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

OBJECTIVES: 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, Recommendation, Assessment, Development and Evaluation). 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. SHAREABLE ABSTRACT: This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.

A three month old infant with severe respiratory distress.

This case report discusses the diagnostic challenge of congenital lobar emphysema (CLE) in a three-month old infant with severe respiratory distress. The infant was initially misdiagnosed and managed as a case of pneumothorax. This case highlights the importance of CT scans as a diagnostic tool for early diagnosis and lifesaving management of CLE. It also signifies the need for adequate funds and infrastructure in the health care system especially in rural areas of developing countries like Pakistan.

Bronchoscopic Lung Volume Reduction as the Treatment of Choice versus Robotic-Assisted Lung Volume Reduction Surgery in Similar Patients with Emphysema - An Initial Experience of the Benefits and Complications.

Objective: There is an assumption that because EBLVR requires less use of hospital resources, offsetting the higher cost of endobronchial valves, it should therefore be the treatment of choice wherever possible. We have tested this hypothesis in a retrospective analysis of the two in similar groups of patients. Methods: In a 4-year experience, we performed 177 consecutive LVR procedures: 83 patients underwent Robot Assisted Thoracoscopic (RATS) LVRS and 94 EBLVR. EBLVR was intentionally precluded by evidence of incomplete fissure integrity or intra-operative assessment of collateral ventilation. Unilateral RATS LVRS was performed in these cases together with those with unsuitable targets for EBLVR. Results: EBLVR was uncomplicated in 37 (39%) cases; complicated by post-procedure spontaneous pneumothorax (SP) in 28(30%) and required revision in 29 (31%). In the LVRS group, 7 (8%) patients were readmitted with treatment-related complications, but no revisional procedure was needed. When compared with uncomplicated EBLVR, LVRS had a significantly longer operating time: 85 (14-82) vs 40 (15-151) minutes (p<0.001) and hospital stay: 7.5 (2-80) vs 2 (1-14) days (p<0.01). However, LVRS had a similar total operating time to both EBLVR requiring revision: 78 (38-292) minutes and hospital stay to EBLVR complicated by pneumothorax of 11.5 (6.5-24.25) days. Use of critical care was significantly longer in RATS group, and it was also significantly longer in EBV with SP group than in uncomplicated EBV group. Conclusion: Endobronchial LVR does use less hospital resources than RATS LVRS in comparable groups if the recovery is uncomplicated. However, this advantage is lost if one includes the resources needed for the treatment of complications and revisional procedures. Any decision to favour EBLVR over LVRS should not be based on the assumption of a smoother, faster perioperative course.

Recurrent spontaneous pneumothorax in an NF1 patient with a novel causative variant: broadening genotype-phenotype correlations.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease with complete penetrance, most commonly known to affect the skin and eyes. Although lung involvement in the form of cysts and bullae occurs in up to 20% of adults, the seemingly intuitive association of NF1 and spontaneous pneumothorax is not widely recognised among clinicians. Here, we report the second case of recurring spontaneous pneumothorax in the context of NF1 with a confirmed molecular diagnosis. In both cases, the NF1 variants featured a premature stop codon in the C-terminal protein domain. Interestingly, our patient had mild skin symptoms, suggesting that spontaneous pneumothorax may not be correlated with cutaneous disease severity. More genotype-phenotype correlation studies are needed for NF1 in general and for its link to spontaneous pneumothorax in particular.

Clinical Variables and Radiomics Features for Predicting Pneumothorax in Patients Undergoing CT-guided Transthoracic Core Needle Biopsy.

