Surgery for secondary spontaneous pneumothorax:

risk factors for recurrence and morbidity

Mitsuhiro Isaka,* Katsuyuki Asai, and Norikazu Urabe This article has been cited by
other articles in PMC.

Abstract

OBJECTIVES

Secondary spontaneous pneumothorax (SSP) is more common in elderly patients; it has high
rates of recurrence and mortality, even if surgery is performed. There has been little study on the
surgical treatment of SSP. Therefore, we analysed the outcomes of surgical treatment of SSP
patients, and investigated the risk factors of recurrence and morbidity.

METHODS

We studied 97 consecutive surgical treatments on 94 patients with SSP who had emphysematous
changes of lung retrospectively. Emphysematous changes on preoperative computed tomography
image were evaluated by the Goddard score, which is a visual scoring system. First, video-
assisted thoracoscopic surgery was performed, followed by bullectomy for the responsible
lesions.

RESULTS

The rate of morbidity was 20.6% and that of mortality was 4.1%. Recurrence rate was 9.3%. By
multivariate analysis, a Goddard score 7 (odds ratio: 8.93, P = 0.033) and treatment of bulla
without the use of staplers (odds ratio: 11.57, P = 0.019) were significant risk factors for
morbidity, while pulmonary fibrosis tended to increase the risk of recurrence (hazard ratio: 4.21,
P = 0.051), and a Goddard score 7 (hazard ratio: 7.79, P = 0.023) was a significant risk factor
for recurrence.
CONCLUSIONS

Surgical treatment in patients with SSP had favourable results. Treatment in which the base of
the bulla cannot be definitely shut off with staplers is associated with increased morbidity.
Significant emphysematous change on preoperative computed tomography image and pulmonary
fibrosis are predictors of recurrence. Patients with these findings should be investigated in terms
of the indications of surgery and additional treatment, not only bullectomy.

Keywords: Secondary spontaneous pneumothorax, Video-assisted thoracoscopic

surgery, Chronic obstructive pulmonary disease, Recurrence, risk factor

Surgery for secondary spontaneous pneumothorax.

Nakajima J1.

Abstract
PURPOSE OF REVIEW:
Secondary spontaneous pneumothorax (SSP) can occur in patients who are suffering from
diffuse lung disease. The main cause of SSP is chronic obstructive pulmonary disease (COPD).
In contrast to primary spontaneous pneumothorax, SSP is a potentially life-threatening condition
because patients with SSP also have limited cardiopulmonary reserve. Prompt diagnosis and
treatment of SSP are mandatory. In this review, thoracoscopy, a less invasive surgical treatment
for SSP, is discussed from the viewpoint of postoperative morbidity, mortality, and recurrence of
SSP.

RECENT FINDINGS:
A meta-analysis showed that postoperative recurrence of pneumothorax is more frequently
observed following thoracoscopy than following open thoracotomy. Recent studies on
thoracoscopic surgery for SSP have shown that the rate of postoperative morbidity is still high
(15-27.7%) and thoracoscopy is sometimes replaced with open thoracotomy because of dense
pleural adhesion or inability to maintain one-lung ventilation during surgery. However, many
thoracic surgeons prefer to perform thoracoscopic surgery for SSP because it is less invasive than
open thoracotomy. Techniques for bullectomy and pleurodesis are currently being adapted to
decrease the recurrence rate of pneumothorax.
SUMMARY:
Thoracoscopic surgery for the treatment of SSP should be less invasive to reduce postoperative
morbidity, and it should also be more effective to reduce the recurrence of pneumothorax.
Secondary spontaneous pneumothorax.
Abstract
To assess the clinical manifestations and therapy of secondary spontaneous
pneumothorax (SSP), 123 episodes of SSP in 67 patients were retrospectively
reviewed and were compared with 254 episodes of primary spontaneous
pneumothorax in 130 patients. The major underlying lung diseases
associated with SSP were emphysema (22 patients) and tuberculosis (21
patients). The average age of patients with SSP was 66.8 years, and the
most common symptom was dyspnea. The average arterial oxygen tension
at onset of SSP was 61.1 +/- 12.1 mm Hg (mean +/- standard deviation),
which was lower than that of patients with primary spontaneous
pneumothorax (p < 0.01). The recurrence rate of open thoracotomy with
pleural abrasion was 12.5% (3 of 24 episodes), which was not lower than that
of thoracostomy tube drainage with chemical pleurodesis using tetracycline
(recurrence rate, 18.8%) (p > 0.5). We concluded that considering the high
age of the patients, the presence of underlying lung diseases, and the
increased operative risk, thoracostomy tube drainage rather than open
thoracotomy was preferred as the first choice of therapy for SSP.
Secondary Spontaneous Pneumothorax (SSP) with Bronchopleural
Fistula in A Patient with COPD
Gautam Rawal, 1 Sankalp Yadav,2 Nitin Garg,3 and Umar Rasool Wani4

