Diagnosis and Treatment of Pneumothorax

1. Diagnosis and Treatment of Pneumothorax Souheil M. Abdel Nour, MD Moderator: Thomas Roy, MD Pulmonary and Critical Care East Tennessee State University

2. Disclosure Statement of Financial Interest • I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Definitions • Primary Spontaneous Pneumothorax (PSP) • No underlying lung disease • Secondary Spontaneous Pneumothorax (SSP) • Complication of underlying lung disease • Traumatic Pneumothorax • Caused by penetrating and or blunt trauma • Iatrogenic Pneumothorax • Complication of diagnostic or therapeutic intervention

5. Prognosis • Prognosis varies among the pneumothorax classifications • Recurrence rate is about 28% for PSP and 43% for SSP over a period of 5 years. • Mortality rate of 1-17% in patients with COPD • 5% of patients with COPD died before a chest tube was placed • Patients with AIDS: inpatient mortality rate of 25% and a median survival of 3 months after the pneumothorax. Difficult Decisions in Thoracic Surgery: An Evidence-based Approach, By Mark K. Ferguson.  2nd ed. 2011

6. Prognosis The overall mortality was 1.26 per million per year for males and 0.62 per million per year for females. Epidemiology of pneumothorax in England.Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Thorax. 2000 Aug; 55(8):666-71.

7. Primary Spontaneous Pneumothorax (PSP) • No precipitating event • No known lung disease • Actually most PSP have unrecognized lung disease (subpleural bleb) • The incidence: men 7.4 (USA) - 37 (UK) per 100,000 population per year • Women << men, 1.2 (USA) – 15.4 (UK) per 100,000 population per year

8. Matching?! • Pneumatocoele • Cavity         • Cyst       • Bleb • Bulla • Thin-walled (< 1mm), gas-filled space in the lung developing in association with acute pneumonia • Intrapleural cystic space • Thin-walled, air- or fluid-filled, with a wall that contains respiratory epithelium, cartilage, and smooth muscle • Thin-walled(<1 mm), contained within the lung ,1 cm in size when distended-Walls may be formed by pleura, septa, or compressed lung tissue • Gas-containing space in the lung having a wall > 1 mm thick

9. Air-containing Structures • Pneumatocoele: Thin-walled (< 1mm), gas-filled space in the lung developing in association with acute pneumonia, such as staph, and frequently transient • Cavity: Gas-containing space in the lung having a wall > 1 mm thick • Cyst: Thin-walled, air- or fluid-filled, with a wall that contains respiratory epithelium, cartilage, smooth muscle and glands • Bleb: Intrapleural cystic space           • Bulla  ≥2 bullae (pronounced bully): Thin-walled(<1 mm), contained within the lung ,1 cm in size when distended-Walls may be formed by pleura, septa, or compressed lung tissue

10. Which of these is NOT associated with an increased risk of recurrence? • Male gender • Tall stature in men • Low body weight • Failure to stop smoking

11. Recurrence of primary spontaneous pneumothorax. • Retrospective study of 275 episodes of PSP in 153 patients over a four year period • Incidence of recurrence (54.2%) • PSP was twice as common in men • Women were significantly more likely to develop a recurrence • Male height was the second most important factor • Smoking cessation the only variable which significantly influenced the risk of recurrence Thorax. 1997;52(9):805

12. Increased incidence of PSP • Birt-Hogg-Dube syndrome • Marfan syndrome • Homocystinuria • Catamenial pneumothorax (PSP temporally related to menstruation) • Anorexia nervosa

13. Which of the following is Not seen on physical exam? • Diminished breath sounds, absent fremitus, and hyperresonance to percussion on the affected side. • Decreased chest excursion on the opposite side • Subcutaneous emphysema may be present. • Tracheal deviation from the midline is a rare and typically late finding in pneumothorax .

14. Physical Exam!!! • Place your hands on the patient's back with thumbs pointed towards the spine. Your hands should lift symmetrically outward when the patient takes a deep breath. • Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree

15. Typical Clinical Presentation  • Occurs at rest • Early 20s (rarely after age 40) • Sudden onset of dyspnea and pleuritic chest pain • Decreased chest excursion on the affected side, diminished breath sounds, and hyperresonant percussion • +/- Subcutaneous emphysema • Labored breathing + hemodynamic => tension PTX • Hypoxemia is common • hypercapnia is unusual • Acute respiratory alkalosis

17. Tension Pneumothorax

18. Evidence Based Medicine

20. Supine and lateral XR: trauma Pts- less sensitive • Expiratory films: no additional benefit • US: supine trauma • CT : ‘gold standard’ (small PTX/size estimate)

22. Underestimate or overestimate?!

23. USA: over- vs. UK: underestimate • Guidelines from the USA (ACCP-Chest 2001) overestimate the volume in a localised apical pneumothorax.

