Recurrent Spontaneous Pneumothorax Research Articles

A Case of Vascular-type Ehlers-Danlos Syndrome Associated with Recurrent Spontaneous Hemoptysis and Pneumothorax

A Case of Vascular-type Ehlers-Danlos Syndrome Associated with Recurrent Spontaneous Hemoptysis and Pneumothorax

Recurrent spontaneous pneumothorax in a patient with Birt–Hogg–Dubé syndrome☆

Recurrent spontaneous pneumothorax is a disorder often managed by thoracic surgeons. Most etiologies are benign in nature; however, there are several syndromes that are associated with potentially fatal pulmonary or systemic manifestations. One such example is Birt-Hogg-Dubé syndrome, a rare inheritable syndrome characterized by papular skin lesions involving the scalp, head, face and neck; pulmonary cysts; and a propensity to develop renal carcinoma. In our report, we describe a patient, who was diagnosed with Birt-Hogg-Dubé syndrome after presenting with a history of recurrent spontaneous pneumothorax, and a family history of spontaneous pneumothorax and renal cell carcinoma. This case is of particular interest to the cardiothoracic surgery community as the patient described as well as several of his family members were managed by multiple thoracic surgeons, who did not appreciate the diagnosis.

Preventing recurrence of spontaneous pneumothorax after thoracoscopic surgery: A review of recent results

Spontaneous pneumothorax (SP) is now commonly treated with thoracoscopic surgery, which is associated with less pain and a shorter hospital stay than thoracotomy; however, in its initial stages, thoracoscopic stapled bullectomy resulted in an unexpectedly high incidence of postoperative SP recurrence. Thus, new thoracoscopic procedures, designed to be performed in addition to stapled bullectomy, were developed, which resulted in a gradual decline in the postoperative recurrence rate. We review the recent literature on SP recurrence after thoracoscopic surgery with these other surgical procedures. Pleurectomy and pleural abrasion have been performed for a long time with low recurrence rates; however, they cause the lung to adhere to the parietal pleura, often resulting in complications such as postoperative bleeding. Other surgical procedures that may be recommended to minimize the risk of recurrence are reinforcement of the staple lines using fleece-coated glue or an absorbable sheet. These procedures are now considered to be the thoracoscopic treatment of choice for SP.

Radiological Predictors of Recurrent Primary Spontaneous Pneumothorax Following Non-surgical Management

Studies to date have not identified any reliable predictors for recurrence of primary spontaneous pneumothorax (PSP) on plain chest radiograph (CXR). The aim of this study was to assess whether abnormalities on CXR at first presentation of PSP can be used to predict recurrence of PSP. The study included all patients admitted to The Canberra Hospital between 1998 and 2004. CXRs taken at initial presentation were reviewed retrospectively by an independent radiologist. Radiological abnormalities on CXR included: pleural thickening: blebs/bullae; pleural irregularities and pleural adhesions. One hundred patients were followed up for a mean duration of 57 months. The total rate of recurrence was 54%. Multivariate analysis found that the presence of an abnormality (irrespective of the type) increased the likelihood of recurrence and the risk of recurrence increased with each additional abnormality. Patients having one, two and three or more abnormalities were 3.0 (95% CI=2.09, 3.91, p=0.018), 5.3 (95% CI=4.47, 6.13, p<0.001) and 12.6 (95% CI=11.57, 13.63, p<0.001) times more likely to develop recurrence respectively. In view of these results we now offer surgical treatment at first presentation PSP in patients in whom we identify two or more radiological abnormalities on CXR.

Pleural aspergillosis complicated by recurrent pneumothorax: a case report

IntroductionPneumothorax as the first symptom of pleural aspergillosis is rare.Case presentationA 31-year-old asthmatic Chinese man presented with recurrent spontaneous pneumothorax and underwent lobectomy due to persistent air leakage. Aspergillus was detected histopathologically in the visceral pleural cavity. He was treated with itraconazole at 200 mg a day, and nine months later he had no recurrent pneumothorax or aspergillus infection.ConclusionRecurrent pneumothorax may be a rare manifestation of aspergillus infection. Aspergillus species infection should be considered in the differential diagnosis of recurrent pneumothorax patients, particularly those with chronic lung disease.

