Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 5, 2003, pp. 423-426

Indian Journal of Surgery, Vol. 65, No. 5, Sept-Oct, 2003, pp. 423-426

Spontaneous pneumothorax

A. G. Ahangar, Shah Shabir Hussain, Ishtyak Ahmad Mir, Abdul Majid Dar, Mohd. Akbar Bhat, Ghularn Nabi Lone, Rauf Ahmad Wani, Mohd. Afzal-u-din

Department of Cardiovascular and Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences Srinagar, India
Address for correspondence Dr. Shah Shabir Hussain, Senior Resident, Department of Cardiovascular & Thoracic Surgery, Sher-i-Kashmir Institute of Medical Sciences, Postbag 27, Soura Srinagar 190011, Kashmir, India

Paper Received: October 2002. Paper Accepted: July 2003. Source of Support: Nil.

How to cite this article: Ahangar AG, Hussain SS, Mir IA, Dar AM, Bhat MK, Lone GN, et al. Spontaneous pneumothorax. Indian J Surg 2003;65:423-6.

Code Number: is03084

ABSTRACT

Background: Spontaneous pneumothorax is classified into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP). PSP occurs without any cause, usually as a result of the rupture of subpleural blebs. SSP is related to the presence of underlying lung disease. The pathological consequences depend primarily on the site of pneumothorax and the condition of the underlying lung.
Material and Methods: Data related to 84 patients with 126 episodes of pneumothorax presenting from January 1998 to December 2000 were retrospectively reviewed to assess the clinical manifestations and therapy of spontaneous pneumothorax.
Results: There were 52 patients with 80 episodes of PSP and 32 patients with 46 episodes of SSP. The common causes for SSP were tuberculosis (18 patients with 29 episodes) and emphysema (7 patients with 10 episodes). The age of presentation was 27±11 years for PSP and 58.8±15.2 years for SSP (p<0.01). The commonest clinical manifestation with PSP was chest pain (86.25 %)whereas dyspnoea was the commonest manifestation with SSP (84.78%). Seventy-three (91.25%) episodes of PSP and 37 (80.43%) episodes of SSP were managed with non-operative treatment. Thoracotomy was done in 7 (8.7%) and 9 (19.5%) episodes of PSP and SSP respectively. The overall recurrence rate of PSP was 31.25% and 26.08% in SSP. No recurrence was seen with open thoracotomy in both groups of patients.
Conclusions: We conclude that patients with both PSP and SSP should be managed initially with nonoperative treatment. Thoracostomy tube drainage is the mainstay of treatment. Patients with SSP are generally debilitated from the respiratory standpoint and may have other significant comorbid diseases. Effective treatment must be individualized.

Key Words: Spontaneous pneumothorax, Therapy.

INTRODUCTION

Pneumothorax is the accumulation of air within the pleural space. Spontaneous pneumothorax (SP) is classified into primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP). PSP occurs without any cause, usually as a result of the rupture of subpleural blebs.^1,2 SSP is related to the presence of underlying lung disease. The pathological consequences depend primarily on the site of pneumothorax and the condition of the underlying lung.The purpose of this study is to describe the clinical manifestations and to assess different modalities of treatment, especially the role of open thoracotomy in SP.

MATERIAL AND METHODS

The medical records of 82 patients with 126 episodes of SP, treated at Sher-I-Kashmir Institute of Medical Sciences from January 1998 to December 2000 were reviewed for this study. Patients with traumatic and iatrogenic pneumothorax were excluded from the study. Patients with obvious cause of pneumothorax were categorized as SSP. The results of PSP were compared with SSP. The patients were followed up on an OPD basis. Statistical analysis was done using x2 test and continuous data were compared by Student's test.

RESULTS

The age of patients with PSP was 27±11 years and for SSP 58.8±15.2 years (p<0.01). Eighty-nine (94.23%) patients of PSP were males and 3 (5.76%) were females. Among SSP patients, there were 30 (93.75%) males and 2 (6.25%) females.

Clinical manifestations

The clinical manifestations are summarized in Table 1. Pain was the commonest symptom with PSP episodes (86.25% PSP vs. 54.34% SSP) whereas dyspnoea was the most common feature of SSP episodes (20% PSP vs. 84.78% SSP). There was one patient (1.25%) of PSP who was asymptomatic in comparison to 2 patients (4.3%) of SSP.

Aetiology

The commonest underlying cause of SSP was tuberculosis (Table 2). Twenty-nine episodes (63.04%) in 18 patients (56.25%) occurred with this disease. Ten episodes (21.73%) in 7 patients (21.87%) were due to emphysema. Pulmonary fibrosis, lung cancer and pneumonia were responsible for 4, 2 and 1 episodes respectively.

Treatment

Nonoperative treatment: The commonest mode of treatment was tube thoracostomy for both groups of patients (Table 3). Sixty-three (78.75%) episodes of PSP were managed with tube thoracostomy in comparison with 30 episodes (65.21%) of SSP (30.43%). Pleurodesis was performed in 47 episodes (58.75%) of PSP in comparison to 14 episodes (3043%) of SSP. Other non-operative modes of management were needle aspiration (8.7% in PSP vs. 19.56% in SSP) and observation (5% in PSP vs. 6.5% in SSP).

Operation (Table 3)

Seven episodes (8.7%) of PSP had open thoracotomy as compared to 9 (19.5%) episodes of SSP. The commonest indication for surgery in PSP was recurrent episodes whereas the commonest indication in SSP was persistent air leak. Open thoracotomy through the posterolateral approach was used for all the patients. All 7 patients of PSP were managed by excision of blebs and bullae with oversewing of area and pleural abrasion. Patients with SSP were managed by lobectomy in 4 and pneumectomy in 1 episode. Excision of bullae with oversewing of area with pleural abrasion and pleurectomy was done in 2 episodes each.

