106:342–346, 1994.
cumulative recurrence rate after first spontaneous pneumothorax. 40. Kennedy L, Sahn SA: Talc pleurodesis for the treatment of pneu-
Eur Respir J 4:324–331, 1991. mothorax and pleural effusion. Chest 106:1215–1222, 1994.
16. Casali C, Stefani A, Ligabue G, et al: Role of Blebs and Bullae 41. NTP Toxicology and Carcinogenesis Studies of Talc (CAS No.
Detected by High-Resolution Computed Tomography and Recur- 14807-96-6) (Non-Asbestiform) in F344/N Rats and B6C3F1 Mice
rent Spontaneous Pneumothorax. Ann Thor Surg 1:249–255, 2013. (Inhalation Studies). Natl Toxicol Program Tech Rep Ser 421:1–287,
17. Seremetis MG: The management of spontaneous pneumothorax. 1993.
Chest 57:65–68, 1970. 42. Heffner JE, Standerfer RJ, Torstveit J, et al: Clinical efficacy of
18. Engdahl O, Toft T, Boe J: Chest radiograph—a poor method for doxycycline for pleurodesis. Chest 105:1743–1747, 1994.
determining the size of a pneumothorax. Chest 103:26–29, 1993. 43. Kitamura S, Sugiyama Y, Izumi T, et al: Intrapleural doxycycline
19. Henry M, Arnold T, Harvey J: BTS guidelines for the management for control of malignant pleural effusion. Curr Ther Res Clin Exp
of spontaneous pneumothorax. Thorax 58(Suppl 2):ii39–ii52, 2003. 30:515–521, 1981.
20. Waitches GM, Stern EJ, Dubinsky TJ: Usefulness of the double- 44. Murray KD, Matheny RG, Howanitz EP, et al: A limited axillary
wall sign in detecting pneumothorax in patients with giant bullous thoracotomy as primary treatment for recurrent spontaneous pneu-
emphysema. AJR Am J Roentgenol 174:1765–1768, 2000. mothorax. Chest 103:137–142, 1993.
21. Waseem M, Jones J, Brutus S, et al: Giant bulla mimicking pneu- 45. Simansky DA, Yellin A: Pleural abrasion via axillary thoracotomy
mothorax. J Emerg Med 29:155–158, 2005. in the era of video assisted thoracic surgery. Thorax 49:922–923,
22. Sawada S, Watanabe Y, Moriyama S: Video-assisted thoracoscopic 1994.
surgery for primary spontaneous pneumothorax: evaluation of indi- 46. Cardillo G, Carleo F, Giunti R, et al: Videothoracoscopic talc pou-
cations and long-term outcome compared with conservative treat- drage in primary spontaneous pneumothorax: a single-institution
ment and open thoracotomy. Chest 127:2226–2230, 2005. experience in 861 cases. J Thorac Cardiovasc Surg 131:322–328,
23. Schramel FM, Postmus PE, Vanderschueren RG: Current aspects 2006.
of spontaneous pneumothorax. Eur Respir J 10:1372–1379, 1997. 47. Lange P, Mortensen J, Groth S: Lung function 22-35 years after
24. Cole FH, Jr, Cole FH, Khandekar A, et al: Video-assisted thoracic treatment of idiopathic spontaneous pneumothorax with talc pou-
surgery: primary therapy for spontaneous pneumothorax? Ann drage or simple drainage. Thorax 43:559–561, 1988.
Thorac Surg 60:931–933, discussion 934–935, 1995. 48. Park JS, Han WS, Kim HK, et al: Pleural abrasion for mechanical
25. Massard G, Thomas P, Wihlm JM: Minimally invasive manage- pleurodesis in surgery for primary spontaneous pneumothorax: is
ment for first and recurrent pneumothorax. Ann Thorac Surg it effective? Surg Laparosc Endosc Percutan Tech 22:62–64, 2012.
66:592–599, 1998. 49. Nathan DP, Taylor NE, Low DW, et al: Thoracoscopic total pari-
26. Baumann MH, Strange C, Heffner JE, et al: Management of spon- etal pleurectomy for primary spontaneous pneumothorax. Ann
taneous pneumothorax: an American College of Chest Physicians Thorac Surg 85:1825–1827, 2008.
Delphi consensus statement. Chest 119:590–602, 2001. 50. Nkere UU, Kumar RR, Fountain SW, et al: Surgical management
27. Bevelaqua FA, Aranda C: Management of spontaneous pneumo- of spontaneous pneumothorax. Thorac Cardiovasc Surg 42:45–50,
thorax with small lumen catheter manual aspiration. Chest 81:693– 1994.
694, 1982. 51. Ng CS, Lee TW, Wan S, et al: Video assisted thoracic surgery in
28. Light RW: Management of spontaneous pneumothorax. Am Rev the management of spontaneous pneumothorax: the current status.
Respir Dis 148:245–248, 1993. Postgrad Med J 82:179–185, 2006.
29. O’Rourke JP, Yee ES: Civilian spontaneous pneumothorax. Treat- 52. Barker A, Maratos EC, Edmonds L, et al: Recurrence rates of
ment options and long-term results. Chest 96:1302–1306, 1989. video-assisted thoracoscopic versus open surgery in the prevention
30. Ayed AK, Chandrasekaran C, Sukumar M: Aspiration versus tube of recurrent pneumothoraces: a systematic review of randomised
drainage in primary spontaneous pneumothorax: a randomised and non-randomised trials. Lancet 370:329–335, 2007.
study. Eur Respir J 27:477–482, 2006. 53. Videm V, Pillgram-Larsen J, Ellingsen O, et al: Spontaneous
31. Noppen M, Alexander P, Driesen P, et al: Manual aspiration versus pneumothorax in chronic obstructive pulmonary disease: complica-
chest tube drainage in first episodes of primary spontaneous pneu- tions, treatment and recurrences. Eur J Respir Dis 71:365–371,
mothorax: a multicenter, prospective, randomized pilot study. Am 1987.
J Respir Crit Care Med 165:1240–1244, 2002. 54. Alifano M, Roth T, Broet SC, et al: Catamenial pneumothorax: a
32. Andrivet P, Djedaini K, Teboul JL, et al: Spontaneous pneumotho- prospective study. Chest 124:1004–1008, 2003.
rax. Comparison of thoracic drainage vs immediate or delayed 55. Peikert T, Gillespie DJ, Cassivi SD: Catamenial pneumothorax.
needle aspiration. Chest 108:335–339, 1995. Mayo Clin Proc 80:677–680, 2005.
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