Purpose To develop a prediction model combining both clinical and CT texture analysis radiomics features for predicting pneumothorax complications in patients undergoing CT-guided core needle biopsy. Materials and Methods A total of 424 patients (mean age, 65.6 years ± 12.7 [SD]; 232 male, 192 female) who underwent CT-guided core needle biopsy between January 2021 and October 2022 were retrospectively included as the training data set. Clinical and procedure-related characteristics were documented. Texture analysis radiomics features were extracted from the subpleural lung parenchyma traversed by needle. Moderate pneumothorax was defined as a postprocedure air rim of 2 cm or greater. The prediction model was developed using logistic regression with backward elimination, presented by linear fusion of the selected features weighted by their coefficients. Model performance was assessed using the area under the receiver operating characteristic curve (AUC). Validation was conducted in an external cohort (n = 45; mean age, 58.2 years ± 12.7; 19 male, 26 female) from a different hospital. Results Moderate pneumothorax occurred in 12.0% (51 of 424) of the training cohort and 8.9% (four of 45) of the external test cohort. Patients with emphysema (P < .001) or a longer needle path length (P = .01) exhibited a higher incidence of moderate pneumothorax in the training cohort. Texture analysis features, including gray-level co-occurrence matrix cluster shade (P < .001), gray-level run-length matrix low gray-level run emphasis (P = .049), gray-level run-length matrix run entropy (P = .003), gray-level size-zone matrix gray-level variance (P < .001), and neighboring gray-tone difference matrix complexity (P < .001), showed higher values in patients with moderate pneumothorax. The combined clinical-radiomics model demonstrated satisfactory performance in both the training (AUC 0.78, accuracy = 71.9%) and external test cohorts (AUC 0.86, accuracy 73.3%). Conclusion The model integrating both clinical and radiomics features offered practical diagnostic performance and accuracy for predicting moderate pneumothorax in patients undergoing CT-guided core needle biopsy. Keywords: Biopsy/Needle Aspiration, Thorax, CT, Pneumothorax, Core Needle Biopsy, Texture Analysis, Radiomics, CT Supplemental material is available for this article. © RSNA, 2024.

Aerostasis to limit air leak following extended pleurectomy-decortication.

Extended pleurectomy-decortication is a cytoreductive surgical treatment for malignant pleural mesothelioma. Prolonged air leak remains a major postoperative challenge, lengthening hospital stay and increasing morbidity. In this video report, we present a stepwise approach for visceral decortication and introduce the concept of aerostasis by construction of an artificial neopleura. Our results suggest that improved aerostasis results in shortened air leak duration.

Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis.

BACKGROUND: Patients with persistent air leak (PAL) pose a therapeutic challenge to physicians, with prolonged hospital stays and high morbidity. There is little evidence on the efficacy and safety of bronchial valves (BV) for PAL. METHODS: We systematically searched the PubMed and Embase databases to identify studies evaluating the efficacy and safety of BV for PAL. We calculated the success rate (complete resolution of air leak or removal of intercostal chest drain after bronchial valve placement and requiring no further procedures) of BV for PAL in individual studies. We pooled the data using a random-effects model and examined the factors influencing the success rate using multivariable meta-regression. RESULTS: We analyzed 28 observational studies (2472 participants). The pooled success rate of bronchial valves in PAL was 82% (95% confidence intervals, 75 to 88; 95% prediction intervals, 64 to 92). We found a higher success rate in studies using intrabronchial valves versus endobronchial valves (84% vs. 72%) and in studies with more than 50 subjects (93% vs. 77%). However, none of the factors influenced the success rate of multivariable meta-regression. The overall complication rate was 9.1% (48/527). Granulation tissue was the most common complication reported followed by valve migration or expectoration and hypoxemia. CONCLUSION: Bronchial valves are an effective and safe option for treating PAL. However, the analysis is limited by the availability of only observational data.

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.

Advancements in the Management of Postoperative Air Leak following Thoracic Surgery: From Traditional Practices to Innovative Therapies.

Background: Postoperative air leak (PAL) is a frequent and potentially serious complication following thoracic surgery, characterized by the persistent escape of air from the lung into the pleural space. It is associated with extended hospitalizations, increased morbidity, and elevated healthcare costs. Understanding the mechanisms, risk factors, and effective management strategies for PAL is crucial in improving surgical outcomes. Aim: This review seeks to synthesize all known data concerning PAL, including its etiology, risk factors, diagnostic approaches, and the range of available treatments from conservative measures to surgical interventions, with a special focus on the use of autologous plasma. Materials and Methods: A comprehensive literature search of databases such as PubMed, Cochrane Library, and Google Scholar was conducted for studies and reviews published on PAL following thoracic surgery. The selection criteria aimed to include articles that provided insights into the incidence, mechanisms, risk assessment, diagnostic methods, and treatment options for PAL. Special attention was given to studies detailing the use of autologous plasma in managing this complication. Results: PAL is influenced by a variety of patient-related, surgical, and perioperative factors. Diagnosis primarily relies on clinical observation and imaging, with severity assessments guiding management decisions. Conservative treatments, including chest tube management and physiotherapy, serve as the initial approach, while persistent leaks may necessitate surgical intervention. Autologous plasma has emerged as a promising treatment, offering a novel mechanism for enhancing pleural healing and reducing air leak duration, although evidence is still evolving. Conclusions: Effective management of PAL requires a multifaceted approach tailored to the individual patient's needs and the specifics of their condition. Beyond the traditional treatment approaches, innovative treatment modalities offer the potential to improve outcomes for patients experiencing PAL after thoracic surgery. Further research is needed to optimize treatment protocols and integrate new therapies into clinical practice.

