[Clinical Features in Surgical Cases of Female Spontaneous Pneumothorax;Comparison with Male Patients].

We assessed the clinical features in surgery cases of female spontaneous pneumothorax by comparing them with male patients. One hundred six patients ( female/male:16/90)who had undergone surgery for spontaneous pneumothorax between January 2003 and August 2013 was retrospectively studied. Patient background, pneumothorax classification and treatment were assessed. No significant difference was found in patient background and treatment. In pneumothorax classification, the frequency of secondary pneumothorax in females was significantly greater than that in males (p<0.001). Additionally, in females, the number of bulla identified during surgery was significantly fewer and the number of recurrences before surgery was more frequent than that in males.

Acute Pneumothorax.

Pneumothorax is defined as the abnormal presence of air within the pleural space (cavity) that results in the partial or complete collapse of a lung. It can occur spontaneously or due to a traumatic event. Symptoms can vary from a nondescriptive complaint of shortness of breath or chest pain to complete cardiopulmonary collapse. Diagnosis is based on a combination of clinical suspicion along with supporting imaging studies. Treatment often involves surgical or nonsurgical approaches with goal to alleviate symptoms and prevent recurrence.

Spontaneous tension pneumothorax: what is it and does it exist?

Tension pneumothorax is variously defined but is generally thought of as a pneumothorax in which the pressure of intrapleural gas exceeds atmospheric pressure, producing adverse effects, including mediastinal shift associated with cardiovascular collapse, often attributed to reduced venous return and kinking of the great vessels. The mechanism of tension pneumothorax is said to be a valvular defect in the visceral pleura such that air enters the pleural space in inspiration but cannot exit in expiration, leading to a progressive increase in pressure. However, as the driving pressure forcing air into the pleura in inspiration is atmospheric pressure, the pleural pressure can never exceed 1 atm during inspiration in a spontaneously breathing subject. Furthermore, all pneumothoraces must have pressures greater than atmospheric during expiration, or conventional treatment with intercostal tube drainage would not work. Pilot experiments have failed to show any re-entry of pleural gas into the lung in patients with persistent air leaks but no evidence of tension, suggesting these behave as valvular pneumothoraces. Case reports of tension pneumothorax in spontaneously breathing patients are rare, and most patients have other explanations for clinical deterioration. Although a large and rapidly expanding pneumothorax may require urgent intervention, it is unlikely that the effects are mediated by high intrapleural pressures. The term tension pneumothorax in spontaneously breathing patients should be reconsidered.

Anatomical distribution of traumatic pneumothoraces on chest computed tomography: implications for ultrasound screening in the ED.

OBJECTIVES: We sought to assess the anatomical distribution of traumatic pneumothoraces (PTXs) on chest computed tomography (CT) to develop an optimized protocol for PTX screening with ultrasound in the emergency department (ED). METHODS: We performed a retrospective review of all chest CTs performed in one ED between January 2005 and December 2008 according to presence, location, and size of PTX. Pneumothoraces were then measured and categorized into 14 anatomical regions for each hemithorax. RESULTS: A total of 277 (3.8%) PTXs were identified, with 26 bilateral PTX, on 3636 chest CTs performed during the study period. Etiology was blunt (85%) or penetrating trauma (15%). Eighty-three (45%) PTXs were radiographically occult on initial chest x-ray. One hundred eighty-three (66%) PTX had no chest tube at the time of CT. For both hemithoraces, the distribution demonstrated increasing PTX frequency and size from lateral to medial and from superior to inferior. Region 12 (parasternal, intercostal spaces [ICS] 7-8) was involved in 68% of PTX on either side; region 9 (parasternal, ICS 5-6), in 67% on the left and in 52% on the right; and region 11 (lateral to midclavicular line, ICS 7-8), in 46% on the left and in 53% on the right. The largest anterior-to-posterior PTX dimension was seen in region 12. CONCLUSIONS: Our results indicate that 80.4% of right- and 83.7% of left-sided traumatic PTXs would be identified by scanning regions 9, 11, and 12. These findings suggest that a standardized protocol for PTX screening with ultrasound should include these regions.

