Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.

BACKGROUND: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

The impact of outpatient versus inpatient management on health-related quality of life outcomes for patients with malignant pleural effusion: the OPTIMUM randomised clinical trial.

BACKGROUND: The principal aim of malignant pleural effusion (MPE) management is to improve health-related quality of life (HRQoL) and symptoms. METHODS: In this open-label randomised controlled trial, patients with symptomatic MPE were randomly assigned to either indwelling pleural catheter (IPC) insertion with the option of talc pleurodesis or chest drain and talc pleurodesis. The primary end-point was global health status, measured with the 30-item European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) at 30 days post-intervention. 142 participants were enrolled from July 2015 to December 2019. RESULTS: Of participants randomly assigned to the IPC (n=70) and chest drain (n=72) groups, primary outcome data were available in 58 and 56 patients, respectively. Global health status improved in both groups at day 30 compared with baseline: IPC (mean difference 13.11; p=0.001) and chest drain (mean difference 10.11; p=0.001). However, there was no significant between-group difference at day 30 (mean intergroup difference in baseline-adjusted global health status 2.06, 95% CI -5.86-9.99; p=0.61), day 60 or day 90. No significant differences were identified between groups in breathlessness and chest pain scores. All chest drain arm patients were admitted (median length of stay 4 days); seven patients in the IPC arm required intervention-related hospitalisation. CONCLUSIONS: While HRQoL significantly improved in both groups, there were no differences in patient-reported global health status at 30 days. The outpatient pathway using an IPC was not superior to inpatient treatment with a chest drain.

Malignant pleural effusion: current understanding and therapeutic approach.

Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.

Novel Insights from Clinical Practice Autologous Blood Patch Pleurodesis and Endobronchial Valves for Management of Persistent Air Leaks in Two Cases of Tuberculosis.

INTRODUCTION: Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate. CASE PRESENTATION: Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves. CONCLUSION: The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients.

Management of malignant pleural effusion and trapped lung: a survey of respiratory physicians and thoracic surgeons in Australasia.

BACKGROUND: Malignant pleural effusions (MPEs) are common, and a third of them have underlying trapped lung (TL). Management of MPE and TL is suspected to be heterogeneous. Understanding current practices in Australasia is important in guiding policies and future research. AIMS: Electronic survey of Australia-New Zealand respiratory physicians, thoracic surgeons and their respective trainees to determine practice of MPE and TL management. RESULTS: Of the 132 respondents, 56% were respiratory physicians, 23% were surgeons and 20% were trainees. Many respondents defined TL as >25% or any level of incomplete lung expansion; 75% would use large-volume thoracentesis to determine whether TL was present. For patients with TL, indwelling pleural catheters (IPCs) were the preferred treatment irrespective of prognosis. In those without TL, surgical pleurodesis was the most common choice if prognosis was >6 months, whereas IPC was the preferred option if survival was <3 months. Only 5% of respondents considered decortication having a definite role in TL, but 55% would consider it in select cases. Forty-nine per cent of surgeons would not perform decortication when the lung does not fully expand intra-operatively. Perceived advantages of IPCs were minimisation of hospital time, effusion re-intervention and usefulness irrespective of TL status. Perceived disadvantages of IPCs were lack of suitable drainage care, potentially indefinite duration of catheter-in-situ and catheter complications. CONCLUSION: This survey highlights the lack of definition of TL and heterogeneity of MPE management in Australasia, especially for patients with expandable lungs. This survey also identified the main hurdles of IPC use that should be targeted.

Mechanical and biological properties of poly-ε-caprolactone membrane for pleurodesis: A preclinical study in pigs.

