Spontaneous Pneumothorax

Welcome to the latest episode of Stay Current and Pediatric Surgery. Today's episode is created and edited by Todd Ponsky, Alex Cassar, Ray Hankey, and me, Alexander Gibbons. Today we discuss the often controversial management of spontaneous pneumothorax. Think we have all the answers? Don't hold your breath. But if you want to hear the latest evidence behind the role of aspiration or whether or not pleurodesis is effective, you'll see that we're not just full of hot air. So please join us for another episode and then help us spread our message that knowledge should be free. Welcome to State Current and Pediatric Surgery. This is Todd Ponsky recording from Cincinnati Children's Hospital, and today we have a very special guest, Doctor Dan Osley, who is surgeon in Chief and Chair of Surgery and executive vice president of Phoenix Children's Hospital, and he's gonna be talking to us today about a common problem we see and a lot of discussion recently on how to manage spontaneous pneumothorax. Dan, thanks for joining us. Thanks, Todd. Happy to be here. So, uh, Dan, let's, uh, jump right into this. I, I know that you have a great deal of interest in pneumothorax. You've published some papers about it, and you're, uh, currently doing some studies that we're gonna get into. Uh, so I appreciate you talking to us about this. Sure, so, Uh, so Dan, let's start with, uh, a classic case. You get called to the emergency room with a 16 year old that comes in with some right-sided chest pain. Chest X-ray shows a moderate-sized pneumothorax. How do you approach that patient? OK, so, um, you said 16-year-old female or male? Male, male. OK. Uh, the reason I ask is because the spontaneous pneumothorasis obviously are, are more common in male, uh, by about 3 to 1. Um, so we're gonna, we're gonna forego the, you know, the actual workup, was there trauma, etc. etc. etc. and, uh, assume that no trauma, yeah, we're working with a, uh, primary spontaneous pneumothorax. So how symptomatic is he? Yeah, so he's actually doing quite well. His only symptoms are really some right-sided chest pain, very mild shortness of breath, but otherwise doing well. His vital signs are all stable, and he looks pretty good. OK. Um, I'm gonna, I'm gonna give you a little bit of a history here, Todd, um, and why I'm gonna do this is to kind of outline the progression of, of where we were and where we've come to, OK, um, and I hope it's not too boring for you, but I think it'll be interesting to, um, whoever's gonna be listening to the podcast. So if you had asked me that question five years ago. I would have said We were going to admit the patient and put a chest tube in. And observe him, and then we would consider getting a CT scan to look for blebs. Yep. I think that's probably what most people would have done 5 years ago, and it may be still what a lot of people would do today. However, plus or minus on the CAT scan, right, but yeah, I think you're right, yeah, plus or minus on the CAT scan because I think that data fairly convincingly shows that it probably is not beneficial with regard to changing treatment parameters or outcomes. Um, all right, and just so you know, that's what, that's what I currently do right now. So I am eager to learn. OK, yeah, so you do do a chest, you do do a CT scan. No, I don't do a CAT scan, but I would put a chest tube in that patient. Yes, yes. So I think that most people at this point in time would, not most people, I think there's, there's a, there's a, um, there's a group of individuals that still believe the chest tube is the right treatment option. Um, now, if we look at the data from, um, a multi-institutional trial that we did with, uh, Kansas City and Michigan and Wisconsin, The the, what we found in that trial was that chest tubes worked about 50% of the time, OK? Um, but that they didn't really help us with regard to treatment because, because the treatment algorithms for those people were so disparate. So people would put a chest tube in and they would leave it for 1 day, they leave it for 2 days, they'd wait for the air leak to go away, they would, you know, they test it on water seal for a few, few days or a day and then take it out. And so, there was no real rhyme or reason. Um, and that just goes to show to you the difficulty of managing primary spontaneous pneumothorax because there is, has never been a lot of solid. Information generated in the literature from a research standpoint. So, um, we, we would have put a chest tube in that patient. I would have watched him for at least 48 hours, and if the, if he had an air leak, I would continue to watch him or at 48 hours, I would, I would take him to the operating room and do a VAT. And if he didn't have an air leak, then I would leave the chest tube for 24 hours on water seal, and we'd take it out, and if he didn't have pneumothorax, he would go home. OK. What we know now is that the failure rate for patients that get a chest tube and resolve is about 50%. That's kind of across the board. It's not, not exactly 50%, but everything you read is around 50% of the patients that get a chest tube and go home will fail and be back and have to have another operation. Patients that Get a chest tube and fail in the in the hospital and subsequently go on to vets, OK. Uh, interestingly, Still