Essentials in Cardiothoracic Surgery Management of Pneumothorax and Bullous Disease for SCRIBD

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Essentials in Cardiothoracic SurgeryEssentials in Cardiothoracic Surgery

ManagementManagement

of of

PneumothoraxPneumothorax andand BullousBullous DiseaseDisease

Punnarerk Thongcharoen, MD

Siriaj Hospital Medical School



Management of Pneumothorax

� Background

� Management of primary spontaneous

pneumothorax

� Management of secondary spontaneous

pneumothorax� Management of iatrogenic pneumothorax



References



Background

� Terms

±

Primary spontaneous pneumothorax (PSP)

± Secondary spontaneous pneumothorax (SSP)

±

Iatrogenic PTX

± Tension PTX

±

Catamenial PTX



Recommendations

� SSP higher morbidity / mortality than PSP

� Strong emphasis on smoking cessation,

to minimise the risk of recurrence

� PTX is not usually associated with physical exertion

�

Symptoms in PSP may be minimal or absent� Symptoms are greater in SSP,

even if PTX is relatively small in size



� The presence of breathlessness influences the

management strategy

� Severe symptoms and signs of respiratory

distress suggest the presence of tension PTX



Diagnosis









X-ray

� Standard CXR upright in inspiration are

recommended, rather than expiratory films

� It is currently recommended that a diagnostic

PACS workstation is available for image review

� CT scanning is recommended for uncertain or

complex cases



� In defining a management strategy,

the size of a PTX is less important than the

degree of clinical compromise

� The differentiation of a large/ small PTX

�CT ± Most accurate PTX size calculations

± Not neceassary



Size of pneumothorax



3 dimension estimation

9.5 cm

12 cm

Volume of Pneumothorax

= (123 9.53) / 123

= 50%





SSSC7 ACCP BTS PT

Sizing PTX < or > 3 cm

apex-to-

cupola

distance

< or >2 cm

lung margin -

lateral chest

wall

Either ACCP or

BTS



Treatment

� The distinction between PSP and SSP should

be made, to guide appropriate management

� Breathlessness indicates the need for active

intervention

�

The size of PTX ± determines the rate of resolution

± relatively indicates active intervention



PSP

� Conservative/ ambulatory care

� Active interventions

± Medical

± Surgical



Management of pneumothorax

� Observation

� Needle aspiration

� Small-bore catheter drainage

� Tube thoracostomy (ICD)

� Chemical pleurodesis

� Surgery

Unfit for surgery, only



� Observation is the treatment of choice for small

PSP, without significant breathlessness



SSSC7 ACCP BTS PT

Treatment for

asymptomatic

small PSP,

Observe Observe Observe Observe

PT = Author



� Pt with significant breathlessness, whatever

size, should undergo active intervention

� ICD is required for tension or bilateral PTX

� A large PSP, but without significant

breathlessness, may be managed by

observation alone.



2009



Cochrane review

� 1239 publications 6 studies only one eligible for

inclusion

� No significant between NA and ICD

± Immediate success rate

± Early failure rate

± Hosp stay

± One year success rate

± No of patient requiring pleurodesis in one year

� NA reduction in the percent of pt hospitalised



Needle aspiration?

SSSC7 ACCP BTS PT

Role of needle

aspiration

(NA)

Delayed

asymptomatic

PSP,< 30% PSP

May consider

in enlarging

PSP afterobservation

Initial

treatment for

non-tensionPSP

May consider

in delayed

asymptomaticPSP

Fail NA Small bore

catheter chest

drain.

NA should not

repeat.

Small bore

catheter chest

drain.

NA should not

repeat.



SSSC7 ACCP BTS PT

Significant PSP

(>30% PSP)

with

symptom,

initial

treatment

ICD, 20Fr, with

water seal

drainage

system

Small bore

catheter

(<14Fr) or

medium bore

tube (16-

22Fr),

Heimlich valveor water seal

NA is

procedure of

choice in most

cases

Small bore

catheter

(<14Fr) or

medium bore

tube (16-

22Fr),

Heimlichvalve or water

seal

Large bore

chest drain

(24-28 Fr)

Not

recommend.

May use inBPF, or patient

with positive

pressure

ventilation

Not

recommend

Not

recommend



ICD with suction?

