Transcript Management of Secondary Spontaneous Pneumothorax

Management of Secondary Spontaneous
Pneumothorax
Randal L. Croshaw, MD, Scott Matherly, MD, James M. Nottingham, MD, FACS
University of South Carolina Department of Surgery
Case report:
This 22 year old African American man presented to the ED
complaining of one month history of exertional dyspnea that
acutely and progressively worsened four days prior to admission.
He underwent tube thoracostomy and was noted to have a
persistent air leak. That and the unusual appearance of his CXR
prompted a CT scan. He underwent thoracotomy with stapled
blebectomy and pleural abrasion with no complications. Pathology
confirmed the diagnosis of pulmonary Langerhan’s cell
histiocytosis. He returned to the ED one week after discharge for
recurrent SOB. He was found to have a contralateral
pneumothorax which again necessitated blebectomy and
mechanical pleurodesis. Since that time he has had no further
episodes of pneumothorax.
The case for early definitive treatment:
Spontaneous
pneumothorax
Primary
Delay definitive
surgical
management until
after the first
recurrence.
Secondary
Perform definitive
surgical procedure once
the patient is stable
upon the first
occurrence.
The recurrence rates of primary and secondary pneumothoraces
for patients in patients not undergoing definitive management are
31.8% and 43%, respectively. Patients that develop a
pneumothorax secondary to pulmonary Langerhan’s cell
histiocytosis have a 58% chance of recurrence if not treated
definitively. The recurrence rates of pneumothorax due to AIDS or
CF are 11%-65% and 50%-79%, respectively. Mortality for
secondary spontaneous pneumothorax is 1.8% to 3.3% while
mortality for primary spontaneous pneumothorax is 0.06% to
0.09%.
Introduction:
Secondary spontaneous pneumothoraces occur due to an
underlying lung disease such as COPD, cancer, Pneumocystis
jerovici, cystic fibrosis, tuberculosis or other lung diseases. The
incidence of primary and secondary spontaneous are roughly
equal with an incidence of 6.3 and 2 per 100,000 per year for men
and women, respectively.
Management options:
Observation: Rarely effective and reserved for clinically stable
patients with small (<2-3cm collapse) pneumothoraces.
Simple aspiration: Consider for young patients with clinically
stable, nonexpanding small pneumothoraces. Success rate is
37% for secondary pneumothoraces compared to 75% for
primary spontaneous pneumothoraces.
Tube thoracostomy: The ACCP recommends placement of
a small (14F-22F) tube for stable patients while unstable patients
or those at risk for mechanical ventilation may benefit from a
larger tube (24F-28F). They may be managed with water seal
unless there is a persistent leak or failure to re-expand.
Recurrence prevention: Bullectomy with parietal
Initial CXR 2/25/05
Note the hyperinflated lungs,
increased interstitial markings
and cystic changes.
CT 2/28/05
Cystic changes are
prominent throughout the
lungs with relative sparing
of the bases.
pleurectomy or abrasion limited to the upper hemithorax is the
preferred procedure. VATS, pleural abrasion, and talc pleurodesis
are acceptable alternatives. Tube-directed pleurodesis is an
alternative for patients unable or unwilling to undergo an operative
intervention. Contralateral occurrence rates range from 5.2% to
29%, but no recommendations exist for prophylactic intervention
in patients who have suffered from a secondary spontaneous
pneumothorax.
CXR prior to D/C 3/8/05
Return to ED 3/13/05
References:
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Spontaneous Pneumothorax: An American College of Chest
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Talc Poudrage for Pneumothorax Prevention in Advanced COPD.
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