BACKGROUND/PURPOSE: Biomaterial implants are emerging as a treatment choice for pleurodesis; however, the optimal biomaterial and form for managing spontaneous pneumothorax, particularly post-video-assisted thoracic surgery, remain under investigation. This study evaluated the mechanical and biological properties of the poly-ε-caprolactone (PCL) membrane as a sclerosing agent for pleurodesis in Landrace pigs. METHODS: Twenty-four Landrace pigs were split into two groups for mechanical abrasion and PCL membrane pleurodesis, with the latter group's PCL meshes inserted using video-assisted thoracic surgery. The mechanical and biological properties of the PCL membrane were assessed in pigs at three, six, and 12 months after the procedure. This assessment involved a range of techniques, such as the T-Peel test, macroscopic evaluation with a scoring scale, microscopic examination, and biomechanical and molecular weight analysis. RESULTS: The PCL membrane group outperformed the traditional abrasion group, with stronger adhesions seen over longer implantation durations. This group also showed superior and more consistent results in both macroscopic and microscopic evaluations compared to the control group. The membrane-based method was easier and faster to perform than the control group's method, and importantly, no mortality occurred following membrane implantation. CONCLUSION: This study is the pioneering effort to present long-term findings regarding the mechanical and biological properties of the PCL membrane in an in vivo animal model. The membrane demonstrated better adhesion ability than that of traditional abrasion and showed reassuring biocompatibility in both the pig model, suggesting its potential as treatment for patients with primary spontaneous pneumothorax. Further clinical studies are needed to support these observations.

Prolonged Non-Steroidal Anti-Inflammatory Drug Exposure After Pleurodesis Increases Pneumothorax Recurrence: A Retrospective Cohort Study.

INTRODUCTION: The use of non-steroidal anti-inflammatory drugs (NSAID) in patients undergoing pleurodesis remains controversial. Although many surgeons are comfortable prescribing NSAIDs post-operatively, some oppose this practice due to concerns of suppressing the inflammatory response and quality of pleurodesis. Only a small body of inconsistent publications exists with respect to guiding therapy in this common clinical scenario. METHODS: A retrospective cohort study was undertaken assessing effect of NSAID exposure on pleurodesis outcomes. An institutional thoracic surgery database was reviewed yielding 147 patients who underwent pleurodesis for pneumothorax between 2010 and 2018. Medical records and imaging were reviewed for patient characteristics, NSAID exposure, recurrent pneumothorax and other adverse events. RESULTS: There was no overall difference between rates of recurrence and procedural failure of pleurodesis (Relative Risk [RR] 1.67 [95% CI 0.74-3.77]). However, NSAID exposure of >48 hours was associated with increased risk of recurrent pneumothorax (RR 2.16 [95% CI 1.05-4.45]). There was no increased rate of other adverse events related to NSAID usage. CONCLUSIONS: NSAID exposure does not increase failure rates or other adverse events following pleurodesis for pneumothorax. However, prolonged NSAID exposure post-pleurodesis may increase procedural failure rates. Further large volume randomised control trials are required.

[Management of Malignant Pleural Effusion]. / Management des malignen Pleuraergusses.

Malignant pleural effusion is a common diagnosis in metastasized cancers. It is always of palliative character. Main symptoms are dyspnoea and reduced quality of life. Diagnosis is made by ultrasound-guided puncture of the pleural effusion (cytology) and often video-assisted thoracic surgery with biopsy of the pleural surface (histology). The goal of treatment is a fast, sustainable, minimally invasive, patient-centred therapy that increases quality of life. Besides systemic therapy and best supportive care the patient can be treated with local therapy including either pleurodesis (via drainage or VATS) or an indwelling-pleural catheter (IPC). Decision for one of these procedures is made upon performance index (ECOG), expandability of the lung, prognosis and the patient's wish. For the first technique, the lung must be expandable. The latter one (IPC) can be implanted both with expandable and trapped lung. Both are similarly effective in symptom control.

Management of refractory hepatic hydrothorax: a report of two cases and review of the literature.

Hepatic hydrothorax is a transudative pleural effusion in patients with cirrhosis. A 56-year-old cirrhotic patient presented with dyspnea and desaturation; his chest images showed a right pleural effusion. Another 66-year-old woman with cirrhosis, developed during her hospitalization acute respiratory failure, and her chest X- ray showed left pleural effusion. Initially, both patients were prescribed a dietary sodium restriction and diuretics. Nevertheless, they didn't have a good response so a chest tube was placed, and an octreotide infusion partially reduced the volume of the pleural drainage allowing a pleurodesis. We report two cases of refractory hepatic hydrothorax with multiple treatments including octreotide and pleurodesis.

Early Water Seal of Chest Tubes Following Video-Assisted Thoracic Surgery Pleurodesis.