have a failure rate of around 25 to 30%. OK, and we can talk about other options for those patients, um, as well, OK, so, OK, 5 years ago I would have done what I described there based on the study that the, the retrospective study, and mind you the data is retrospective, but it is from three institutions, um, what we concluded in that study, we looked at all the patients. That came to those 3 hospitals, there were 81 patients that were identified. Their age was about 15.5 to 16 years of age. And what we found was that The chest tube failures were consistent across institutions, so it wasn't dependent on how the chest tube was put in or how long the chest tube was left. Um, it was really just a matter of the disease process. And ultimately, what the recommendation was from that study, although it was retrospective, is that We couldn't identify how to make chest tube. Management superior to that, because VTS is superior to chest tube alone, although VATS carries with it the risk of an operation. So then The next question was, well, how do we figure out which patients are gonna fail a chest tube and then move them more quickly down the pathway. So instead of sitting in a hospital for 4 days with a chest tube wondering if they're gonna, gonna need an operation, how do we move that 4 days from 1 day? Identify the patients that we hopefully can identify that are gonna fail no matter what we do, not the 50% that do well, right? The 50% that do well with chest tube. Um, and go home and never have recurrence, we don't wanna operate in those patients, but we wanna improve the care of the patients that are getting a chest tube that are ultimately gonna fail. So how do we identify those patients? You with me? Yep, got you. OK. By the way, Dan, let me just tell you where my head is right now. Yeah, you said one thing that's already slightly, even before you present what you're about to tell me, I want, you already have changed me a little bit by telling me that 50% of people fail. That's already swaying me to this other argument. Uh, which I know is not what you do, of going, just going and doing a VATs, because, um, instead of putting in a chest tube, just take them for a VATs because if that's that high, you might as well try to do surgery, which you're saying fails 25% of the time. Is that right? Patients that get immediate VATs have a, have about a 10 to 15% failure rate. For some reason, patients that get a chest tube and come back. And then get a vats, their failure rates are higher. So those patients may be predisposed to, uh, uh, uh, a recurrence no matter what. Or in the data, it may be a little, it may have been a little bit quote unquote dirty because it was retrospective data. OK. All right. And that, so I'm, I'm gonna restate what you're saying to make sure I'm clear. The 3 different numbers are all comers. If you put in a chest tube and they, and they do well and they go home, they have a 50% chance of coming back again. Exactly. The second group is if you go straight to the operating room and do a VAT, they have a 10 to 15% chance of failure. Correct. The third group is you put in a chest tube, they never got to the point of ever going home, and they had a vats. They have a 25% chance of having a recurrence. That's right. That's, that's from the retrospective data, OK. So What is this, this, this study drove us to do the next study, and at that point in time, we'd formed the Midwest, uh, uh, Research Consortium, um, which is 11 institutions around the Midwest, and you can, you can find out about that online or other research that they've done, OK? That group agreed to do a study. Looking at management of pneumothorax, primary spontaneous pneumothorax to try and decrease the pre. Intervention phase, intervention being VATs, for those patients that it appeared that they were gonna fail, OK? And so what we did in that trial is we When patients came to the emergency room with a primary spontaneous pneumothorax. They were managed uh uh with aspiration alone. So, this data comes from the adult data. The Society of Thoracic Surgery in adult patients recommends primary aspiration for spontaneous pneumothorax to begin with, and we've never translated that to, to children. Um, interestingly though, in most large studies for primary spontaneous pneumothorax, the average age, the mean age, is around 20 to 22. OK, so this is, this is primarily a young adult disease process and our average age in the studies we've looked at have been between 15.5 and 16. OK, OK, but Dan, can I stop you for a second? Yeah, so just for, for everyone out there because for a lot of people this is the first time they're ever hearing about aspirating a pneumothorax. So this idea of just Putting in a needle or angio cath and sucking out the air is predicated on two concepts. One is that, and, and correct me if I'm wrong, that the hole has probably already closed by the time they come to the hospital. OK, so they're not leaking anymore by the time they come in. That's right. The second thing is that this is not that serious of a disease, uh, even if it does happen to come back again. There's a low chance of a life-threatening spontaneous pneumothorax. Correct? I'm not aware. I'm not, I'm sure we could, we could scour the literature, but I'm not aware of a published paper that Documents