28. Which of the following is the right answer? • The O2 does not help if the patient is not hypoxic • It helps symptomatically but it delays the resorption of the pleural air • No effect on the resorption of the pleural air • The rate of resorption can be markedly increased if supplemental oxygen is administered Normal rate of resorption is approximately 1.25% of the volume of the hemithorax per 24 hours. However, the rate of resorption increases six-fold if humidified 100 percent oxygen is administered!

29. Secondary Spontaneous Pneumothorax (SSP)

30. Secondary Spontaneous Pneumothorax (SSP) • COPD is the most common cause of SSP, ~50- 70% • Severity of COPD correlates with likelihood of SSP • Cystic fibrosis: • 3 to 4% of all patients with CF will have an episode of SSP • Primary and metastatic lung malignancy (COPD often co-exists) • Necrotizing pneumonia • Pneumocystisjirovecii • Tuberculosis • Catamenial pneumothorax

31. MATCHING • COPD • CF • PCP • TB • Rupture of apical subpleural cysts • Rupture of apical blebs • Rupture of a cavity into the pleural space • Alveolar and pleural tissue invasion and rupture of large subpleural cysts that are caused by tissue necrosis. 1 - b 2 - a 3 - d 4 - c

32. Less common causes of SSP • Histiocytosis X • Interstitial lung disease • Lymphangioleiomyomatosis • Metastatic sarcoma • Sarcoidosis

33. Clinical Presentation Depends upon: Symptoms: Volume of air Rapidity of onset Tension within the pleural space Age and respiratory reserve Dyspnea Chest pain More severe than PSP Infectious cause of SSP may have cough, fever, chills, or fatigue!

34. Could it be a routine CXR? Y/N

37. Small bore catheters can be safely used in all the following cases of SSP except? • PTX in a pt with advanced emphysema • In COPD with AE. • Pts receiving mechanical ventilation • Iatrogenic PTX (s/p FNA*)

38. Thoracostomy tube size in SSP • Small bore catheters have advantages over larger tubes • Ease of insertion • Patient comfort • Equally efficacious in most patients in retrospective studies • One possible exception to the use of small bore tubes for SSP would be patients receiving mechanical ventilation. • Large bore tubes (24 to 28 fr) in patients receiving mechanical ventilation

39. Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adult Am J Emerg Med. 2006 Nov;24(7):795-800.

40. Chest Tube Management • Water seal device is preferable • No suction due to the risk of RPE • Failure of PTX to resolve => suction if it was not initially applied. • Keep the chest tube until a procedure is performed to prevent recurrent SSP • Pt declines preventive interventions => clamp tube 12hrs after the lung has expanded radiographically and no further air leak is detected via the chest tube.

41. Heimlich Valve • Stable patients & >90% expanded, but + air leak => Heimlich Valve and discharge • Advantage: avoid a long-term hospitalization • However, a separate procedure to prevent a recurrent SSP is typically performed in patients who are surgical candidates

42. Persistent air leakage  • More common and persist longer in SSP • Persistent air leaks may be due to subpleuralbullae or cysts or to necrotic lung • Air leak > 3 days => spontaneous closure is less likeley and need additional interventions

43. For surgical candidates Persistent leak and/or incomplete expansion (<90%) Preferred procedure is stapling or resection of blebs + mechanical pleurodesis Not candidates for surgery Pleural blood patch: persistent air leak complicating ARDS Chemical pleurodesis via chest tube-tetracycline  derivative or talc Success is much lower than with VATS Conservative management: Spontaneous resolution has been described with conservative management after as long as 14 days

44. Preventing recurrence • Recurrence of SSP is common and life-threatening  • 50% recurrent SSP over 3 years among patients with a SSP due to COPD • Intervention in almost all patients treated for an initial SSP (even if with full re-expansion and no evidence of persistent air leak) • Intervention=control the leak + prevent recurrence (pleurodesis) • Performed within 3 to 5 days of hospitalization • 3 options: thoracotomy, VATS and chemical pleurodesis.

45. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials. Lancet. 2007 Jul;370(9584):329-35.

46. Surgical options: open thoracotomy vs. VATS • Lower recurrence rates with open procedures (1 % vs. 5% with VATS) • Greater blood loss, more postoperative pain, and longer hospital stays with open thoracotomy • Preferred intervention in most patients: VATS with stapling of blebs followed by obliteration of the pleural space • Emphysema + meet inclusion and exclusion criteria for LVRS=> LVRS at the same time

47. Nonsurgical chemical pleurodesis • For patients who refuse VATS or are not operative candidates=> chemical pleurodesis (better than no further intervention) • Not as effective as the VATS • Reduces the SSP recurrence to ~ 15 % • Choice of a sclerosant is controversial

48. Am J Respir Crit Care Med. 2000;162(6):2023.

49. Other potential questions!!  Lung transplant candidates Air travel Avoid chemical pleurodesis It does not preclude future lung transplantation VATS-apical pleurodesis. Air travel is postponed for at least two weeks in PSP. In SSP ? not known. Simple drainage vs. pleurodesis influences the risk of recurrence Potential in-flight hypoxemia.

50. Tube Thoracostomy Management