INTRODUCTION: Early water seal following minimally invasive pulmonary lobectomy has been shown to reduce chest tube duration and postoperative length of stay (LOS). We evaluated chest tube duration and postoperative LOS following a standardized chest tube management protocol change (water seal on postoperative day 1) after video-assisted thoracic surgery (VATS) pleurodesis. METHODS: We identified adult patients undergoing VATS pleurodesis from August 2013 to December 2021. The chest tube protocol was changed in January 2017 such that patients were placed to water seal on the morning of postoperative day 1. Patients were divided into two groups, before the change (Group 1: August 2013-December 2016) and after (Group 2: January 2017-December 2021). We compared demographics, clinical characteristics, operative details, postoperative chest tube duration and output, and postoperative LOS between the groups. Descriptive statistics and log-transformed multivariable linear regression models were used to identify differences in patient outcomes that were associated with the protocol change. RESULTS: A total of 488 patients underwent VATS pleurodesis during the study period (Group 1: 329 patients; Group 2: 159 patients). The median age was 61 y (interquartile range [IQR] 49-68), 51% were females, 69% were White, and 29% were Black. For postoperative LOS, Group 1 had an IQR of 3-7 d, while Group 2 had an IQR of 2-6 d (P < 0.001). The multivariable log-transformed linear regression models demonstrated that the practice change was associated with reduced chest tube duration (0.77 times the chest tube duration before the change; P < 0.001) and reduced LOS (0.81 times the LOS before the change; P = 0.006). There was an associated reduction in patients needing to return to the operating room (P = 0.048) and needing postoperative extended ventilatory support (P = 0.035). CONCLUSIONS: Development of a standardized protocol to water seal chest tubes on postoperative day 1 following VATS pleurodesis is associated with reduced chest tube duration and LOS without an increase in postoperative complication rates.

Efficacy and safety of doxycycline versus iodopovidone for pleurodesis through an intercostal tube in malignant pleural effusions: a randomized trial.

PURPOSE: The search for an inexpensive agent for chemical pleurodesis in malignant pleural effusion (MPE) continues. We aimed to compare the efficacy and safety of iodopovidone versus doxycycline for pleurodesis in MPE. METHODS: We randomized consecutive subjects with recurrent symptomatic MPE (1:1) to undergo pleurodesis with either doxycycline or iodopovidone administered through an intercostal tube. The primary outcome was the success rate of pleurodesis at 30 days. The secondary outcomes were the time to pleurodesis, chest pain (assessed using visual analog scale [VAS]) after pleurodesis, and complications (hypotension, acute respiratory failure, empyema). RESULTS: We randomized 52 and 58 subjects to receive either doxycycline or iodopovidone. The mean (standard deviation [SD]) age of the study population (51% women) was 54.1 (13.6) years. Lung cancer (≥ 60%) was the most common underlying cause of MPE. We observed a similar frequency of success in the doxycycline vs. the iodopovidone group (complete response: 43 (82.7%) vs. 46 (79.3%) subjects; partial response: 7 (13.5%) vs. 10 (17.2%) subjects; p = 0.3). The mean (SD) time to pleurodesis was 1.5 (1.9) days and 1.9 (5.4) days in the doxycycline and iodopovidone groups, respectively. While the VAS for chest pain was significantly higher with iodopovidone (mean [SD] VAS: doxycycline, 31.9 [20.9]; iodopovidone, 41.3 [21.8]; p = 0.017), it did not reach the minimal clinically important difference. The complication rates were similar between the two groups. CONCLUSION: Iodopovidone was not superior to doxycycline for pleurodesis in MPE. TRIAL REGISTRATION NUMBER/DATE: clinicaltrials.gov (NCT02583282) / October 22, 2015.

Indwelling Pleural Catheter: Management of Complications.

Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.

Device assessed activity behaviours in patients with indwelling pleural catheter: A sub-study of the Australasian Malignant PLeural Effusion (AMPLE)-2 randomized trial.