Lung Injury Following Thoracoscopic Talc Insufflation: Experience of a Single North American Center

Thoracoscopic talc insufflation (TTI) has been used to obliterate the pleural space and prevent recurrent pleural effusions or pneumothorax. Reports of acute pneumonitis and ARDS after the use of talc raised concern about its safety. Differences in particle size of various talc preparations may explain the variable occurrence of pneumonitis. We sought to determine the incidence of lung injury after TTI over a 13-year period at our institution. Patients who underwent TTI between January 1994 and July 2007 were identified from a prospectively maintained logbook. The talc used was commercially available sterile talc (Sclerosol). The hospital course was reviewed in detail, and all cases of respiratory insufficiency were examined with regard to onset, suspected cause, and outcome. Talc-related lung injury was defined as the presence of new infiltrates on chest radiograph and increased oxygen requirements, with no other identifiable trigger than talc exposure. A total of 138 patients underwent 142 TTIs for recurrent pleural effusions or spontaneous pneumothorax. TTI was performed most frequently for malignant pleural effusions (75.5% of effusions). The median dose of talc was 6 g (range, 2-8 g). Dyspnea with increased oxygen requirements developed within 72 h postprocedure for 12 patients. Four patients (2.8%) had talc-related lung injury, and talc exposure may have contributed to the respiratory deterioration in four additional patients. We report the occurrence of lung injury after TTI using the only talc approved by the US Food and Drug Administration. These results reinforce previous concerns regarding the talc used for pleurodesis in North America.

Renal cancer associated with recurrent spontaneous pneumothorax in Birt-Hogg-Dubé syndrome: a case report and review of the literature

IntroductionBirt-Hogg-Dubé syndrome is a rare genodermatosis characterized by hair follicle hamartomas, renal tumors and spontaneous pneumothorax. We present the case of a patient with pulmonary cysts and recurrent spontaneous pneumothorax. She had typical skin lesions, and was found to have a hybrid oncocytoma which was surgically excised.Case presentationA 60-year-old Caucasian woman had a 10-year history of cystic lung disease and recurrent spontaneous pneumothoraces. She was noted to have papular lesions over her face and forehead. The result of a biopsy showed these lesions to be fibrofolliculomas. A diagnosis of Birt-Hogg-Dubé syndrome was made and she was screened for renal tumors since these are a recognized association. A hybrid oncocytoma was detected which was surgically excised by partial nephrectomy.ConclusionIt is important to consider a possible diagnosis of Birt-Hogg-Dubé syndrome in cases of recurrent pneumothorax. Affected individuals must be screened for renal tumors, a potentially lethal consequence of this syndrome.

Primary spontaneous pneumothorax—the role of the emergency observation unit

Objective The objective of this study was to compare an expedited 24-hour management pathway against traditional inpatient ward management of patients with primary spontaneous pneumothorax (PSP) and recurrent spontaneous pneumothorax (RSP). Method This was a retrospective chart review of all patients who presented with either PSP or RSP to an urban tertiary university hospital in 2007. Results Eighty-two patients were included in the study, of which approximately a third (27) were managed in the emergency department observation unit (EDOU). Five of the EDOU patients were admitted to the ward. Emergency department observation unit treatment failures as defined by recurrences within a week were comparable to those managed in the ward. One of 5 PSP patients receiving only oxygen therapy managed in the EDOU had their pneumothorax recur within a week on discharge, whereas none of the 15 receiving needle aspiration recurred within a week. For the RSP patients managed in the EDOU, 1 of 3 managed with oxygen therapy alone and discharged recurred within a week, whereas with needle aspiration, 1 of 4 recurred within a week. The success rate of aspiration in our study was comparable with that of published rates (75% versus 50%-60%). Conclusions Small to moderate PSPs can be safely and efficiently managed within 24 hours in an EDOU.