Nursing care and management of patients with intrapleural drains.

Most nurses working in an acute hospital setting will encounter patients with chest drains and underwater seal drainage at some point in their careers. This article is primarily written for the non-specialist nurse who requires a good working knowledge of chest drain insertion and underwater seal drainage. The article discusses the indications for chest drain insertion and the merits of different approaches, and provides a detailed analysis of the nursing care of a patient with a chest drain.

Occult pneumothorax in trauma patients: development of an objective scoring system.

BACKGROUND: The incidence of occult pneumothorax (OPTX) has dramatically increased since the widespread use of computed tomography (CT) scanning. The OPTX is defined as a pneumothorax not identified on plain chest X-ray but detected by CT scan. The overall reported incidence is about 5% to 8% of all trauma patients. We conducted a 5-year review of our OPTX incidence and asked if an objective score could be developed to better quantify the OPTX. This in turn may guide the practitioner with the decision to observe these patients. METHODS: This is a retrospective review of all trauma patients in a Level I university trauma center during a 5-year period. The patients were identified by a query of all pneumothoraces in our trauma registry. Those X-ray results were then reviewed to identify those who had OPTX. After developing an OPTX score on a small number, we retrospectively scored 50 of the OPTXs by taking the largest perpendicular distance in millimeters from the chest wall of the largest air pocket. We then added 10 or 20 to this if the OPTX was either anterior/posterior or lateral, respectively. RESULTS: A total of 21,193 trauma patients were evaluated and 1,295 patients with pneumothoraces (6.1%) were identified. Of the 1,295 patients with pneumothoraces, 379 (29.5%) OPTXs were identified. The overall incidence of OPTX was 1.8%: 95.7% occurred after blunt trauma, 222 (59%) of the OPTX patients had chest tubes and of the remaining 157 without chest tubes, 27 (17%) were on positive pressure ventilation. Of the 50 studies selected for scoring, the average score was 28.5. The average score for those with chest tubes was 34. The average score for those without chest tubes was 21. The positive predictive value for need of chest tube if the score was >30 was 78% and the negative predictive value if the score was <20 was 70%. Area under the receiver operator characteristic curve was 0.72, which was significant with p < 0.007. CONCLUSIONS: The OPTX score could quantify the size of the OPTX allowing the practitioner to better define a "small" pneumothorax. The management of OPTX is not standardized and further study using a more objective classification may assist the surgeon's decision-making. The application of a scoring system may also decrease unnecessary insertion of chest tubes for small OPTXs and is currently being prospectively validated.

Simple aspiration as initial treatment for primary spontaneous pneumothorax: results of 91 consecutive cases.

Varying opinions exist regarding the choice of initial treatment for primary spontaneous pneumothorax (PSP). This study aims to determine the success rate of simple aspiration of PSP, identify factors associated with failure, and identify associated complications. A retrospective analysis was performed on 91 consecutive patients receiving simple aspiration for PSP at the Emergency Department of a university teaching hospital in Hong Kong, China. The overall success rate was 50.5%. Failed cases had significantly larger sizes of pneumothorax, and significantly larger volumes of air aspirated. Pneumothorax size > or =40% was significantly associated with failure. In a multivariate analysis, pneumothorax size > or =40%, compared to size 21-39%, independently predicted failure, with an odds ratio of 8.88 (95% CI, 2.49 to 31.63). Complications were rarely encountered. It is concluded that the success rate may be significantly improved by excluding patients with pneumothorax size 40% or larger from this modality of treatment.

Spontaneous pneumothorax: time to rethink management?

There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.

Thoracoscopic appearance of bilateral spontaneous pneumothorax.