The role of thoracic surgery in the management of complicated acute and post-acute COVID-19 pneumonia (PASC).

INTRODUCTION: COVID-19 is considered a respiratory virosis in its classic form, although it may present with heterogeneous symptoms. Thoracic complications occur in a small percentage of patients. Our objective was to evaluate existing experience with this disease and its thoracic manifestations and to determine the real-world status of care of these patients. METHODS: This study is a retrospective, single-institution analysis of a group of patients hospitalized with acute and post-acute COVID-19 pneumonia at Thomayer Hospital in Prague in the period from December 2020 to March 2022 and indicated for a thoracic surgical procedure. RESULTS: During the peak of COVID-19 pandemic, a thoracic intervention was performed in 46 admitted patients. Thoracic drainage (due to pneumothorax in 18 cases, fluidothorax in 3 cases, CT-guided lung abscess drainage in 2 cases, and CT-guided pneumatocele drainage in 2 cases) were the most common thoracic surgical procedures. Pleurectomy/decortication surgery was done in 10 cases. Additionally, 12 lung parenchyma-sparing resections were performed, while lobectomy was required in 2 cases. Resection of postintubation tracheal stenosis due to a severe course of COVID-19 pneumonia was indicated in 2 patients. CONCLUSION: Even mild COVID-19 may cause a considerable morphological a functional alteration of the respiratory system. The most common complications of COVID-19 pneumonia that require a thoracic surgical intervention include pathologies associated with an air leak and accumulation of air (pneumothorax, pneumomediastinum and subcutaneous emphysema). The development of pulmonary necrosis, symptomatic bronchiectasis, pneumatocele, and bullous-fibrotic formations may result in pneumothorax, hemothorax or thoracic empyema in sporadic cases. An early thoracic surgical intervention to treat thoracic complications of COVID-19 pneumonia can improve the survival of COVID-19 patients.

Endobronchial valves for emphysema and persistent air-leak: 10-year experience in an Asian country.

BACKGROUND: Endobronchial valve (EBV) therapy, a validated method for bronchoscopic lung volume reduction (BLVR) in severe emphysema, has been explored for persistent air-leak (PAL) management. However, its effectiveness and safety in the Asian population require further real-world evaluation. In this study, we assessed the outcomes of treatment with EBV within this demographic. METHODS: We conducted a retrospective analysis of medical records from 11 Korean centers. For the emphysema cohort, inclusion criteria were patients diagnosed with emphysema who underwent bronchoscopy intended for BLVR. We assessed these patients for clinical outcomes of chronic obstructive pulmonary disease. All patients with PAL who underwent treatment with EBV were included. We identified the underlying causes of PAL and evaluated clinical outcomes after the procedure. RESULTS: The severe emphysema cohort comprised 192 patients with an average age of 70.3 years, and 95.8% of them were men. Ultimately, 137 underwent treatment with EBV. Three months after the procedure, the BLVR group demonstrated a significant improvement in forced expiratory volume in 1 s (+160 mL vs. +30 mL; P = 0.009). Radiographic evidence of lung volume reduction 6 months after BLVR was significantly associated with improved survival (adjusted hazard ratio 0.020; 95% confidence interval 0.038-0.650; P = 0.010). Although pneumothorax was more common in the BLVR group (18.9% vs. 3.8%; P = 0.018), death was higher in the no-BLVR group (38.5% vs. 54.5%, P = 0.001), whereas other adverse events were comparable between the groups. Within the subset of 18 patients with PAL, the predominant causes of air-leak included spontaneous secondary pneumothorax (44.0%), parapneumonic effusion/empyema (22.2%), and post-lung resection surgery (16.7%). Following the treatment, the majority (77.8%) successfully had their chest tubes removed. Post-procedural complications were minimal, with two incidences of hemoptysis and one of empyema, all of which were effectively managed. CONCLUSIONS: Treatment with EBV provides substantial clinical benefits in the management of emphysema and PAL in the Asian population, suggesting a favorable outcome for this therapeutic approach.