Spontaneous Feline Pneumothorax Caused by Ruptured Pulmonary Bullae Associated With Possible Bronchopulmonary Dysplasia

Spontaneous pneumothorax is rarely reported in the cat. This case report describes the use of computed tomography (CT) to diagnose pulmonary bullae in an adult cat with recurrent spontaneous pneumothorax. A large bulla in the right middle lung lobe and several blebs in other lobes were identified by CT. Partial lobectomy of the right middle and right and left cranial lung lobes was successfully performed to remove the affected portions of lung. Histopathological examination suggested bronchopulmonary dysplasia (BPD) as the underlying cause for development of the pulmonary bulla. This is the first case report in the veterinary literature describing the use of CT to identify pulmonary bullae in the cat with BPD as a possible underlying cause.

Video-assisted thoracic surgery for recurrent primary spontaneous pneumothorax in reoperated chests

There are few reports on video-assisted thoracic surgery (VATS) for recurrent primary spontaneous pneumothorax (PSP) in reoperated chests. We report our experience of performing redo VATS for recurrent PSP in reoperated chests. Between July 1, 2005 and December 31, 2007, 55 patients at Jikei University Kashiwa Hospital and 80 patients at Jikei University Hospital underwent VATS for PSP. In this period, no patient underwent thoracotomy for PSP. Ten of these patients underwent surgery for recurrent PSP in a reoperated chest: five from our hospital and five who were referred from other institutions. Video-assisted thoracic surgery revealed minimal to strong adhesions in all ten patients. Nine patients underwent bullectomy using endoscopic staplers, and seven had covering pleural adhesions. There were no major complications or mortality, and no patient showed any sign of recurrence of PSP in the follow-up period. Redo VATS on a reoperated chest is a promising technique for treating recurrent PSP.

Recurrent pneumothorax associated with pulmonary nodules after leflunomide therapy in rheumatoid arthritis: a case report and review of the literature

Rheumatoid arthritis (RA) is a multisystem inflammatory disease characterized by destructive synovitis and systemic extraarticular involvement. One of the most common pulmonary manifestations of RA is rheumatoid nodule. Spontaneous pneumothorax also very rare pulmonary finding and could be associated with pulmonary nodules. Antirheumatic drugs, methotrexate, leflunomide (LEF), infliximab and etanercept, were known as risk factors for developing rheumatoid nodule. However, there was no case report of rheumatoid nodule-associated pneumothorax with the use of LEF. We report, first, herein a case of 46-year-old woman with RA who suffered recurrent spontaneous pneumothorax associated with multiple bilateral subpleural cavitary nodules during treatment with LEF. We reviewed the cases of LEF-related pulmonary nodules developed in patients with RA. Thus, we suggested that pneumothorax can be a rare respiratory fatal complication in patients with RA with pulmonary nodules and LEF can be a rare cause of these manifestations.

Recurrent spontaneous pneumothorax during pregnancy: a case report

IntroductionSpontaneous recurrent pneumothorax during pregnancy is a rare condition. Few cases have been reported previously in the literature. There is no universal guideline for the management of this condition. Treatment options include conservative management with intercostal drain and surgical management in the form of thoracotomy or video-assisted thoracoscopy.Case presentationWe report a case of recurrent spontaneous pneumothorax in a 38-year-old Afro-Caribbean woman on her third trimester of pregnancy. The disease was managed with the insertion of an intercostal drain on three occasions, which was then followed by surgical intervention immediately after pregnancy.ConclusionThe diagnosis of pneumothorax should be considered in the differential diagnosis of pregnant women experiencing chest pain and dyspnoea. No adverse maternal or foetal outcome has been reported in well-managed cases. Management involves good coordination between the obstetric and surgical teams.

TREATMENT OF RECURRENT SPONTANEOUS PNEUMOTHORAX BY PLEUROSCOPIC TALC PLEURODESIS WITH CONSCIOUS SEDATION

PURPOSE: The treatment of recurrent spontaneous pneumothorax is either by VATS with pleurodesis, chemical pleurodesis, or thoracotomy. Few reports have described pleuroscopy with talc pleurodesis for recurrent pneumothorax. We describe our experience using pleuroscopy for talc pleurodesis of recurrent spontaneous pneumothorax.