� Air might be removed at a rate that exceeds

the rate of air leak

� Promote healing by apposition of the visceral

and parietal pleural layers.

�Optimal suction pressures -10 to -20 cm H2O



� The addition of suction too early

±

may precipitate reexpansion pulmonaryoedema

± especially in the case of a PSP that may

have been present for more than a few days



SSSC7 ACCP BTS PT

Suctioned

drainage

system

If the lung is

not completely

reexpanded.

If lung fails to

reexpand

quickly withwater seal

system

Should not be

routinely used.

May consider if persistent air

leak > 48 hr

Should not be

routinely used.

May consider if persistent air

leak or lung is

not completely

reexpanded

after 48 hr



SSSC7 ACCP BTS PT

Medicalchemical

pleurodesis

Acceptablein high risk

patients or

wish to

avoid surgery

Should onlybe used o high

risk patients

or wish to

avoid surgery

Same as ACCPand BTS



BTS 2003

� Persistent air leak/failure of the lung to re-expand,

early (3-5 days) thoracic surgical opinion

� Open thoracotomy + pleurectomy

lowest recurrence rate

� Minimally invasive procedures, VATS, pleural

abrasion, and surgical talc pleurodesis - effective

alternative strategies



ACCP 2001

� Patients with air leaks persisting > 4 days

should be evaluated for surgery

± Patients should not undergo the placement of an

additional chest tube or bronchoscopy to seal

endobronchial sites of air leaks.



� Although the relative value of VATS compared

to a limited thoracotomy has not been clearly

defined, the panel selected VATS as the

preferred management.



� VATS is the preferred intervention.

� Clinical trials do not demonstrate the

superiority of VATS vs limited thoracotomy.

� The panels preference for VATS was based on

practice preferences.



SSSC7 ACCP BTS PT

Persistent air

leak requiring

surgicalintervention

> 5 7 days > 3 5 days > 5 7 days > 3 5 days



SSSC7 ACCP BTS PT

Surgical

approach

VATS is

preference.

Experience with

minithoracotomy

has been

favorable.

VATS (based

on panels

practice

preference)

Open limited

posterolateral

thoracotomy

has lowest

recurrence

rate while

VATS is better

tolerated.

VATS or

axillary

thoracotomy



Bleb/bullae management

� Bullectomy should be performed by staple

bullectomy/ hand sewing

� Options include electrocoagulation, laser

ablation

± Depending on institutional expertise and

experience



Recurrence prevention BTS 2003

� There is debate between

± surgical pleurodesis or pleural abrasion

± partial or total pleurectomy

� Pleurectomys recurrence rate = 0.4,

Pleural abrasions recurrence rate = 2.3%.



Recurrence Prevention ACCP 2001

� Same as BTS

� 15% of panel members, however, would offer

patients an intervention to prevent a

recurrence after the first pneumothorax.



Recurrence Prevention ACCP 2001

� Surgical pleurodesis should be performed with

parietal pleural abrasion limited to the upper

half of the hemithorax.

� Parietal pleurectomy is an acceptable

alternative.



SSSC7 ACCP BTS PT

Recurrence

prevention

procedure

Parietal

pleural

abrasion or

resection

Pleural

abrasion >

pleurectomy/

talc insufflation

Combined

upper half

pleurectomy

and pleural

abrasion

Combined

2/3 -3/4

pleurectomy

and pleural

abrasion



� Secondary pneumothorax

± Open thoracotomy is the recommended

approach.

± VATS procedures should be reserved for

those with poor lung function.



Secondary pneumothorax

� All patients with SSP should be admitted to

hospital for at least 24 hours

� Most patients will require the insertion of a

small-bore chest drain

� Those with a persistent air leak should be

discussed with a thoracic surgeon at 48 hours



� Medical pleurodesis may be appropriate for

inoperable patients

� Patients with SSP can be considered for

ambulatory management with a Heimlich

valve



ACCP

� Most members of the panel recommend an

intervention to prevent pneumothorax recurrence

after the first occurrence. ***

� Medical or surgical thoracoscopy is preferred. ***

� a muscle- sparing (axillary) thoracotomy is an

acceptable alternative.

� A standard thoracotomy is not appropriate therapy

for most patients. ***



Recent data on VATS outcome

� Recently reported recurrence rates following VATS

bullectomy combined with surgical pleurodesis has

been 1.7-5.7%

� Shorter postoperative hospital stay, lesspostoperative pain, and better pulmonary gas

exchange in the postoperative period

± RCT ???