Abstract
The aim of this article is to report a case of secondary spontaneous pneumothorax (SSP) with
bronchopleural fistula in a patient with chronic obstructive pulmonary disease (COPD). SSP is a
common life threatening complication in a patient with COPD and usually creates confusion in
the mind of the treating physician during an episode of acute exacerbation of COPD. A 52-year-
old male presented with a three day history of dry cough and breathing difficulty. He had a
history of COPD. A large pneumothorax on the left side was confirmed after chest X-ray. Tube
thoracostomy was performed which showed a persistent air-leak suggesting a bronchopleural
fistula. The patient was treated conservatively with patience and the leak sealed spontaneously.
The patient recovered uneventfully. This case emphasizes that SSP should be considered in the
differential diagnosis of patients having a history of long-term COPD who are in a relatively
stable condition with non- critical respiratory distress and the importance of conducting a chest
X-ray along with repeated clinical examination in a patient of COPD who does not improve with
adequate therapy.

Keywords: Chest X-ray, Emphysema, Thoracostomy

Secondary spontaneous pneumothorax associated with emphysema
and ruptured bullae at the azygoesophageal recess.

Asai K , Urabe N
Department of General Thoracic Surgery, Numazu City Hospital, 550 Harunoki Higashi-shiiji,
Numazu, Shizuoka 410-0302, Japan. asaik@msc.biglobe.ne.jp
General Thoracic and Cardiovascular Surgery [2008, 56(11):539-543]
Type: Evaluation Studies, Journal Article, Comparative Study

Abstract
PURPOSE: With secondary spontaneous pneumothorax (SSP) associated with emphysema,
lesions responsible for pneumothorax can be located anywhere along the lung surface. Among
such lesions, ruptured bullae at the azygoesophageal recess (AER) have received little attention
thus far.

METHODS: We conducted a retrospective study of 38 right SSP patients with emphysema who
underwent surgery. Among them, we reviewed the clinical characteristics and technical problems
of patients with surgically proven ruptured bullae at the AER.

RESULTS: Ruptured bullae at the AER were found in 10 of 38 patients. They accounted for
26.3% of all 38 patients and for 66.7% of 15 patients whose bullae at the AER were identified by
preoperative computed tomography (CT). On CT, all the bullae were relatively large and oriented
in a predominantly vertical axis. At surgery, they were confirmed as white, thin-walled structures
originating from the mediastinal part of the apical segment of the right lower lobe. Surgery
typically consisted of stapling bullectomy with video-assisted thoracic surgery. Technical
problems in surgical treatment included poor mobilization of the base of the bulla and a restricted
working space. CONCLUSION: Bullae at the AER are common and possibly lead to rupture.
The presence of a bulla at the AER seen by CT can be predictive of rupture. Although the AER is
a unique location, video-assisted bullectomy is the method of choice for treating these lesions.
Secondary spontaneous pneumothorax in adults'
Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous
pneumothorax.
Kiely DG, Ansari S, Davey WA, Mahadevan V, Taylor GJ, Seaton DSO
Thorax. 2001 Aug;56(8):617-21.