tension physiology for a spontaneous pneumothorax, which is such an uh an interesting part of this is that not all pneumothoraxes are the same. That's what sort of you're, you're discovering here that spontaneous pneumothorax is a different disease than a traumatic pneumothorax, and they don't usually have tension physiology, which is fantastic, uh, discussion. Yeah, I mean, I, I could be wrong on that, but. Now, I could ask you, have you ever seen a patient that's had tension physiology with a, with a spontaneous pneumothorax, and you and I have discussed this in the past, and I have never, and nor have anyone that I've asked ever seen a patient come in in extremis, uh, with tension pneumothorax from a spontaneous pneumothorax. And of the 81 patients in our retrospective study, none of those patients presented with tension physiology. So that's 33 institutions, um, across 13 years of data collection. OK. So, back to what you were saying about the aspiration. OK. So, the, the next study, which is a fabulous study, although maybe didn't go as far as we, we had initially started the study. Our initial study of design was gonna be, OK, they're gonna get randomized to immediate vats or they're gonna get randomized to a chest tube and see which does better, do a kind of a more classic randomized controlled trial of two treatment arms, OK? The Midwest Consortium felt That there wasn't adequate data out there to support immediate VATs even though we had people that were doing it. It was retrospective data and it wasn't clear cut about what the benefit would be for immediate VATs for those 50% of patients that may never need an operation. Completely agree with that, by the way. I completely agree that the, the focus doesn't, the focus needs to be more how do we. Treat the patients that are gonna fail. We know how to treat the patients who don't fail because they do fine with the chest tube and they don't need an operation. The adult thoracic surgeons, the recommendations from the Society of Thoracic Surgery is aspiration as the initial treatment for spontaneous pneumothorax. Beyond that, they don't really predicate what they should do, OK, unless something's changed and I'm not aware of. So, what we did in the Midwest Consortium was we designed a trial where all patients that presented with primary spontaneous pneumothorax would get an immediate aspiration. And they would have a catheter left in place, so you'd aspirate with a catheter, pigtail or something like that, and they would have a catheter left in place for 6 hours. If there was no recurrent pneumothorax, that catheter was just, it wasn't placed, it was just locked, OK? It wasn't placed a water seal or anything like that. Um, it was just capped off after you aspirated the pneumothorax. If there was no recurrent pneumothorax, the catheter was taken out and the patient was discharged. After 6 hours. After 6 hours. If there was a recurrent pneumothorax, Then the treatment algorithm was at the discretion of the surgeon. So we didn't, we didn't force them to do anything because we're trying to identify the patients that were gonna fail. So, what we found in that is that, not surprising, 50% of the patients that got an aspiration failed. So that number of failure is pretty consistent. So can I, can I just, can I just make one assumption? Is that means that 50% of those patients still had an open hole that was still leaking? That's all that tells you, right? I think that's right. Even though there may not have been an air leak, there was some, some air escaping from the lung parenchyma in those patients. OK, got it. So we got 50/50. So the patients that got aspiration and didn't fail were discharged and went home. From the ED or from a holding area, whatever hospital, whatever the hospital could do, OK? And the 50% that failed. Some of those underwent chest tube management, OK? So, there were, there were 17, uh, this is a pretty small study cause it's not very common. This is 11 institutions, right? That did this over 2 years. So, there were, there were, I think actually, I'm taking it back. I think there were only 9 institutions that participated. Over 2 years, there were 33 patients that, that came in for those 99 institutions. So, there were 17 that failed out of those 33. So of those 1710 of those patients, the surgeons decided to go forward with chest tube management and not do an operation. So this is amazing. This, this is, this is great data that people will find fascinating and I think will probably help change the treatment for primary spontaneous pneumothorax and shorten hospital stays. 83% of the patients who failed and got a chest tube failed their chest tube. So, I, I wanna make sure I'm understanding this. So, we're talking about 10 patients though, right? 