BACKGROUND AND OBJECTIVE: Device-assessed activity behaviours are a novel measure for comparing intervention outcomes in patients with malignant pleural effusion (MPE). Australasian Malignant PLeural Effusion (AMPLE)-2 was a multi-centre clinical trial where participants with MPE treated with an indwelling pleural catheter were randomized to daily (DD) or symptom-guided (SGD) drainage for 60-days. Our aim was to describe activity behaviour patterns in MPE patients, explore the impact of drainage regimen on activity behaviours and examine associations between activity behaviours and quality of life (QoL). METHODS: Following randomization to DD or SGD, participants enrolled at the lead site (Perth) completed accelerometry assessment. This was repeated monthly for 5-months. Activity behaviour outcomes were calculated as percent of daily waking-wear time and compared between groups (Mann-Whitney U test; Median [IQR]). Correlations between activity behaviour outcomes and QoL were examined. RESULTS: Forty-one (91%) participants provided ≥1 valid accelerometry assessment (DDn = 20, SGD n = 21). Participants spent a large proportion of waking hours sedentary (72%-74% across timepoints), and very little time in moderate-to-vigorous physical activity (<1% across timepoints). Compared to SGD group, DD group had a more favourable sedentary-to-light ratio in the week following randomization (2.4 [2.0-3.4] vs. 3.2 [2.4-6.1]; p = 0.047) and at 60-days (2.0 [1.9-2.9] vs. 2.9 [2.8-6.0]; p = 0.016). Sedentary-to-light ratio was correlated with multiple QoL domains at multiple timepoints. CONCLUSION: Patients with MPE are largely sedentary. Preliminary results suggest that even modest differences in activity behaviours favouring the DD group could be meaningful for this clinical population. Accelerometry reflects QoL and is a useful outcome measure in MPE populations.

The Impact of Anticoagulation on Indwelling Pleural Catheter Removal due to Pleurodesis in Patients with Malignant Pleural Effusion.

BACKGROUND: A well-recognized therapy to improve the symptoms of patients with malignant pleural effusion (MPE), indwelling pleural catheters (IPCs) can also achieve spontaneous pleurodesis. Chemical pleurodesis is associated with a significant pro-coagulation and fibrinolytic environment. Hence, anticoagulation could theoretically interfere with this process. OBJECTIVE: The aim of this study was to evaluate if anticoagulation can interfere with successful spontaneous pleurodesis in patients treated with IPC. METHODS: This was a cohort study of all patients with MPE treated with IPC. The primary objective was to determine if anticoagulant use after IPC placement decreased the rate of spontaneous pleurodesis. The secondary objective was to identify other factors associated with spontaneous pleurodesis. We used a Fine-Gray subdistribution hazard model and a direct acyclic graph to identify variables associated with time to spontaneous pleurodesis. RESULTS: Of the included 410 patients, 210 patients (51.2%) achieved pleurodesis and had their IPC removed. We found no association between anticoagulation and likelihood of pleurodesis. Multivariate analyses revealed that prior chemotherapy, ECOG score of 2-4 were associated with unsuccessful pleurodesis, while chemotherapy or radiotherapy after IPC placement remained associated with increased likelihood of spontaneous pleurodesis. CONCLUSIONS: We failed to demonstrate an association between anticoagulation and pleurodesis. We found that better performance status and chemotherapy or radiotherapy after IPC placement can increase the rate of pleurodesis and catheter removal.

Efficacy of mesh coverage in surgical bullectomy for primary spontaneous pneumothorax: A systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Thoracic surgeons are now adopting a new method of using a mesh covering to reduce recurrence in surgical pleurodesis for pneumothorax. We aimed to review the literature and compare the outcomes of using mesh covering as an additional procedure during surgical pleurodesis. METHODS: A comprehensive search was performed from inception to October 2022 on PubMed, Embase, Cochrane and Scopus. Randomised controlled trials (RCTs) and observational cohort studies (OCSs) comparing the use of mesh coverage, and different materials were included. Data were extracted to compare recurrence and other outcomes using a random effect model. RESULTS: 23 studies consisting of 2 RCTs and 21 OCSs totalling 5092 patients were included. Patients with a mesh had a significantly lower recurrence (OR = 0.22, 95% CI 0.12-0.42, p < 0.0001) and a shorter duration of chest tube drainage (SMD = -0.74 days, 95% CI -0.28 to -1.20, p < 0.0001) but no significant difference in the length of operation. The use of polyglycolic acid (PGA) and vicryl mesh was associated with a significantly shorter duration of chest tube drainage [(PGA, SMD = 0.83 days, 95% CI 0.14-1.52, p < 0.0001), (vicryl, SMD = 1.06 days, 95% CI 0.71-2.82, p = 0.0005)]. They also had a shorter post-operative length of stay than oxidized regenerative cellulose (ORC) but this was not statistically significant. CONCLUSION: The use of a mesh material reduced the incidence of post-operative air leaks in the short term and the recurrence rate in the long term. Some mesh materials such as PGA and vicryl performed better than other materials.