Establishment of stellate ganglion block in mice.

BACKGROUND: There have been no reports on the successful implementation of stellate ganglion block (SGB) in mice. OBJECTIVES: This study aims to investigate a new method for implementing SGB in mice by placing them in a supine position with abducted upper limbs and touching the trachea and sternoclavicular joint with the hand. METHODS: Fifty BABL/C mice, 8-10 weeks, were selected and randomly divided into four groups: control group (n = 5); SGB-R group (n = 15); SGB-L group (n = 15); and SGB-L + R (group n = 15). SGB was administered with 0.15% ropivacaine solution in a volume of 0.1 mL. The control group received equal volumes of saline. Horner's syndrome, heart rate, and complications such as brachial plexus block, vascular injury, pneumothorax, local anesthetic toxicity, and death were observed. RESULTS: Horner's syndrome developed in 100% of SGB surviving mice; no difference was seen in the time to onset (100.4 ± 13.4 vs 96.7 ± 12.4, mean ± SD, seconds) and duration (264.1 ± 40.5 vs 296.3 ± 48.0, mean ± SD, min) of Horner's syndrome in the left and right SGB (P > 0.05). Compared with the control group (722 [708-726], median [IQR], bpm), the heart rate was significantly slowed down in the right SGB (475 [451.5-491], median [IQR], bpm) (P < 0.05). While the heart rate was slowed down after performing the left SGB, the difference was not statistically significant (P > 0.05). The overall complication rate was 18.4%, with a brachial plexus block rate of 12.3%, a vascular injury rate of 4.6%, and a mortality rate of 1.5%, as well as no local anesthetic toxicity (includes bilateral implementation of SGB) or pneumothorax manifestations were found. CONCLUSIONS: This method allows for the successful implementation of SGB in a mouse model.

Pneumothorax during shoulder surgery. / Pneumothorax under skulderkirurgi.

Background: Pneumothorax following shoulder arthroscopy, although rare, is documented in over 30 PubMed case reports as occurring during or within 10 hours post-procedure. Case Presentation: A fit septuagenarian underwent a two-hour arthroscopic rotator cuff repair with IV anaesthesia and laryngeal mask airway, without a nerve block. With one hour remaining of the operation, the patient had desaturation and hypotension. Lung sliding was absent on ultrasound and x-ray confirmed left-sided tension pneumothorax. Successful thoracic drain insertion and lung re-expansion facilitated his recovery, allowing discharge after 24 hours and symptom-free status at 6 months. Interpretation: This case highlights pneumothorax as an uncommon yet possible post-arthroscopic event. The speculated aetiology is the surgical procedure, where pump-induced pressure fluctuations may displace air into surrounding tissue. Instances of pneumomediastinum and subcutaneous emphysema without pneumothorax suggest arthroscopic origin of air. Prompt perioperative ultrasound can aid in detecting such critical complications.

Medical and surgical management of pneumothorax in diving and hyperbaric chambers.

The presence of a pneumothorax within a pressurized chamber represents unique diagnostic and management challenges. This is particularly the case in the medical and geographic remoteness of many chamber locations. Upon commencing chamber decompression, unvented intrapleural air expands. If its initial volume and/or degree of chamber pressure reduction is significant enough, a tension pneumothorax will result. Numerous reports chronicle failure to diagnose and manage in-chamber pneumothorax with resultant morbidity and one fatal outcome. Such cases have occurred in both medically remote and clinically based settings. This paper reviews pneumothorax and tension pneumothorax risk factors and clinical characteristics. It suggests primary medical management using the principle of oxygen-induced inherent unsaturation in concert with titrated chamber decompression designed to prevent intrapleural air expanding faster than it contracts. Should this conservative approach prove unsuccessful, and surgical venting becomes necessary or otherwise immediately indicated, interventional options are reviewed.

Pneumothorax during manned chamber operations: A summary of reported cases.