17 patients failed aspiration total of the 33. So that's the failure arm. Of those 17, The surgeons in 12 of those patients decided to treat it with a chest tube instead of an operation. So 12 got a chest tube after the aspiration, and And 80% of those 12 patients Had a persistent air leak, I guess is what we're calling failed. I don't know what you mean by failed. They, they had a persistent air leak that required either a vats or another spontaneous pneumothorax. I see. I see. OK, so they either they either did OK, went home and came back again, or they ended up going to the OR on that hospital stay, right? Exactly. So, and of the ones that failed, there, uh, there are a group of those that went on immediately to VATS. So remember there were 5 of those patients, 17 failed. Yep, 5 decided, the surgeons decided to say, OK, you failed. I'm taking you directly to VATs. OK. And none of those recurred. Do you think these are enough numbers to make conclusions from? I don't think there are enough numbers. To make definitive conclusions from because I'm pretty sure that there would be people that got immediate VATs that ultimately will fail. But I think that's enough numbers for us to seriously consider. Whether keeping a patient in the hospital who fails an aspiration for days on end for chest tube management. is what we should be doing when we've already identified that they're at very high risk for recurrence because they failed their aspiration. So are you suggesting then that everyone gets an aspiration if you if you have recurrent pneumothorax after 6 hours you go directly to vats? Yes. Wow. So that's the algorithm. That's the, that's the current algorithm that comes out of the Midwest Consortium study. That was presented at ABSA this last year. Did any patients in the study group? Uh, ever have any sequelae of being sent home, uh, after aspiration with and coming back with a recurrent pneumothorax. No There was no, there was no sequelae related to that, but the other question that we need to ask ourselves, which we haven't gotten to yet, but it's very salient, is what happened to the 16 that didn't fail. 16 got aspiration, the pneumothorax resolved, they went home. Right, yeah, that's really the question I think you're trying to get at. I think the oi, meaning, you know, did they have a recurrence? Did they present back with tension physiology? Did they attempt to present back with pain? What happened to those patients? So it's a good question, right? So. It's not, it's not zero, OK, so of the 16 that passed the aspiration test, 40% of them came back with a pneumothorax. So remember that failure rate then is 44%, yes, OK. The failure rate for those that failed aspiration. Immediately That got chest tubes and got managed in the hospital for a period of time was 83%. So the positive predictor value for the positive predictive value of aspiration in being able to treat the pneumothorax was 83% with a negative predictive value of 56. So they're not great, but the positive predictive value is, is legitimate. And that we know that 83% of the time if they get, if, if they resolve their spontaneous pneumothorax with aspiration, They will not need further intervention. Right, right, OK. But, but the problem is that the other half that, that did succeed. You're sending half, almost half the patients are going home and they are going to come back again. Half the patients of the patients that go home, uh, not quite, but half the patients of the patients that go home will, will end up coming back again with a, with a pneumothorax, 40%, yeah. But that's better than the 83% that sit in the hospital and end up having to have an intervention. It is, it is unless you're an advocate of taking all these patients to the OR for vats. Yes, yeah. Then you're looking at around somewhere between 25 and 30% of patients that would get an unnecessary operation. OK, so, so Dan, you've just told us all this data. So tell me, how are you interpreting this? How are you gonna counsel a family with all this information? Great question. Now, now we gotta get the history behind us. So, what, what I do now is I go and talk to the family, and I explain to them where we're at. I don't give them the history we just talked about here, but I do explain that aspiration is safe and in some circumstances, it is effective. Um, it will allow us to identify if your child is at risk, immediate risk for an ongoing pneumothorax, and if, if we aspirate them and they are recurred, then I, I would recommend we just take them directly to the operating room tomorrow morning or whenever, um, and do an operation to remove the portion of the lung that's leaking. But if aspiration does work and you go home, you have to understand that there's about a 40% chance that you'll come back and we'll have to do something else. Um, but you'll, you're at less risk than the aspiration will identify that you're at less risk if it resolves pneumothorax than those that don't resolve pneumothorax. If I decide, if you recommend, or if you decide that you'd like to just do an operation, we can do that. Um, it is an operation, there's risks associated with that operation, and the recurrence rates are around 10%, 10 to 15% after an operation. So, you're carrying yourself around a 20% difference, which is, you know, 2 times out of 10 that you go home and you'll come back and need an operation. That's your, that's your risk that you have to balance over doing an immediate operation right now. Well, 20% of the time, you won't have needed that operation. Um, I start everybody out with aspiration at this point, I don't put chest tubes in anybody. And when you aspirate, what do you use to aspirate? We use an, uh, like an 8 French pigtail, you know, you just, just like you would if you were gonna do, uh, fibrinolysis for Eyima. Use it 8 or 12 French pigtail. Actually, at