[Chinese expert consensus on treatment of malignant pleural effusion (2023 Edition)].

Malignant pleural effusion (MPE) is a pleural effusion that is caused by a malignant tumor originating in the pleura or by a metastatic malignant tumor from another site that has invaded the pleura. MPE is associated with poor prognosis. Members of the Pleural and Mediastinal Diseases Working Group (preparatory) of Chinese Thoracic Society and some external experts selected clinical issues related to the management of MPE and conducted rigorous evidence retrieval and evaluation. After several meetings and revisions of the manuscript, recommendations were made. This consensus applies to patients aged≥18 years old with MPE caused by various malignancies except for pleural mesothelioma. It included four chapters: pathogenesis of MPE, prognostic evaluation of MPE, local thoracic treatment, and systemic anticancer therapy for MPE.The main recommendations of this consensus are as follows:1. Prognosis evaluation of MPE was valuable in formulating treatment options. It is suggested to comprehensively evaluate the patient's prognosis by combining the patient's performance status, tumor type, and laboratory examination.2. It is recommended that in patients with symptomatic MPE, therapeutic thoracentesis could be used as the initial therapeutic option. Evaluate whether the lung is expandable after thoracentesis and drainage, and then develop a therapeutic regimen.3. In patients with MPE and known expandable or nonexpandable lung, an indwelling pleural catheter (IPC) is recommended as a first-line pleural management. Daily IPC drainages are recommended. In patients with MPE and expandable lung, talc pleurodesis by talc poudrage or talc slurry is recommended if the drug is accessible. Other pleurodesis agents include povidone iodine, bleomycin, and doxycycline.4. After drainage, it is suggested to consider the option of intrapleural use of recombinant human endostatin or bevacizumab alone or in combination with intrapleural chemotherapy. Intrapleural intervention including electrocautery, argon knife, cryotherapy, laser and radiofrequency ablation, is recommended for use in patients who have undergone rigorous evaluation in eligible hospitals. The use of intrapleural urokinase or streptokinase via pleural catheter is recommended for patients with symptomatic MPE and loculated effusion.5. For patients with good performance status and metastatic malignancies, systemic anti-cancer treatment is recommended as standard of care.

[Interstitial Lung Disease after OK-432 Pleurodesis for Malignant Pleural Effusion in Breast Cancer-A Case Report].

The patient was a 42-year-old woman. After 4 courses of capecitabine therapy for right chest wall recurrence of breast cancer, ER(+, 10-15%), PgR(-), HER2(-), she underwent pleurodesis using OK-432 for increased right pleural effusion. On the 12th day after pleurodesis diffuse infiltrative shadows in the right lung, and frosted shadows in both lungs, were observed, and she was diagnosed with drug-induced lung injury. About 3 weeks after administration of prednisolone 1 mg/ kg a tendency for improvement in lung injury was observed, but the patient died of breast cancer progression. Drug- induced lung injury by pleurodesis carries the risk of delaying resumption of chemotherapy. We report this case with a review of the literature.

[Spontaneous pneumothorax: new concepts and current management]. / Pneumothorax spontané: nouveaux concepts et prise en charge actuelle.

Spontaneous pneumothorax is a classical medical condition encountered in emergency centers, and by primary care and respiratory physicians. The traditional distinction between primary and secondary pneumothorax, although old and increasingly blurred, still allows to guide initial management and to determine whether pleurodesis is indicated. In case of spontaneous pneumothorax, a targeted family history is essential because it can suggest the presence of a genetic syndrome as the underlying cause of the pneumothorax, a condition often associated with a high risk of pneumothorax recurrence, and the occurrence of extrathoracic manifestations which may be serious if recognized late. This review addresses the classification of spontaneous pneumothorax, its pathogenesis, the risk factors of occurrence including genetic syndromes, and its management.