� VATS performed under local anaesthetic

supplemented by nitrous oxide inhalation

± increasing the risk of missing a leaking bleb or

bulla.



Conclusion from BTS, ACCP

� Indication Surgery for first time PTX ???

� Surgical approach

±

Preferred Open VATS - minithoracotomy ± Alternative VATS, transaxilary thoracotomy

� Recurrence prevention

± Pleural abrasion pleurectomy surgical chemical

pleurodesis



Surgery for pneumothorax

� Posterolateral thoracotomy

� Transaxillary thoracotomy

� Median sternotomy

� VAT



SkinIncision

Muscleincision





Catamenial PTX



Catamenial PTX

� Catamenial PTX is underdiagnosed in female

PTX patients

� A combination of

± surgical intervention (include diaphragmatic

resection or plication of the fenestrations seen)

± hormonal manipulation - gonadotrophin-releasing

hormone analogues



PTX and pregnancy

� PTX recurrence is more common in pregnancy

� Observation/ simple aspiration usually effective

� Elective assisted delivery and regional

anaesthesia at or near term

� A corrective surgical procedure (VATS) should be

considered after delivery



Iatrogenic PTX

� The majority observation alone

� If intervention is required simple aspiration

� COPD ICD

� On ventilator ICD



Traumatic pneumothorax

� The indication of VATS included:

± Persistent PTX

± On-going bleeding in stable patients

± Retained hemothorax/ infected pleural space and

collections

± Evaluation of the diaphragm in penetrating injuries

and management



Bullous Lung Disease

� Generalised emphysematous or normal lung

with large emphysematous bullae



Surgical indication

� Symptomatic patients

� Giant bullae occupying over one third of a

hemithorax� Mediastinal shift

� Bullae complications

± Pneumothorax, infection, and enlargement with

time







Treatment options

� Surgery VATS/ thoracotomy

± Bullectomy

± Modified Monaldi technique

� opening the bulla, placing a purse-string suture at the

neck of the bulla



































� Talc is a, natural, hydrated magnesium silicate

that has the approximate chemical formula of

Mg3(Si2O5)2(OH)2.

± aerosol (insufflation)

± in a suspension (slurry)











Cost analysis of

VATS versus thoracotomy: critical review

� 8 studies specifically looked at cost

± Lung biopsy

± Wedge resection of lung nodules

± Pneumothorax

± LVRS

± Lung cancer

± Eur Respir J 2003; 22:735-8





The cost-effectiveness of VATS

� Mainly retrospective studies

� VATS - initially more expensive, but a shorter

hospital stay may compensate this.

� Economically justified as an initial procedure

instead of ICD for 1st and recurrent PSP

± Less Cx, lower cost ?

Prospective randomized trial



Prospective randomized trial

VATS vs Open

� VATS vs limited m. sparing thoracotomy

� VATS

± Less physiologic deterioration (FEV1, FVC)

± Longer op time

± Less early PO analgesics required

± Shorter LOS

± PSP > SSP

Prospective trial



Prospective trial

VATSvs

Open

� VATS vs transaxillary mini-thoracotomy (nonRT)

� Op time, early PO analgesics required and

duration of chest tube placement

± No statistically difference

± Op time, ICD duration in VATS are longer



Historical series comparison

� VATS is better

± Less PO narcotic required

± Less op bleeding

± Cheaper

± Earlier return to work



Historical series comparison 2

� VATS is probably better

± Shorter or the same ICD duration

± Shorter or the same LOS, PO stay



Historical series comparison 3

� Inconclusive

± Shorter, longer or the same op time

± Less, more, or the same PO Cx

� VATS is probably worse

± Higher or the same recurrence rate



Surgical approaches to both lungs

� Bilateral thoracotomy/ VATS

� Median sternotomy

� Bilateral apical stapling & apical pleurectomy

through unilateral axillary thoracotomy/ VATS



�

The most common approach - bilat VATS

± lateral decubitus position, with side-changing

±

Or supine position, modify the sites of the

trocars,

�

2 on the anterior axillary line

� 1 on the midclavicular line/ 2nd ICS

Essentials in Cardiothoracic Surgery Management of Pneumothorax and Bullous Disease for SCRIBD

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