In-chamber pneumothorax has complicated medically remote professional diving operations, submarine escape training, management of decompression illness, and hospital-based provision of hyperbaric oxygen therapy. Attempts to avoid thoracotomy by combination of high oxygen partial pressure breathing (the concept of inherent unsaturation) and greatly slowed rates of chamber decompression proved successful on several occasions. When this delicate balance designed to prevent the intrapleural gas volume from expanding faster than it contracts proved futile, chest drains were inserted. The presence of pneumothorax was misdiagnosed or missed altogether with disturbing frequency, resulting in wide-ranging clinical consequences. One patient succumbed before the chamber had been fully decompressed. Another was able to ambulate unaided from the chamber before being diagnosed and managed conventionally. In between these two extremes, patients experienced varying degrees of clinical compromise, from respiratory distress to cardiopulmonary arrest, with successful resuscitation. Pneumothorax associated with manned chamber operations is commonly considered to develop while the patient is under pressure and manifests during ascent. However, published reports suggest that many were pre-existing prior to chamber entry. Risk factors included pulmonary barotrauma-induced cerebral arterial gas embolism, cardiopulmonary resuscitation, and medical or surgical procedures usually involving the lung. This latter category is of heightened importance to hyperbaric operations as an iatrogenically induced pneumothorax may take as long as 24 hours to be detected, perhaps long after a patient has been cleared for chamber exposure.

Prospective Observation Study for Primary Spontaneous Pneumothorax: Incidence of and Risk Factors for Postoperative Neogenesis of Bullae.

PURPOSE: Details of the neogenesis of bullae (NOB), which causes recurrent primary spontaneous pneumothorax (PSP) following bullectomy, have not been reported and risk factors for NOB remain unclear. We aimed to clarify the details of NOB. METHODS: We conducted a prospective study using three computed tomography (CT) examinations performed 6, 12, and 24 months after bullectomy to identify the incidence of and risk factors for NOB. We enrolled 50 patients who underwent bullectomy for PSP. RESULTS: After excluding 11 patients who canceled the postoperative CT examination at 6 months after bullectomy, only 39 patients were analyzed. The incidence of NOB at 6, 12, and 24 months after bullectomy was 38.5%, 55.2%, and 71.2%, respectively. The rate of NOB in the operated lung was almost 2 times higher than that in the contralateral nonoperative lung. Male sex, multiple bullae on preoperative CT, long stapling line (≥7 cm), deep stapling depth (≥1.5 cm), and heavier resected sample (≥5 g) were suggested to be risk factors for NOB. CONCLUSIONS: We recognized a high incidence of postoperative NOB in PSP patients. Bullectomy itself seems to promote NOB. Postoperative NOB occurs frequently, especially in patients who require a large-volume lung resection with a long staple line.

Successful Needle Aspiration of a Traumatic Pneumothorax: A Case Report and Literature Review.

Traumatic pneumothorax (PTX) occurs in up to 50% of patients with severe polytrauma and chest injuries. Patients with a traumatic PTX with clinical signs of tension physiology and hemodynamic instability are typically treated with an urgent decompressive thoracostomy, tube thoracostomy, or needle decompression. There is recent evidence that non-breathless patients with a hemodynamically stable traumatic PTX can be managed conservatively through observation or a percutaneous pigtail catheter. We present here a 52-year-old woman who presented to the emergency department with a 55 mm traumatic PTX. Following aspiration of 1500 mL of air, a clinical improvement was immediately observed, allowing the patient to be discharged shortly thereafter. In hemodynamically stable patients with a post-traumatic PTX, without specific risk factors or oxygen desaturation, observation or simple needle aspiration can be a reasonable approach. Although the recent medical literature supports conservative management of small traumatic PTXs, guidelines are lacking for hemodynamically stable patients with a significantly large PTX. This case report documents our successful experience with needle aspiration in such a setting of large traumatic PTX. We aimed in this article to review the available literature on needle aspiration and conservative treatment of traumatic pneumothorax. A total of 12 studies were selected out of 190 articles on traumatic PTX where conservative treatment and chest tube decompression were compared. Our case report offers a novel contribution by illustrating the successful resolution of a sizable pneumothorax through needle aspiration, suggesting that even a large PTX in a hemodynamically stable patient, without other risk conditions, can be successfully treated conservatively with simple needle aspiration in order to avoid tube thoracostomy complications.

An 88-Year-Old Woman With Pneumothorax and Black Pleural Effusion.

CASE PRESENTATION: An 88-year-old woman was admitted to our hospital with the sudden onset of dyspnea after eating. The patient had undergone nephrectomy for a left renal tumor 24 years previously. The patient had been prescribed ferrous citrate for iron-deficiency anemia. She complained of appetite loss a few days before admission but had no abdominal pain. CT scan showed no abnormalities in the lungs but a mass in the liver.