Topic overview

This podcast is an interactive discussion about the management of spontaneous pneumothorax between Dr. Todd Ponsky and Dr. Dan Ostlie.

Intro and outro tracks are adapted from "I dunno" by grapes, featuring J Lang, Morusque.
Artist URL: ccmixter.org/files/grapes/16626

Introduction

Dr. Dan Ostlie is Surgeon-in-Chief, Chair of Surgery, and Executive Vice-President at Phoenix Children’s Hospital

Case Scenario: 16-year-old male with right-sided chest pain

CXR shows a moderate pneumothorax
Spontaneous pneumothoraces are more common in males, by about 3:1
There was no trauma
Symptoms are right-sided chest pain and mild shortness of breath, but with stable vital signs

Historical Management of Spontaneous Pneumothorax

Five years ago, management would have involved admission with placement of a chest tube, with possible CT Chest to evaluate for blebs

CT Chests are probably not beneficial in terms of changing treatment parameters or outcomes
http://bit.ly/2PpAZOo

A retrospective multi-center trial between Kansas City, Michigan, and Wisconsin showed that chest tubes work about 50% of the time, but the management of the chest tube after it was placed was too disparate to create an algorithm (i.e. some would leave it for one day, some would wait for the air leak to go away, some would test on water seal, etc.)
There has never been a lot of solid research information generated
Historically, a chest tube would have been placed and watched for at least 48 hours

If he had an air leak at 48 hours, he would go to the OR for VATS
If he did not have an air leak, the chest tube would have been placed to water seal for 24 hours prior to chest tube removal

What We Know Now

The failure rate of patients who get a chest tube and resolve is about 50%
Patients who get a chest tube, fail in the hospital, and then undergo VATS have a failure rate of 25-30%
Based on the multi-center study mentioned above, chest tube failures were consistent across institutions; chest tube management alone was not superior to VATS
The next question became how to identify the 50% of patients who will fail chest tube management

Option of Immediate VATS

Patients with immediate VATS have a 10-15% failure rate
Patients with a chest tube first and then undergo VATS have a 25-30% failure rate

Midwest Consortium

http://www.mwpsc.org/
This group of 11 hospitals agreed to look at management of spontaneous pneumothorax to decrease the pre-VATS phase for patients who appeared as if they were going to fail chest tube management
Patients who presented with spontaneous pneumothorax underwent initial aspiration alone

In adults, the Society of Thoracic Surgery recommends primary aspiration for spontaneous pneumothorax

Rationale of Aspiration

This management is predicated on two things:

The hole has probably already closed by the time they reach the hospital, so they are no longer leaking
Even if it recurs, there is a very low chance of a life-threatening spontaneous pneumothorax

Tension physiology in a spontaneous pneumothorax has not been described in the literature
In the retrospective study of three centers mentioned above, none of the 81 patients presented with tension physiology

Aspiration Study from Midwest Consortium

This study was presented at APSA 2019 but is not yet published
All patients (33 total) who presented with spontaneous pneumothorax underwent immediate aspiration, with a capped catheter left in place for six hours

If there was no recurrent pneumothorax on CXR after six hours, the catheter was removed
If there was a recurrent pneumothorax, then management was left to the discretion of the surgeon

50% (16/33) did not fail and were discharged home
50% (17/33) of the patients who underwent aspiration failed, which is consistent with chest tube management alone

12 of the 17 who failed had a chest tube placed; 83% (10/12) of these patients failed their chest tube (either required VATS or returned with a recurrent pneumothorax)
5 of the 17 went immediately to the OR for VATS; none of these five patients recurred

There are not enough numbers to make definitive conclusions, but there are enough to seriously consider whether placing a chest tube in a patient who has failed aspiration and then keeping them in the hospital for days is worthwhile, when the vast majority of them will fail

Algorithm from the Aspiration Study

All patients presenting with spontaneous pneumothorax should undergo aspiration
Patients with recurrent pneumothorax after six hours should undergo immediate VATS

Outcomes in Patients Discharged Home after Aspiration Alone

Of the 16 patients who passed the aspiration test, 44% (7/16) came back with a pneumothorax
The positive predictive value of the aspiration was 83%; the negative predictive value was 56%
If all patients were taken directly for VATS, 25-30% would receive an unnecessary operation

How would you counsel a family based on this study?

Aspiration is safe, and in some circumstances it is effective
It will allow us to identify if your child is at immediate risk for an ongoing pneumothorax
If they are aspirated and then recur, we would take them directly to the operating room for VATS
If they are aspirated and are able to be sent home, there is about a 40% chance you will return
There is an option for immediate operation, which has a recurrence rate of 10-15% and is unnecessary in 20% of patients

Technique for Aspiration

An 8-12 Fr pigtail (similar to fibrinolysis for empyema) is placed; if Interventional Radiology is available, they can place this pigtail

Technical Considerations for VATS

The patient is positioned with the affected side up
Blebectomy is performed

Is there a role for pleurodesis?

There are good data that suggest that pleurodesis is not beneficial in preventing recurrence
In the retrospective three-center trial described above, those patients who underwent VATS with pleurodesis had the same recurrence rate as those who underwent VATS alone
In a randomized controlled trial from China, adult patients were randomized to undergo wedge resection with or without mechanical pleurodesis

The apex of the parietal pleura was abraded the same in every case
The recurrence rates between the groups were the same
http://bit.ly/38dRJ3U

Talc or Chemical Pleurodesis

There are no large studies looking at chemical pleurodesis
Talc is not available at all hospitals
Anecdotally, these methods may be more effective than mechanical pleurodesis; however, it can be so effective that it makes operating in the chest again much more difficult

Role of CT

The premise behind CT was to identify bilateral blebs, since identifying them on both sides may encourage surgeons to operate on both sides at the same time
However, there are patients with blebs who never develop pneumothoraces, so CTs may be overcalling findings that are not clinically relevant
Dr. Ostlie no longer gets CT scans in these patients

Management of Multiply Recurrent Pneumothorax

These are difficult patients to manage
Thoracoscopic pleurectomy, with stripping of the pleura from the apex to at least a couple of ribs above the diaphragm

The operation is arduous, bloody, and painful for the patient
Patients are usually in the hospital for 7-10 days post-operatively, since a chest tube is necessary to keep the lung up while the blood and fluid is removed

Aerosolized talc can be a great option for these patients, and can be an option instead of pleurectomy

Small Recurrence after VATS with Pleurodesis

A patient had a VATS with pleurodesis, and came back with a small recurrence, but is just a small drop off of the apex, showing that the pleurodesis was effective in preventing the lung from dropping
This patient does not need an operation
Consider aspiration if symptomatic
If they are totally asymptomatic, repeat a CXR in 48 hours

If it is the same, just leave it alone, since you risk injuring the lung and cause a larger pneumothorax
If it is larger, start the aspiration pathway

Conclusion and Future Steps

The next study design will involve taking those patients who fail aspiration directly to VATS, and compare them to those who do not fail aspiration and come back with a recurrence
Study from Korea suggesting that pleurodesis may not be necessary

http://bit.ly/33W0FYq

Spontaneous Pneumothorax