STUDY OBJECTIVES: We investigated the macroscopic features of bilateral pneumothorax (BLP) and compared them with those of unilateral pneumothorax (ULP). METHODS: Surgical cases of spontaneous pneumothorax (236 cases) were divided into two groups based on unilateral occurrence (206 cases) or bilateral occurrence (30 cases). The patients were divided into three groups by the macroscopic findings of lung disease. The first group consisted of those patients with solitary and small bullae (type I pneumothorax), the second group consisted of those with multiple and large bullae (type II pneumothorax), and the third group consisted of those with an aggregation of diffuse and tiny bullae (type III pneumothorax). RESULTS: In metachronous BLP cases, 18 patients (66.7%) revealed type III pneumothorax in the first occurrence site, and 13 of 18 patients (72.2%) revealed type III pneumothorax in the contralateral site. Type III pneumothoraces were more frequently found in patients with BLP (18 of 27 patients; 66.7%) compared with ULP (73 of 206 patients; 35.4%; p = 0.0086 [chi(2) test]). During a follow-up ranging from 12 to 129 months (median, 69 months), 7 patients (23.3%) in the BLP group developed recurrences. This rate was higher than that of the ULP group (5.3%; p = 0.0009 [chi(2) test]). Contralateral CT scan findings of their first occurrence were retrospectively reviewed. In 3 patients (15.8%) in the BLP group and 17 patients (12.3%) in the ULP group, apical lung bullae and blebs (ruptured or intact) could be detected on the contralateral lung (p = 0.703 [chi(2) test]). CONCLUSIONS: The patients with an aggregation of diffuse and tiny bullae in their thoracoscopic findings had a high risk of contralateral recurrence. Macroscopic lung appearance in the contralateral site in such patients tended to reveal the same type as that in the primary site. CT scanning was not useful for predicting the risk of contralateral occurrence.

Thoracoscopic pleurectomy for treatment of complicated spontaneous pneumothorax.

This report describes a thoracoscopic approach for performing parietal pleurectomy. We have developed and used this technique successfully in 12 patients for treatment of recurrent spontaneous pneumothorax with extended bullous lung alterations (stage 4 according to the classification of Vanderschueren). For this purpose we need videoendoscopy and specially designed equipment, including pliable silicone trocars and angled instruments. The mean age of the patients was 38 years; no deaths and no complications occurred. The average period of postoperative hospitalization was 3.3 days. During the follow-up period ranging between 5 and 10 months (mean 7.5), no relapsing pneumothorax was observed.

Blast lung injury from an explosion on a civilian bus.

OBJECTIVE: To assess clinical signs and management of primary blast lung injury (BLI) from explosions in an enclosed space and to propose a BLI severity scoring system. DESIGN: Retrospective analysis. PATIENTS: Fifteen patients with primary BLI resulting from explosions on two civilian buses in 1996. RESULTS: Ten patients were extremely hypoxemic on admission (PaO2 < 65 mm Hg with oxygen supplementation). Four patients remained severely hypoxemic (PaO2/fraction of inspired oxygen (FIO2) ratio of < 60 mm Hg) after mechanical ventilation was established and pneumothoraces were drained. Initial chest radiographs revealed bilateral lung opacities of various sizes in 12 patients (80%). Seven patients (47%) had bilateral pneumothoraces and two patients had a unilateral pneumothorax. Five (33%) had clinically significant bronchopleural fistulae. After clinical and laboratory data were collected, a BLI severity score was defined based on hypoxemia (PaO2/FIO2 ratio), chest radiographic abnormalities, and barotrauma. Severe BLI was defined as a PaO2/FIO2 ratio of < 60 mm Hg, bilateral lung infiltrates, and bronchopleural fistula; moderate BLI as a PaO2/FIO2 ratio of 60 to 200 mm Hg and diffuse (bilateral/unilateral) lung infiltrates with or without pneumothorax; and mild BLI as a PaO2/FIO2 ratio of > 200, localized lung infiltrates, and no pneumothorax. Five patients developed ARDS with Murray scores > 2.5. Respiratory management included positive pressure ventilation in the majority of the patients and unconventional methods (ie, high-frequency jet ventilation, independent lung ventilation, nitric oxide, and extracorporeal membrane oxygenation) in patients with severe BLI. Of the four patients who had severe BLI, three died. All six patients with moderate BLI survived, and four of five with mild BLI survived (one with head injury died). CONCLUSIONS: BLI can cause severe hypoxemia, which can be improved significantly with aggressive treatment. The lung damage may be accurately estimated in the early hours after injury. The BLI severity score may be helpful in determining patient management and prediction of final outcome.