Early Surgeryfor Treatment of Spontaneous Hemopneumothorax

Spontaneous hemopneumothorax (SHP) is a rare life threatening disorder. We retrospectively investigated patients with SHP who were treated with video- assisted thoracic surgery (VATS), and report our results. From January 1993 to July 2006, 239 patients with spontaneous pneumothorax were treated, among whom 11 (4.6%) were diagnosed with SHP. All 11 patients had a collapsed lung condition worse than moderate and a chest tube inserted, of whom 10 underwent an emergency operation. The points of hemorrhaging, each of which were in the apical portion of the lung, were easily revealed during VATS, and we were able to distinguish between brisk flow and seepage. Hemostasis was acquired using VATS in all surgery cases, while the other was treated with tube drainage. The single patient who did not undergo surgical treatment had recurrent spontaneous pneumothorax 3 months later. It is important to perform surgery for SHP at the appropriate time. VATS was found to be an easily performed and safe procedure for initial treatment in patients with active hemorrhaging and massive blood clotting in the thorax. The long-term outcome of our patients with early surgical indication was excellent and we recommend early surgical treatment for SHP.

Pocket-Sized Heimlich Valve (Pneumostat) After Bullae Resection: A 5-Year Review

This study was conducted to evaluate the practicability, effectiveness, and potential complications of a newly improvised pocket-sized Heimlich valve named the Pneumostat (Atrium Medical Corp, Hudson, NH). This was a retrospective review of 98 patients who underwent bullae resection after recurrent spontaneous pneumothorax at our center from January 2002 until June 2007. Data from the patients' files were collected and analyzed. The mean age of the patients was 28.5 years (range, 17 to 52). There were 80.6% smokers and 5.1% diabetics. Pneumostat (Atrium Medical Corp) was inserted and the patients started to ambulate on day 1 after surgery. The mean hospital stay was 3.08 days. The mean duration of the affected lung to fully expand and the drain to be removed was 7.5 days. No other complications occurred, apart from drain site wound infection in 4.1% of the patients, which resolved with oral antibiotics and simple wound care. This review proved that the pocket-sized Pneumostat was safe and practical in this group of patients. It improved the patients' recovery in terms of mobilization and reduced the length of hospital stays with no significant complications.

Treatment of Persistent Pulmonary Air Leaks Using Endobronchial Valves

Prolonged pulmonary air leaks are a significant source of frustration for patients and physicians. When conventional therapy fails, an alternative to prolonged chest tube drainage or surgery is needed. Bronchoscopic blockage of a bronchus can be performed with the hope of accelerating closure of the air leak by reducing the flow of air through the leak. To our knowledge, this article presents the largest series of patients with prolonged air leaks treated with an endobronchial valve. With Internal Review Board approval, endobronchial valves were compassionately placed using flexible bronchoscopy in patients with prolonged air leaks at 17 international sites. Between December 2002 and January 2007, 40 patients (15 women; mean age +/- SD, 60 +/- 14 years) were treated with one to nine endobronchial valves per patient. The air leaks had recurrent spontaneous pneumothorax (n = 21), postoperative (n = 7), iatrogenic (n = 6), first-time spontaneous pneumothorax (n = 4), bronchoscopic lung volume reduction (n = 1), and trauma (n = 1) etiologies. Nineteen patients (47.5%) had a complete resolution of the air leak, 18 (45%) had a reduction, 2 had no change, and 1 had no reported outcome. The mean time from valve insertion to chest tube removal was 21 days (median, 7.5 days; interquartile range [IQR], 3 to 29 days) and from valve procedure to hospital discharge was 19 +/- 28 days (median, 11 days; IQR, 4 to 27 days). Use of endobronchial valves is an effective, nonsurgical, minimally invasive intervention for patients with prolonged pulmonary air leaks.

Management of recurrent primary spontaneous pneumothorax after thoracoscopic surgery: should observation, drainage, redo thoracoscopy, or thoracotomy be used?

