1. Spontaneous Pneumothorax

2. Definitions Primary Spontaneous Pneumothorax (PSP)  No underlying lung disease Secondary Spontaneous Pneumothorax (SSP)  Complication of underlying lung disease

3. Definitions  Iatrogenic Pneumothorax  Complication of diagnostic or therapeutic intervention  Traumatic Pneumothorax  Caused by penetrating and or blunt trauma

4. PSP - Epidemiology Fairly common 10 cases per 100,000 in men 3 cases per 100,000 in women Typically in tall, thin males between ages of 10 and 30 Risk increases with smoking in dose dependent manner

5. PSP - Pathology Patients have no clinical lung disease On thoracoscopy, 75 to 100 percent have sub-pleural Bullae Increased numbers in smokers (89%) vs. non smokers (81%)

6. PSP - Pathophysiology Air leak due to increased alveolar pressure, secondary to inflammation Air leaks into lung interstitium then into hila, causing pneumomediastinum Mediastinal pressure rises, mediastinal parietal pleura ruptures No defect seen in visceral pleura or evidence of bullous rupture

7. PSP - Pathophysiology Due to air in pleural space, decrease in vital capacity Hypoxemia results – decreased ventilation perfusion ratio Hypercapnia occurs only rarely

8. PSP – Clinical Presentation History of chest pain while resting. Physical findings are minimal.  Tachycardia.  If large pneumothorax. Hyper resonance on percussion. Decreased fremitus. Decreased or absent breath sounds.

9. PSP – Clinical Presentation  Clinical clearance of symptoms Usually within 24-48 hours, even if air in pleural cavity is not evacuated  If HR > 135 or hypotension or cyanosis TENSION PNEUMOTHORAX

10. PSP – Diagnosis History Chest x-ray  PA is only one of significance  Expiration & inspiration views were found to have no clinical significance

11. PSP – Recurrence Average rate of recurrence is 30% Most recurrences within six months to two years Increased risk with:  Tall, thin habitus  Pulmonary fibrosis  History of smoking  Young age No increased risk with number of Bullae

12. SSP Potentially life threatening, as limited reserve Most often associated with COPD and PCP pneumonia in HIV Risk in COPD increases with worsening disease 6% of HIV patients will suffer from PCP associated pneumothorax  (30-40% mortality)

13. SSP Also seen in:  Langerhan’s granulomatosis  Lymphangioleiomyomatosis  Interstitial lung disease  Catamenial Pneumothorax Seen in women, within 72 hours of menses

14. SSP - Epidemiology Same rates as PSP Peak is later in life  60 to 65 years 26 per 100,000 patients per year with COPD Occasionally seen as first presenting symptom of pleural and lung CA

15. SSP – Mechanism Two hypothesis  Same as PSP  Ruptured alvelous leaks air directly into pleural space secondary to necrosis – evidence seen in PCP associated pneumothorax

16. SSP – Clinical Presentation Dyspnea, usually severe Chest pain Hypoxemia and hypotension Hypercapnia Must exclude in patient with Chest pain and COPD

17. SSP – Diagnosis Clinical Presentation Radiological assessment  Bullae may mask presence of air within the pleural cavity  Only in patients with previous pulmonary disease, consider CT scan to rule out presence of Pneumothorax

18. SSP – Recurrence Similar to PSP Various studies show a range in between 39% to 47% Increased rate of recurrence in patients with complicated COPD Smoking most potent risk factor

19. Pneumothorax - Treatment Principles:  Evacuate air from the pleural space  Prevent recurrences

20. Pneumothorax - Treatment Air evacuation is to bring about re- expansion of lung If air within pleural cavity is less than 15% of hemithorax (< 2 ribs) and minimal symptoms:  Consider supplemental oxygen and observation over 6 to 8 hours  Approximately 2% reabsorption per day on room air

21. Pneumothorax - Treatment If air within pleural cavity is greater than 15% or growing:  Simple intravenous catheter or thoracentesis catheter  Chest tube Simple aspiration successful in 70%  Increased success with age < 50 and < 2.5 L of air aspirated

22. Pneumothorax - Treatment Surgical Options  Video Assisted Thoracoscopic Surgery (VATS) with wedge resection & pleurodesis  Limited Axillary Thoracotomy  Thoracotomy

23. Pneumothorax - Treatment VATS is felt to be superior to other options  Decreased time to discharge  Small incisions  Decreased intra-operative stress  Earlier return to function  Decreased post-operative pain

24. Pneumothorax - Treatment If VATS is superior, then when do we use it?  After second episode  High-risk profession  Persistent air-leak at 7 days Yes & No

25. Pneumothorax - Treatment Cole et al. (Ann. Thor. Surg., 1985)  Cohort study  89 treated conventionally 50% were operated on  30 treated with VATS on presentation  LOS was 6 days in VATS group, while average LOS in conventional group was 8 days  Recommended early intervention with VATS, if persistent air leak at 3 days

26. Pneumothorax - Treatment Passlick et al. (Ann. Thor. Surg., 1998)  Cohort study (retrospective)  99 patients treated with VATS, 100 patients treated with lateral thoracotomy  VATS Shorter hospital stay Shorter CT drainage Decreased use of narcotics

27. Pneumothorax - Treatment Falcoz et al. (Ann. Thor. Surg. 2003)  Using Decision Analysis methodology, attempted to arrive at best decision for second episode of pneumothorax  Conventional Management entailed intercosta drainage, followed by VATS/Thoracotomy for persistent air-leak

28. Pneumothorax - Treatment

29. For second episode,  VATS is cost-effective  Shorter stay by 5 days  Slightly less effective than CM

30. Pneumothorax - Treatment For second episode,  VATS is cost-effective  Shorter stay by 5 days  Slightly less effective than CM

31. Pneumothorax - Treatment If it works so well for the second episode, what about the first? Torresini et al. (EJ Card. Thor. Surg., 2003)  RCT  35 patients treated with CT  35 patients treated with VATS

32. Pneumothorax - Treatment 35 patients treated with CT  4 air-leaks  8 recurrences  $3,000 per patient 35 patients treated with VATS  2 air leaks  1 recurrence  $2,000 per patient

33. Pneumothorax - Treatment VATS  Decreased cost  Decreased LOS  Decreased recurrence  ? Psychological effect Decreased concern of recurrence Satisfaction with definitive management

34. Pneumothorax - Treatment What are the recommendations?  British Thoracics Society, 2002

35. Pneumothorax - Treatment

36. BTS Guidelines  Do not discuss second or third episode  Only statement Refer to Thoracic Surgeon all cases of difficult pneumothorax and persistent air leaks

37. Pneumothorax - Treatment American Society of Chest Physicians  Guidelines from 2001

38. Pneumothorax - Treatment PSP  1 st episode – simple drainage/aspiration  If no air-leak, reserve definitive treatment till second episode  VATS is preferred treatment SSP  1 st episode necessitates definitive treatment  VATS is preferred treatment

39. Pneumothorax Sclerosing Agents?  Talc (85-92% effective)  Tetracycline/Monocycline  May be used in patients who will not tolerate an operation  High risk of ARDS