Phoenix Children's Hospital, we have, we have radiology available. So lots of times the radiologist will just put the pigtail in for us and cap it off. And, and do you use that as your chest tube if they fail, um, if they, I personally, I push the families down vats. If they fail, I'd, I really, I really try and get them to do a vats because I think that the, the likelihood of if they failed, 83% of the patients that failed ended up going on to vats if they failed early. And so I just don't see the benefit of, of waiting around for 3 days to identify the, the, the 15% who didn't fail. OK. So, uh, let me ask you about the actual operation that you do. So if you take them for baths, um, first of all, simple question, how do you position the patient, supine or, or, uh, affected side up? Affected side up. And, uh, you do your labectomy, um, and then how do you do your pleurodesis and do you do any pleurodesis at all? I do not do pleurodesis. I think that Um, there's good data that suggests that pleurodesis is not beneficial in preventing recurrence. Um, when we looked at the retrospective data from that three-institution trial, um, those patients that underwent pleurodesis had the same recurrence rate as, that, that underwent VATs and pleurodesis had the same recurrence rates as those that underwent VATs. And then, um, as you, you're aware, there's this large trial out of China. It's an adult trial, um, average age of 22 years old, where they randomized patients to get, um, wedge resection with or without mechanical pleurodesis. Uh, they controlled for the mechanical pleurodesis pretty well. They used a sandpaper um of, of whatever caliber. And um They, uh, denuded or abraded the, uh, apex of the lung or apex of the, of the, uh, parietal, uh, pleura. The same in every case to where it's bleeding. And they showed that the recurrence rates, uh, were the exact same between those groups, and that's a large trial. This is 289 patients over a three-year period, um, that, that they studied. So, I think the evidence beyond, now, this is just pleurodesis, OK? Pleurodesis for an initial operations for spontaneous pneumothorax, I'm, I'm sure that there's any evidence that supports that that's gonna decrease your, your recurrence rates. Right. And I, I will say though, they only looked at mechanical pleurodesis, so they did not look at talc or chemical pleurodesis at all. That's true. And I'm not aware of a, of a study, a large study that looked at, that has looked at chemical pleurodesis. In some places you can't get talc anymore, so. Right. And, and I think. The discussion there is, I think many people, even though it hasn't necessarily been studied that I know of, uh, it, it probably is more effective than mechanical pleurodesis, but it's so effective that it's very treacherous to go back into the chest after you use talc, uh, or chemical pleurodesis. So that's another debate. One way we used to do it, talc was awesome. It seemed like it worked. Um, that's anecdotal only, yeah, yeah, yeah, and, and that's anecdotal for me too. Um, I've tried all of these, but talc seems to, to really work, but it's certainly, according to, uh, I think Arnie Corn and Steve Rothenberg on a previous recording had said that it's absolutely treacherous to go back into a chest that's been tal ple pleurodesis. Uh, so, uh, tell me the role of, of CAT scan. Yeah, I think the, the real, the premise behind CAT scan, this is my, my opinion. was to identify bilateral blebs, right? I mean, initially, people might have been doing it to identify where the bleb was at, but I think really where the, the, the expansion of CAT scan use or CT scan use was, if there's bilateral bleb, should you do both blebectomies at the same time, right? Right. Um, and What I What I personally recognize is that There's patients that have blebs that never developed pneumothorasis. It's kind of back to, you know, the identifying the 50% of patients who won't need a VATs, they get a chest tube, right? So, yes, we're really good and CT scans are, are so sensitive now that we may be identifying blebs that are just incidental things, you know, for example, you know, a traumatic pneumatocele, right? And those, those hardly ever rupture, and we almost never need to do anything with them. So, so CAT scans may be overcalling. Findings that may be more common than we've that we've historically have expected and then is that driving us to make a decision based upon a finding that may not be clinically relevant. So I don't do CAT scans on anybody anymore. OK. Uh, Dan, so let me ask you two more questions. Number one, what about the patient that has a recurrent recurrent pneumothorax? How do you manage them? Yeah, they're, that's a difficult patient and you know the patient itself, they're, they're exhausted, they're, they're frustrated, the parents are frustrated and you, you know, you're at your kind of clinical wits end, um. Because you've failed what you've done, they've had, you know, maybe they had a chest tube and it failed, and then you had the VATs and it failed, and they did another VATs and it failed, and you're, you're scratching your head. You did a mechanical pleurodesis and Um, I personally, in those cases would then go on and do a thoracoscopic pleurectomy, uh, of the, of the parietal pleura, and I literally just