BACKGROUND: There is no technique in general use that reliably predicts the outcome of
manual aspiration of spontaneous pneumothorax. We have hypothesised that the absence of a
pleural leak at the time of aspiration will identify a group of patients in whom immediate
discharge is unlikely to be complicated by early lung re-collapse and have tested this hypothesis
by using a simple bedside tracer gas technique.
METHODS: Eighty four episodes of primary spontaneous pneumothorax and 35 episodes of
secondary spontaneous pneumothorax were studied prospectively. Patients breathed air
containing a tracer (propellant gas from a pressurised metered dose inhaler) while the
pneumothorax was aspirated percutaneously. Tracer gas in the aspirate was detected at the
bedside using a portable flame ioniser and episodes were categorised as tracer gas positive (>1
part per million of tracer gas) or negative. The presence of tracer gas was taken to imply a
persistent pleural leak. Failure of manual aspiration and the need for a further intervention was
based on chest radiographic appearances showing either failure of the lung to re-expand or re-
collapse following initial re-expansion.
RESULTS: A negative tracer gas test alone implied that manual aspiration would be successful in
the treatment of 93% of episodes of primary spontaneous pneumothorax (p<0.001) and in 86%
of episodes of secondary spontaneous pneumothorax (p=0.01). A positive test implied that
manual aspiration would either fail to re-expand the lung or that early re-collapse would occur
despite initial re-expansion in 66% of episodes of primary spontaneous pneumothorax and 71%
of episodes of secondary spontaneous pneumothorax. Lung re-inflation on the chest radiograph
taken immediately after aspiration was a poor predictor of successful aspiration, with lung re-
collapse occurring in 34% of episodes by the following day such that a further intervention was
required.
CONCLUSIONS: National guidelines currently recommend immediate discharge of patients
with primary spontaneous pneumothorax based primarily on the outcome of the post-aspiration
chest radiograph which we have shown to be a poor predictor of early lung re-collapse. Using a
simple bedside test in combination with the post-aspiration chest radiograph, we can predict with
high accuracy the success of aspiration in achieving sustained lung re-inflation, thereby
identifying patients with primary spontaneous pneumothorax who can be safely and immediately
discharged home and those who should be observed overnight because of a significant risk of re-
collapse, with an estimated re-admission rate of 1%.
Diagnosis and treatment of primary spontaneous pneumothorax
Shi-ping Luh

ABSTRACT
Primary spontaneous pneumothorax (PSP) commonly occurs in tall, thin, adolescent men.
Though the pathogenesis of PSP has been gradually uncovered, there is still a lack of consensus
in the diagnostic approach and treatment strategies for this disorder. Herein, the literature is
reviewed concerning mechanisms and personal clinical experience with PSP. The chest
computed tomography (CT) has been more commonly used than before to help understand the
pathogenesis of PSP and plan further management strategies. The development of video-assisted
thoracoscopic surgery (VATS) has changed the profiles of management strategies of PSP due to
its minimal invasiveness and high effectiveness for patients with these diseases.