Recurrence (Table 4)

The overall recurrence rate for both groups of patients was higher with non-operative treatment (34.24% in PSP vs. 26.08% in SSP). There were no recurrence rates with operative treatment in both groups of patients.

DISCUSSION

Pneumothorax is the accumulation of air within the pleural space. PSP occurs in young patients without any apparent lung disease. SP with underlying lung disease is categorized as SSP. A pneumothorax compresses lung tissue and reduces pulmonary compliance, ventilatory volumes and diffusing capacity. Patients with SP present with chest pain and dyspnoea. Less common symptoms include non-productive cough and orthopnoea. Rarely, patients may be asymptomatic. In our series chest pain was the commonest symptom of PSP (86.25% in PSP vs. 54.34% in SSP) and dyspnoea was the commonest manifestation of SSP (20% in PSP vs. 84.78% in SSP). Tanaka et al³ reported dyspnoea in 64.24% patients with SSP and in 10.2% patients with PSP. They also reported chest pain as the commonest manifestation in PSP in comparison to SSP (88.16% in PSP vs. 39.8% in SSP). The occurrence of apical blebs and bullae in patients with PSP has been found to be greater than 85% in most recent surgical series.^1,2 The most common underlying lung disease in our series of patients with SSP was tuberculosis, 29 episodes (63.04%) in 18 patients (56.25%) followed by emphysema, 10 episodes (21.73%) in 7 patients (21.87%). The commonest cause of SSP, as per literature, goes in favour of emphysema.^4,5 Getz and Beasley⁶ reported only 10.7% of SSP due to tuberculosis. This suggests that pulmonary tuberculosis is very common in our country.

Simple needle aspiration of a pneumothorax may relieve symptoms and can promote quicker lung re-expansion.¹ It may also help to determine whether the initial fistula that caused the pneumothorax has sealed or whether there is an ongoing air leak that requires chest tube insertion.

Tube thoracostomy and underwater seal drainage are the mainstays of treatment for SP. Full re-expansion of the lung, even in the presence of a continuous leak, can be achieved usually with the application of suction to the thoracostomy drainage systems.

In our series, most of the episodes of SP were managed by non-operative treatment. Non-operative treatment included tube thoracostomy (78.75% in PSP vs. 65.21 % in SSP) with or without pleurodesis, observation (5.5% in PSP vs. 6.5% in SSP) and needle aspiration (7.5% in PSP vs. 8.6% in SSP). Shields and Oilschlager⁵ reported observation in 11.7%, needle aspiration in 6.7% and thoracostomy tube drainage in 65.0% patients with SSP. In a series reported by Tanaka et al,³ 60.6% episodes of PSP and 80.5% episodes of SSP were managed with non-operative treatment. Non-operative treatment included tube thoracostomy with or without pleurodesis (32.7% in PSP vs. 63.4% in SSP), observation (23.2% in PSP vs. 8.1% in SSP) and needle aspiration (4.7% in PSP vs. 8.9% vs. in SSP).

The first line of treatment of SP depends on the size of pneumothorax, associated symptoms and underlying pulmonary disease. In patients with SSP, who are usually older than patients with PSP and also have diminished lung function because of underlying lung diseases, even a small pneumothorax can produce severe respiratory distress.⁷ Patients with small pneumothorax (<20%) who are asymptomatic or have few symptoms can be observed. Indications for intervention include progressive pneumothorax, delayed pulmonary expansion or development of symptoms. The risk of recurrent pneumothorax varies widely in published reports because of the varying age and associated lung disease. DeVries and Wolfe⁸ estimated a recurrence rate of 32% with non-operative methods. Granke and coworkers⁹ reported a recurrence rate of 22.4% with tube drainage and no recurrences in the operative group of 78 patients. Seremetis¹⁰ reported a recurrence rate of 49% with observation, 38% with tube drainage and no recurrence after open thoracotomy. Schoenenberger and coworkers¹¹ reported recurrence rates of 30% in both PSP and SSP. Tanaka et al reported an overall recurrence rate of 28.3% in PSP vs. 30.9% in SSP.³ Their recurrence rate with non-operative treatment was 44.8% in PSP vs. 35.4% in SSP, and with open thoracotomy 3.0% in PSP vs. 12.5% in SSP. Thus, the recurrence rates observed in our series, 31.24% in PSP vs. 26.68% in SSP are comparable with figures seen in other series.

To prevent recurrence, the diseased site should be resected and pleural space obliterated. Surgery for PSP has evolved over recent years from open thoracotomy (axillary or posterolateral) to a minimally invasive video-assisted approach.^12,13 The surgery carried out is identical, despite the differences in approach. Apical blebs are resected. The parietal pleura over the apex of the hemithorax can be removed (pleurectomy), abraded (mechanical pleurodesis) or treated with talc or tetracycline agents (chemical pleurodesis). The recurrence rate for these procedures, performed open or closed, is less than 5%. Naunheim and colleagues¹⁴ reported a recurrence rate of 4% with VATS blebectomy and pleurodesis. They found a reduced drainage time and complication rate and a shorter hospital stay with this approach. Patients also had a high acceptance rate with this procedure.

CONCLUSION

Clinical manifestations and treatment options for primary and secondary spontaneous pneumothorax are similar. However, patients with SSP, generally, are debilitated from a respiratory standpoint and may have other significant comorbid diseases. Effective treatment must be individualized, but should include chemical or surgical pleurodesis in combination with complete lung re-expansion and effective sealing of air leaks.

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