Pneumothorax.

Pneumothorax is a common clinical problem encountered by both surgical and medical physicians. Air leaks into the pleural space occur either spontaneously or as a result of traumatic tears in the pleura following chest injury or surgical procedures. Therapy is directed at removing air from the pleural space, re-expanding the underlying lung, and preventing recurrences.

Ultrasound evaluation of the magnitude of pneumothorax: a new concept.

Pneumothorax is commonly seen in trauma patients; the diagnosis is confirmed by radiography. The use of ultrasound where radiographic capabilities are absent, is being investigated by the National Aeronautics and Space Administration. We investigated the ability of ultrasound to assess the magnitude of pneumothorax in a porcine model. Sonography was performed on anesthetized pigs in both ground-based laboratory (n = 5) and microgravity conditions (0 x g) aboard the KC-135 aircraft during parabolic flight (n = 4). Aliquots of air (50-100 cm3) were introduced into the chest to simulate pneumothorax. Results were videorecorded and digitized for later interpretation. Several distinct sonographic patterns of partial lung sliding were noted including the combination of a sliding zone with a still zone and a "segmented" sliding zone. These "partial lung sliding" patterns exclude massive pneumothorax manifested by a complete separation of the lung from the parietal pleura. In 0 x g, the sonographic picture is more diverse; one x g differences between posterior and anterior aspects are diminished. Modest pneumothorax can be inferred by the ultrasound sign of "partial lung sliding." This finding, which increases the negative predictive value of thoracic ultrasound, may be attributed to intermittent pleural contact, small air spaces, or alterations in pleural lubricant. Further studies of these phenomena are warranted.

[Spontaneous pneumothorax. Apropos 2507 cases]. / Neumotórax espontáneo. A propósito de 2.507 casos.

This retrospective study of 2,507 cases of spontaneous pneumothorax (SP) involves 1,873 patients treated at our hospital over nearly 20 years. Men represented 92.4% and most patients were between 16 and 30 years old (56.2%). Presenting more than one episode were 29.7%. The treatment of choice was placement of a pleural drain whenever SP had led to lung collapse amounting to more than 10% of volume. Thoracotomy was performed when the patient had experienced three or more episodes of SP; when a pleural drain had not resolved the condition 10 days after placement; in hemo-SP with severe hemorrhage; and in 2 cases in which SP was bilateral. A total of 419 thoracotomies were performed on 384 patients (20.7%). All episodes were resolved and complications were few. Six patients died (0.32%), three following thoracotomy. All of these had antecedents of chronic obstructive lung disease and all were over 70, excepting one who was 56.

[Current treatment of primary and secondary pneumothorax]. / Traitement actuel du pneumothorax primaire et secondaire.

INTRODUCTION: The treatment of a primary or secondary spontaneous pneumothorax remains controversial and many therapeutic options exist. In the event of a first episode of pneumothorax, should the patient be treated by observation, aspiration or thoracic drainage? For patients undergoing a thoracoscopic intervention for a spontaneous pneumothorax which is the best technique to treat the lung and parietal pleura? What are the results of thoracoscopy compared to thoracotomy and are the costs comparable? PERSPECTIVES: The optimal treatment for a first episode of pneumothorax remains to be determined. As there are only a limited number of patients in the published randomised controlled studies only grade B or C recommendations can be given. This is also true for the treatment of the lung and parietal pleura during a thoracoscopic intervention. Most authors advise that an apical pleurectomy is performed. With regard to results and cost of thoracoscopy compared to thoracotomy, conflicting results have been published and definite conclusions cannot be drawn. CONCLUSION: As large randomised prospective studies are not available regarding the treatment of pneumothorax only grade B or C recommendations can be given.