Keywords: Primary spontaneous pneumothorax (PSP), Diagnosis, Treatment

SPONTANEOUS PNEUMOTHORAX SECONDARY TO COPD

Article January 2007with149 Reads

BISWAS MANABENDRA

Abstract
Introduction: The high recurrence rate of spontaneous pneumothorax secondary to COPD
highlightsthe need for the prevention of recurrence with cheap and cost effective method.
Chemical pleurodesis with tetracyclinehydrochlorides may be a good option for the prevention of
recurrence of pneumothorax and thereby enablessatisfactory patient outcome. Objectives: (i) To
compare the recurrence rate of spontaneous pneumothorax treatedwith chemical pleurodesis with
tetracycline hydrochloride and tube thoracostomy alone. (ii) To make a standard protocolfor
management. Study design: A prospective randomized case control study. Setting: The dept. of
thoracic surgeryof the National Institute of Diseases of the Chest and Hospital (NIDCH), Dhaka,
Bangladesh. Period: From January2003 to December 2003. Material & Methods: Sixty patients
with spontaneous pneumothorax, secondary to COPD.After randomization, 30 patients were
treated with tube thoracostomy followed by pleurodesis with tetracyclinehydrochloride and
another 30 patients of control group were treated with tube thoracostomy alone. Results:
Patientswere followed up upto 6 months and were looked for recurrence. Patients with
spontaneous pneumothorax were of4 to 6 decades of life and most of them were th th male. Most
patients presented with moderate size of pneumothoraxand required 91-110 hours for lung
expansion after tube thoracostomy. Recurrence rate of spontaneous pneumothoraxsecondary to
COPD in the tetracycline group was 3.3%, whereas in control group it was 30%. Intrapleural
instillationof tetracycline hydrochloride significantly reduces the recurrence of spontaneous
pneumothorax secondary to COPD.(P=0.015). Morbidity related to tetracycline was negligible.
Moreover, tetracycline is cheap, easily available, non-toxic, well tolerated. Conclusion: It is
concluded that recurrence rate of spontaneous pneumothorax secondary to COPDcan be reduced
effectively by chemical pleurodesis with tetracycline hydrochloride without any significant
morbidity related to tetracycline hydrochloride and it is also very cost effective.
Decision Making in the Management of Secondary Spontaneous
Pneumothorax in Patients with Severe Emphysema
K. Robert Shen, MD Press enter key for correspondence information Press enter key to Email
the author
,
Robert J. Cerfolio, MD

In patients who have advanced emphysema, development of a spontaneous pneumothorax can be

a life-threatening event, warranting more aggressive management. Patients who have the most
advanced stages of emphysema are at the highest risk to develop spontaneous pneumothoraces,
have recurrences, and are the most difficult patients to treat. Early surgical intervention should be
recommended for patients who have persistent or large air leaks or those who lack parietal-to-
visceral pleural apposition after a trial of nonoperative management. Video-assisted thoracoscopy
with resection of the offending bulla and pleurodesis or pleurectomy also should be considered to
prevent recurrences in all patients with chronic obstructive pulmonary disease who are safe
operative candidates.

Keywords:

Secondary, Spontaneous, Pneumothorax, Management, Emphysema

Videothoracoscopic operation for secondary
spontaneous pneumothorax
David A. Waller, FRCS , Jonathan Forty, FRCS, Ami K. Soni, MD, Ian D. Conacher, FRCP
,
Graham N. Morritt, FRCS

Abstract

Thoracotomy for the management of a secondary spontaneous pneumothorax is associated with a

high perioperative risk related to the presence of underlying lung disease. Videothoracoscopy
offers the potential therapeutic benefits of a minimally invasive approach. We report on a series
of 22 patients (19 men and 3 women) with a mean age of 70 years (range, 46 to 92 years) who
underwent Videothoracoscopic surgical procedures for the treatment of secondary spontaneous
pneumothorax. All patients had emphysema; their mean preoperative forced expiratory volume
in 1 second was 48% of predicted and their mean forced vital capacity was 64% of predicted.
Eighteen patients presented with a persistent air leak and their mean preoperative hospital stay
was 18 days (range, 6 to 40 days). Fleurectomy was performed in all 22 patients, together with
bullectomy in 20 patients, with a mean overall operating time of 57 minutes (range, 24 to 90
minutes). General anesthesia was used in each patient. Single-lung ventilation, used in the
majority, was found to be superior to high-frequency jet ventilation. The postoperative analgesic
requirement was minimal (average, 15 mg of morphine in the first 12 hours), and no patient
required reventilation. A revisional thoracotomy for the management of a persistent postoperative
air leak was required in 4 patients, one of whom subsequently died in respiratory failure. The
mean postoperative stay was 9 days (range, 3 to 26 days). At a mean follow-up of 8.6 months
(range, 2 to 15 months), no pneumothorax had recurred. In comparison with our experience
using this technique to treat primary spontaneous pneumothorax in 33 patients, the operating
time was not significantly longer, lesa postoperative analgesia was requited, the durations of
postoperative chest drainage and hospital stay were longer, and there were more primary
treatment failures. Videothoracoscopic operation has proved to be an effective treatment for
secondary spontaneous pneumothorax in elderly patients who represent high-risk candidates for
thoracotomy, and thus it increases the surgical options for this condition.