Le pneumothorax spontané constitue une situation médicale classique rencontrée dans les centres d'urgence, chez le médecin de premier recours et le pneumologue. La traditionnelle distinction entre pneumothorax primaire et secondaire, bien qu'ancienne et de plus en plus incertaine, permet encore de diriger la prise en charge initiale et de décider si une pleurodèse est indiquée. En cas de pneumothorax spontané, une anamnèse familiale ciblée est primordiale car elle peut suggérer la présence d'un syndrome génétique à l'origine du pneumothorax, souvent associé à un risque élevé de récidive et à la survenue de manifestations extrathoraciques qui peuvent être graves si diagnostiquées tardivement. Cet article aborde la classification du pneumo thorax spontané, sa patho genèse, ses facteurs de risque y compris génétiques, et sa prise en charge.

Long-Term Recurrence Risk Following Pleurectomy or Pleurodesis for Primary Spontaneous Pneumothorax.

INTRODUCTION: Recurrent primary spontaneous pneumothorax (PSP) is often managed with a wedge resection (or blebectomy) and either pleurectomy or pleurodesis. There is a conflicting data regarding which approach is superior to reduce recurrence. Our objective is to evaluate the long-term recurrence rates following pleurectomy versus mechanical pleurodesis for recurrent PSP. METHODS: The PearlDiver Mariner Patient Claims Database was queried for patients aged 10-25 who were presented with PSP and underwent either pleurectomy or mechanical pleurodesis between 2010 and 2020. The primary outcome was recurrence and secondary outcomes included 30-day opioid prescriptions, pain diagnoses, and reimbursement. Kaplan-Meier analysis and Cox proportional hazards regression models were used with adjustment for age and sex. RESULTS: Of 18,955 patients presenting with PSP, 5.1% (n = 968) were managed operatively with either pleurectomy (18.3%, n = 177) or mechanical pleurodesis (81.7%, n = 791). There was no difference in the rate of recurrence between pleurectomy and mechanical pleurodesis (5-year risk of recurrence: 25.8% versus 26.5%, adjusted hazard ratio (HR) = 1.12 [95% confidence interval (CI): 0.79, 1.58]). Furthermore, there was no difference in rate of outpatient opioid prescription (49.2% versus 52.8%, P = 0.58) or pain diagnoses (22.0% versus 22.8%, P = 0.46) between pleurectomy and mechanical pleurodesis, respectively. The median reimbursement was higher following pleurectomy as compared to mechanical pleurodesis ($14,040 versus $5,811, P = 0.02). CONCLUSIONS: There is no significant difference in recurrence based on type of procedure performed for recurrent primary spontaneous pneumothorax. However, reimbursement is higher following pleurectomy. Given the similar outcomes but higher cost, we recommend mechanical pleurodesis over pleurectomy for recurrent PSP.

Surgical Management of Primary Spontaneous Pneumothorax Without Lung Bullae.

INTRODUCTION: Primary spontaneous pneumothorax (PSP) is a relatively common disease. Different studies have been published but lung resection, when no emphysema-like changes (ELC) are detected, is unclear. The aim of our study is to retrospectively investigate the role of lung resection of the apex of the lung in patients with no ELC. METHODS: This is a retrospective multicenter study of 516 patients who underwent surgical treatment of PSP with no ELC between January 2007 and December 2017. Patients were divided into two groups: pleurodesis alone group, only mechanical pleurodesis performed (53 patients), and apical resection group, apical resection of the lung and mechanical pleurodesis performed (463 patients). The following were the primary end points considered: recurrence rate and perioperative complications; the following were the secondary end points considered: length of stay, chest tube removal, residual pleural space, prolonged air leak, and reoperation rate. RESULTS: No differences were found in the baseline and operative characteristics of the two groups. Both primary end points were statistically different: recurrence rate (15.1% versus 6.5%, P = 0.023) and perioperative complications (18.9% versus 7.3%, P = 0.004). Among secondary end points length of stay (6.94 versus 5.55, P = 0.033) and prolonged air leak (15.1% versus 4.3%, P = 0.001) were statistically different. On multivariate analysis, lung resection emerged as a protective factor for recurrence (hazard ratio 0.182, P < 0.001). CONCLUSIONS: In our experience, apical lung resection in patients without ELC may reduce recurrence rate and perioperative complications when compared with pleurodesis alone.