Video-assisted thoracoscopic surgery (VATS) is the popular method for treating primary spontaneous pneumothorax (PSP). Nevertheless, the optimal management of pneumothorax recurrence after VATS remains unclear. This study evaluated the efficacies of various treatment methods. Between 1992 and 2008, 53 cases of recurrent ipsilateral pneumothoraces were noted after 978 VATS treatments for PSP. The primary treatments included 19 observations, 14 pleural drainages with and without sclerosis, 19 redo VATS, and one thoracotomy. The demographic data and treatment outcomes were collected through retrospective chart reviews. The mean interval between VATS and the first recurrence was 12.8 months. Patients who underwent observation had smaller recurrences than those who underwent pleural drainage or redo VATS. The primary failure rate was 5% (1/19) for observation, 50% (7/14) for pleural drainage, 0% (0/19) for redo VATS, and 0% (0/1) for thoracotomy. After a mean follow-up period of 36 months, the repeat recurrence rate was 63.1% (12/19) for observation, 7.1% (1/14) for pleural drainage, 0% (0/19) for redo VATS, and 0% (0/1) for thoracotomy. The mean total hospital stay was 2.5 days for observation, 8.1 days for pleural drainage, 6.6 days for redo VATS, and 15 days for thoracotomy. Finally, redo VATS was performed as the primary or salvage treatment for 34 patients. Neither conversion to thoracotomy nor blood transfusion was required for any patient. Only one patient had a repeat recurrence (2.9%, 1/34). Redo VATS is a feasible and less invasive alternative to thoracotomy for treating recurrent pneumothorax after VATS. In contrast, both observation and pleural drainage have high treatment failures rates and thus are not recommended.

Pneumothorax récidivant révélateur d’un rhabdomyosarcome primitif de la plèvre

Rhabdomyosarcoma is the most common soft tissue sarcoma in the first two decades of life. Its most common location is the head and neck. It rarely arises in the thorax including the pleura. There are only 7 previously reported cases in the literature. We report a case of primary pleural rhabdomyosarcoma with an unusual clinical presentation and location. Our aim is to discuss the clinical presentation, treatment and prognosis of this uncommon location of rhabdomyosarcoma. We report a case of primary embryonal rhabdomyosarcoma of the pleura in a boy of 21 months. The presentation was characterized by recurrent spontaneous pneumothorax. A computed tomography scan showed only pleural detachment with no evidence of any pleural disease. The malignant cells incidentally found in routine pleural biopsy were the diagnostic clue. The rhabdomyoblastic nature of these cells was confirmed by positive immunostains for myoD1 and desmin. Investigation for metastases was negative. Despite chemotherapy, the tumour quickly increased in size and the infant died from acute respiratory failure. Thoracic rhabdomyosarcoma is rare and remains clinically silent for a long time. Its management is still controversial. Prognosis is generally poor when compared with other locations.

Recurrent Spontaneous Pneumothorax as the Presenting Sign of the Birt–Hogg–Dubé Syndrome

Recurrent Spontaneous Pneumothorax as the Presenting Sign of the Birt–Hogg–Dubé Syndrome

Expectativas y satisfacción en el tratamiento del neumotórax espontáneo primario recurrente tratado por toracotomía o cirugía torácica video-asistida

To compare the outcomes of thoracotomy and video-assisted thoracoscopic surgery (VATS) in the treatment of recurrence of primary spontaneous pneumothorax. Medical records of patients presenting recurrence of primary spontaneous pneumothorax were retrospectively reviewed. Patients were divided into two groups: those who underwent conservative thoracotomy (n = 53, thoracotomy group); and those who underwent VATS (n = 47, VATS group). Although there were no deaths in either group and the length of hospital stays was similar between the two, there was greater morbidity in the thoracotomy group. Patients in the thoracotomy group required more pain medication for longer periods than did those in the VATS group (p < 0.05). In the thoracotomy group, the rate of recurrence was 3%. Pain was classified as insignificant at one month after the operation by 68% of patients in the VATS group and by only 21% of those in the thoracotomy group (p < 0.05). At three years after the surgical procedure, 97% of the VATS group patients considered themselves completely recovered from the operation, compared with only 79% in the thoracotomy group (p < 0.05). Chronic or intermittent pain, requiring the use of analgesics more than once a month, was experienced by 90% of the thoracotomy group patients and 3% of the VATS group patients. In addition, 13% of the thoracotomy group patients required clinical pain management. We recommend VATS as the first-line surgical treatment for patients with recurrent primary spontaneous pneumothorax.