From
StayCurrentMD
Spontaneous Pneumothorax: Update Course 2014
Part of
Spontaneous Pneumothorax 9 items
Chapter 1 of 6 · Case-Based Learning
Pneumonia case
Case presentation: Pediatric pneumonia with intraparenchymal disease
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What the experts said
Ultrasound can sometimes be misleading in pediatric chest pathology; intraparenchymal disease may not show layering or loculations on ultrasound, requiring CT for accurate diagnosis.
Intraparenchymal lung disease (necrotic lung) should be treated with antibiotics alone, not surgical intervention, but may require delayed surgery if lung falls apart and develops effusion and fistula.
For a 5-10% apical pneumothorax in a minimally symptomatic patient, observation with oxygen is appropriate management.
Oxygen is routinely used for pneumothorax management, though there is uncertainty about whether it actually provides benefit.
Simple aspiration of small pneumothorax may cause a larger pneumothorax and is not indicated for small apical pneumothoraces.
Many pneumothorax patients treated with chest tube never show an air leak, questioning the need for tube placement.
Spontaneous pneumothorax is rarely seen in children; it occurs primarily in teenagers and adults.
Every patient with spontaneous pneumothorax in adult thoracic surgery has blebs on the apex of the lung.
Patients with apical blebs cannot be successfully treated with chest tube alone because pneumothorax will recur due to the blebs.
Patients with spontaneous pneumothorax typically have a thin, asthenic chest habitus on X-ray.
CT scan is obtained to visualize blebs on the contralateral (unaffected) side in pneumothorax patients.
CT findings of contralateral blebs inform family counseling about risk of future pneumothorax on that side.
If CT shows contralateral blebs and that side later develops pneumothorax, the surgeon can proceed directly to VATS without wasting time on chest tube placement.
Before the era of VATS, the standard was to wait for a second pneumothorax, then perform anterior thoracotomy to remove blebs and rough up the pleura.
In the current era, the paradigm has shifted to more aggressive first-time intervention with VATS when blebs are identified.
Prophylactic surgery on an asymptomatic contralateral side with blebs may be appropriate in select cases, such as a patient planning extended backcountry hiking where medical access is limited.
Standard VATS technique for pneumothorax includes apical wedge resection and roughing up the pleura; if the patient has had multiple chest tubes, talc pleurodesis may also be considered.
Talc applied thoracoscopically distributes beautifully throughout the pleural space.
Mechanical abrasion of both visceral and parietal pleura improves pleurodesis outcomes.
Some surgeons have observed that in recurrent pneumothorax cases where pleura was previously roughed up, the chest appears as if no prior surgery occurred.
If blebs are identified and resected, pleurodesis may not be necessary.
When performing mechanical pleurodesis, the endpoint is when small blood vessels become prominent on the pleura; at that point adequate adhesion will occur.
Using talc pleurodesis in pediatric patients is inappropriate because it makes future thoracic surgery in adulthood extremely difficult.
Spontaneous pneumothorax is caused by congenital blebs; after resecting visible blebs, there may be no remaining pathology requiring pleurodesis.
It is difficult to be certain all blebs have been removed during surgery; deflating and reinflating the lung multiple times helps identify blebs, particularly on the edges of the lower lobe.
Blebs can be sealed with energy devices rather than stapled, allowing surgery through 3-5mm incisions (now possible with 5mm staplers as well).
A study of 350 patients who underwent lung procedures without chest tube placement showed no complications, though these were lung biopsy patients, not spontaneous pneumothorax cases.
Omitting chest tubes after pneumothorax surgery requires reliable nursing care to detect complications; this approach may not be safe in all hospital settings.
Entering a chest that has had talc pleurodesis is extremely difficult; adult thoracic surgeons describe it as awful and may require extrapleural dissection.
There is a 50% failure rate with chest tube management alone for pneumothorax.
85% of pneumothorax patients can avoid surgery with appropriate management.
2001 ACCP consensus statement found no role for simple aspiration in pneumothorax management.
British Thoracic Society 2010 guidelines recommend simple aspiration as first-line therapy for pneumothorax.
A Cochrane review (2007) identified only one randomized controlled trial comparing manual aspiration versus chest tube for pneumothorax, including patients aged 16 and older.
Simple aspiration showed 59% immediate success rate for pneumothorax, comparable to chest tube outcomes.
Among 11 aspiration failures, 9 required chest tubes and only 2 required VATS; aspiration avoided hospitalization in 50% of patients with no difference in overall hospital stay, recurrence rate, or time to recurrence.
In adult thoracic surgery, the standard approach is to fix the symptomatic side with blebs and verify the other side has blebs, then wait for a pneumothorax on that side before operating—not all patients with contralateral blebs develop pneumothorax.
Tissue sealant (TissueSeal) has been proposed as an alternative to talc after pleural abrasion, though it is more expensive and eventually resorbs.