1. VATS Treatment of Spontaneous Pneumothorax William R. Mayfield, MD, FACS WellStar Thoracic Surgery March 2009

2. Etiology –Bleb rupture Primary Secondary

3. Consensus Statement Management of Spontaneous Pneumothorax** An American College of Chest Physicians Delphi Consensus Statement MICHAEL H. BAUMANNMICHAEL H. BAUMANN, MD, FCCP, et al FOR THE ACCP PNEUMOTHORAX CONSENSUS GROUP†† CHEST FEBRUARY 2001 VOL. 119 NO. 2 590-602

4. Primary Spontaneous Pneumothorax Clinically Stable Small Pneumothorax –Observe in ER for 3-6 hrs –Repeat CXR –If no progression: discharge home –If distant from ER, or compliance unreliable, then admit

5. Primary Spontaneous Pneumothorax Clinically stable Large pneumothorax –Small bore catheter, 14 fr to 22 fr –Water seal –Suction if no re-expansion –Remove chest tube when no air leak –Discharge with one-way valve if unwilling to be admitted

6. Primary Spontaneous Pneumothorax Unstable Large pneumothorax –Chest tube 16 – 22 fr if small leak anticipated –Chest tube 24 – 28 fr if large leak anticipated, or positive pressure ventilation anticipated –Water seal –Suction if lung fails to expand –Remove tube when no leak and lung expanded

7. Persistent Air Leak Greater than 4 days Thoracoscopy –Closure of leak –Pleurodesis Bedside pleurodesis –Only if surgery contra-indicated or patient refuses surgery –Doxycycline or talc slurry

8. Pneumothorax Recurrence Prevention First pneumothorax15% of panel Second pneumothorax 85% of panel Decision modified by desire to fly or scuba Thoracoscopy is treatment of choice –95 – 100% success –Bullectomy –Parietal pleural abrasion of upper 50% –Pleurectomy is acceptable –Talc: no consensus Bedside pleurodesis for high risk patients –78 – 91% success

9. Primary Spontaneous Pneumothorax CT scanning –No consensus for first time pneumothorax –No consensus for second time pneumothorax, persistent air leak, or planned surgery

10. VATS Bullectomy and Pleurectomy

11. Position –Lateral decubitus, flexed Incisions –Two incision technique: 3 rd and 6 th interspace

12. Video –5 mm chip on a stick (Olympus) Endo GIA –Green load Duet in bullous disease

13. Case Report 87 yo male Metastatic angio-sarcoma Multiple pulmonary blebs after chemotherapy Recurrent left pneumothorax Failed bedside talc pleurodesis –prior admission

16. VATS Pleurectomy with talc

17. Conclusions There is consensus on treatment of spontaneous pneumothorax It is acceptable to operate on first time pneumothorax Thoracoscopy is the preferred method Pleurodesis by abrasion, pleurectomy, or (sometimes) talc is acceptable