Management of Secondary Spontaneous Pneumothorax

1. Randal L. Croshaw, MD, Scott Matherly, MD, James M. Nottingham, MD, FACS University of South Carolina Department of Surgery Management of Secondary Spontaneous Pneumothorax Spontaneous pneumothorax The case for early definitive treatment: The recurrence rates of primary and secondary pneumothoraces for patients in patients not undergoing definitive management are 31.8% and 43%, respectively. Patients that develop a pneumothorax secondary to pulmonary Langerhan’s cell histiocytosis have a 58% chance of recurrence if not treated definitively. The recurrence rates of pneumothorax due to AIDS or CF are 11%-65% and 50%-79%, respectively. Mortality for secondary spontaneous pneumothorax is 1.8% to 3.3% while mortality for primary spontaneous pneumothorax is 0.06% to 0.09%. Case report: This 22 year old African American man presented to the ED complaining of one month history of exertional dyspnea that acutely and progressively worsened four days prior to admission. He underwent tube thoracostomy and was noted to have a persistent air leak. That and the unusual appearance of his CXR prompted a CT scan. He underwent thoracotomy with stapled blebectomy and pleural abrasion with no complications. Pathology confirmed the diagnosis of pulmonary Langerhan’s cell histiocytosis. He returned to the ED one week after discharge for recurrent SOB. He was found to have a contralateral pneumothorax which again necessitated blebectomy and mechanical pleurodesis. Since that time he has had no further episodes of pneumothorax. Primary Secondary Delay definitive surgical management until after the first recurrence. Perform definitive surgical procedure once the patient is stable upon the first occurrence. Introduction: Secondary spontaneous pneumothoraces occur due to an underlying lung disease such as COPD, cancer, Pneumocystis jerovici, cystic fibrosis, tuberculosis or other lung diseases. The incidence of primary and secondary spontaneous are roughly equal with an incidence of 6.3 and 2 per 100,000 per year for men and women, respectively. Management options: Observation: Rarely effective and reserved for clinically stable patients with small (<2-3cm collapse) pneumothoraces. Simple aspiration: Consider for young patients with clinically stable, nonexpanding small pneumothoraces. Success rate is 37% for secondary pneumothoraces compared to 75% for primary spontaneous pneumothoraces. Tube thoracostomy: The ACCP recommends placement of a small (14F-22F) tube for stable patients while unstable patients or those at risk for mechanical ventilation may benefit from a larger tube (24F-28F). They may be managed with water seal unless there is a persistent leak or failure to re-expand. Recurrence prevention: Bullectomy with parietal pleurectomy or abrasion limited to the upper hemithorax is the preferred procedure. VATS, pleural abrasion, and talc pleurodesis are acceptable alternatives. Tube-directed pleurodesis is an alternative for patients unable or unwilling to undergo an operative intervention. Contralateral occurrence rates range from 5.2% to 29%, but no recommendations exist for prophylactic intervention in patients who have suffered from a secondary spontaneous pneumothorax. CT 2/28/05 Cystic changes are prominent throughout the lungs with relative sparing of the bases. CXR prior to D/C 3/8/05 Return to ED 3/13/05 References: 1. Baumann M. Management of Spontaneous Pneumothorax. Clinics in Chest Medicine 2006;27(2):369-81. 2. Mendez J, Nadrous H, Vassallo R, et al. Pneumothorax in Pulmonary Langerhans Cell Histiocytosis. Chest 2004;125:1028-32. 3. Baumann M, Strange C, Heffner J, et al. Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement. Chest 2001;119(2):590-602. 4. Lee P, Yap W, Pek W, et al. An Audit of Medical Thoracostomy and Talc Poudrage for Pneumothorax Prevention in Advanced COPD. Chest 2004;125(4):1350-20. 5. Weissberg D, Refaely Y. Pneumothorax: Experience with 1,199 Patients. Chest 2000;117(5):1279-85. Initial CXR 2/25/05 Note the hyperinflated lungs, increased interstitial markings and cystic changes.