[The establishment of the styles of video-assisted thoracoscopic surgery for spontaneous pneumothorax].

Video-assisted thoracoscopic surgery (VATS) has been widely used in the treatment of a pneumothorax, but the high incidence of recurrence from spontaneous pneumothorax after VATS is an important problem. In this study, we classified the groups into two categories from the thoracoscopic observations, and discussed whether or not there was reappearance of pneumothorax. In addition, we examined whether adjunctive procedure contributes to recurrent of pneumothorax after operation or not. We concluded that there is a tendency to recurrence in the group with multiple and skip lesions in the lung, and then concluded that the cases apical covering with absorbable material sheet and the use of fibrin glue spray was thought to be effective of recurrence of pneumothorax in cases of multiple and skip lesions from the intraoperative findings through the thoracoscopes. Finally, we examined application of Foley catheter for spontaneous pneumothorax under VATS. It is possible that the application of Foley catheter to prevention against recurrence of pneumothorax is a valid method.

[Video-assisted thoracoscopic surgery for spontaneous pneumothorax].

OBJECTIVE: To explore the operational procedures, indications, and the long-term results of video-assisted thoracoscopic surgery (VATS) in the treatment of spontaneous pneumothorax. METHODS: One hundred seventy three cases of spontaneous pneumothorax treated with VATS in our hospital between 1995 and 2001 were analyzed. Primary spontaneous pneumothorax (PSP) was found in 157 cases and secondary spontaneous pneumothorax (SSP) in 16 cases. In patients with PSP, pneumothorax occurred for the first time in 65 (41.4%) cases, and recurred at least once in 92 (58.6%) cases. Among them three patients underwent simultaneous bilateral VATS for simultaneous bilateral pneumothorax, and 6 underwent two-stage bilateral VATS. In patients with SSP, 6 had recurrent pneumothorax. RESULTS: According to the Vanderschueren's classification, no abnormality was found in 34 (19.7%) cases, pleuro-pulmonary adhesions in 41 (23.7%) cases and bullae in 98 (56.7%) cases. Pleurodesis and stapling under Endo-cutter were the major operational procedures used in these cases. The median follow-up time was 53 months. The long-term recurrence rate was 1.8%. Complications related to surgery occurred in 3.0% of the cases, which included subcutaneous emphysema, localized pleural effusion and prolonged air leakage. CONCLUSION: VATS is a safe and effective treatment for both initial and recurrent spontaneous pneumothorax, and therefore it is becoming the primary treatment modality for this disease.

[Pneumothorax].

Most of the patients with spontaneous pneumothorax are young male adults without significant pulmonary disease and the prognosis in these patients is usually very good. But in a few cases when tension pneumothorax develops, immediate diagnosis and chest tube drainage is required to avoid life-threatening emergency. Needless to say mechanical ventilation with tracheal intubation is contraindication even if the patient has severe respiratory distress or hypoxia. Re-expansion pulmonary edema is another severe complication. This occurs to a long-term (over 1 week) complete collapse lung when it is rapidly re-expanded with high negative pressure. To treat such patient it is necessary to decompress the lung slowly using lower negative pressure or water seal suction. When persistent bleeding of hemothorax is present, it is important to decide to perform open thoracotomy or video-assisted thoracoscopic surgery to avoid blood transfusion. The diagnosis of pneumothorax is simply done by chest X-ray film. When the pneumothorax is suspected, chest X-ray examination has to be done first. A scheduled operation to prevent recurrence of pneumothorax has to be performed under relative indication in consideration of both the medical factor and the social factor of the patient.