Rishabh Shah, MD Seattle Children’s Hospital October 31, 2013

 Case report-CW  Discuss classification, presentation, and symptoms of spontaneous pneumothorax  Discuss operative management  Discuss factors complicating operative intervention

 16 year old male presents to outside ED with sudden onset of left sided chest pain, without shortness of breath  Transferred to SCH after chest xray demonstrated left pneumothorax, treated with ketorolac  History of recurrent right sided pneumothorax requiring with talc and mechanical pleurodesis

 PMH-recurrent right-sided pneumothorax, FTT requiring G-tube, eosinophilic esophagitis, ADHD, insomnia  PSH-VATS RUL wedge resection of bullae, talc and mechanical pleurodesis, G-tube placement, myringotomies with tube placement  FH-bipolar disorder, emphysema(PGF), no history of connective tissue disorders  SH-denies cigarette use

 Vitals: T: 37˚, HR: 53, BP: 109/59, RR: 16, O 2 : 100% on room air  No increased work of breathing  Reduced lung sounds in anterior and apex of left lung field

 Taken to OR for VATS bleb resections and talc pleurodesis  24 French chest tube placed intraoperatively and maintained on 20 cmH 2 O suction for 48 hours  Stable chest xray after being placed on water seal  Discharged post-operative day 3

 Primary-spontaneously occuring pneumothorax in an individual without evidence of underlying lung disease  Occurs primarily in tall, thin males (male-to- female ratio of :1)  Average age range of  In adults, smoking history important, but less so in pediatric poplation

 Secondary –related to underlying disease, which can cause weakening of the connective tissue of the lung  Causes range from primary lung disorders, such as cystic fibrosis, asthma, etc. to systemic diseases such as connective tissue disorders and autoimmune processes to infectious and malignant processes  Less male dominance ( :1 male-to-female ratio)

 Presents most commonly with sudden one- sided chest pain and dyspnea  Less often, anxiety, cough, and fatigue  Secondary pneumothoraces present with more severe dyspnea due to underlying reduced lung function

 Initially, placement of chest tube for first occurrence of primary spontaneous pneumothorax  If failure to resolve pneumothorax (persistent air leak), proceed to pleurodesis

 Method to obliterate pleural space  Promotes scarring between parietal and visceral pleura

 American College of Chest Physicians Delphi Consensus Statement, “Management of Spontaneous Pneumothorax,” recommends surgical intervention following:  second occurrence of a primary spontaneous pneumothorax  first occurrence of a secondary spontaneous pneumothorax.  persistent air leak for greater than 4 days.

 high-risk occupations (i.e., airline pilots, divers)  a contralateral pneumothorax,  bilateral pneumothoraces,  AIDS

 Chemical-can be introduced through nonoperative and operative methods  Talc and tetracycline derivatives most common agents utilized  Operative approach provides added benefit of resection of affected lung tissue as well as ability to assess lung expansion  Mechanical-create raw surfaces that further produce inflammation  Scrubbing pleural surface with a rough gauze pad or stripping of pleura can be done

 Patients with trapped lung and incomplete lung expansion  Severe inflammatory disease in which further inflammation would compromise pulmonary function

 If successful, pleurodesis causes strong scarring of visceral to parietal pleura with obliteration of pleural space  In patients who are eligible for lung transplant, these strong adhesions cause great difficulties for transplant surgeon

 HC-23 year old female with tuberous sclerosis with history of multiple left and right pneumothoraces finally treated with mechanical pleurodesis in 2012 and 2013

 KS-47 year old female with severe bronchiectasis secondary to cystic fibrosis leading to spontaneous right pneumothorax in 2008 treated with mechanical pleurodesis, bilateral lung transplant in 2013 with multiple morbidities in the postoperative phase

 Dotson, K., Johnson, L. Pediatric spontaneous pneumothorax. Pediatr Emer Care. 2012;28:  Cameron, J. Pneumothorax, Current Surgical Therapy, 9 th Ed. 2008:  Light, R. Primary spontaneous pneumothorax. Uptodate. April  Langenburg, S., Lelli, J. Childhood Lung Disorders. Seminars in Pediatric Surgery. 2008;17:  Baumann, M., et al. Management of Spontaneous Pneumothorax. Chest. 2001;119(2):