stripped the pleura from the apex down to at least a couple of ribs above the diaphragm. It's a pretty arduous operation. It's a bloody operation. It's super painful for the kids. Um, and so we usually will use epidurals and things like that, um, and they're usually in the hospital for a week or 10 days while they're recovering and, and their bloody output goes away because you gotta keep a tube in to keep the lung up well, while the, uh, while the blood and all, all the fluids doesn't allow for separation. But here's where your comment earlier about tek, and this is a, this is a great population that if you have tec and you're doing everything you can to not go back into the chest again, where if I had the ability to use tec in this, in that, in that patient population, I would use tec for sure. I think you just gave me a great, uh, algorithm, um, regarding this part. I was also trained on, uh, pleurectomy. Uh, by Doctor Rothenberg, that's what he taught me. Uh, and I have switched to the aerosolized talc. It comes in a can, you just spray it, it looks like it's snowing inside the chest. But I, I've learned from others that this is probably not a good first-line therapy because it works too well. Uh, but for someone that has a recurrent recurrent, I probably will either do a pleurectomy or use aerosolized talc because we know it works. I haven't used the pleur uh the aerosol talc. I'll have to look into it because I, that sounds like a great, great option for this patient. It, it's fantastic. It comes in a little can with a little straw that comes out of the end. You just put it down the, the Chokar site and push, push the button and it just shoots talc everywhere. It's really cool. Um, so, uh, what, I have a, I had a patient that I, I'd love your advice on. Uh, patient had a vats with a pleurodesis, uh, and has, comes back with a recurrence, but all the recurrences is just a little drop off of the apex. So basically, the pleurodesis worked. He's probably got a recurrent bleb, but his lung doesn't drop. It drops about, you know, a couple of centimeters maybe. Would you operate on that child, or would you just sit tight, maybe aspirate them? I would not operate. I might consider aspiration if they were symptomatic. Um, if they were totally asymptomatic, I would, what I would do is bring them back in 48 hours and repeat the chest X-ray. And if it was the same, and hadn't changed, um, I'd probably just leave it alone. My concern would be, OK, you've got a lung who's fixed a little chest wall. You've got a tiny pneumothorax, which is not physiologically important. You may end up with a potential dead space there. That's OK. But the risk of injuring the lung and having a worse situation where now you've got a larger pneumothorax or larger air leak and you're not trying to deal with that to me outweighs the minimal risk of having a 2 centimeter residual space without any significant volume loss to the lung. If they came back with a larger pneumothorax, then I would aspirate, um, and see where I would start down that pathway, yeah. We did exactly what you said and, and, uh, it, it uh stayed the same, so we, we sent him home. Yeah, well, Dan, uh, uh, that was a, uh, great, uh, discussion. I, I know this is one of the most common things we discuss. I know around the country, everyone asks me about that, so I've been very eager to do this recording with you. Um, so, uh, thank you for talking about a subject. It sounds like we still don't have all the answers, but we're making some progress. No, yeah, we're making progress. I think the next study design is gonna be taking those patients that fail aspiration and taking them straight to, to vats, um, and then seeing how they compare against the patients who don't fail aspirations and end up coming back with a recurrence and eliminating that group and people who sits there for days and days and then ends up failing anyway. You know, it'll be a stepwise progression here, but at least we've now got a group of, of institutions who are interested in this disease process that hopefully we can continue to push the envelope forward for, for, uh, optimal management. Absolutely. And I, we all appreciate your work on this and guiding the rest of the world on how we should be managing this. We will attach, uh, in this podcast, we will attach all the articles that we referenced, uh, including the, uh, and one that we didn't talk about, which was, uh, in a study out of Korea that looks at the, uh, the fact that pleurodesis may not be necessary. So, uh, uh, Dan, thanks again. I appreciate your time. It's great and uh hopefully you'll do with one of, one of these again in the future when we have more data. Great, thanks, Todd. Thanks for inviting me. I really appreciate it. Thank you. This is Alexander Gibbons from Akron Children's Hospital, the contributing editor for this episode of Stay Current Pediatric Surgery. We hope that you found Doctor Osley and Doctor Ponsky's discussion on pneumothorax to be a breath of fresh air. Obviously though there are still a lot of unanswered questions, if you have any you can think of, please share them with us on our state current and pediatric surgery app. We'd also love to hear your ideas for future podcast episodes. Our next topic will be everything you need to know about Wilm's tumor in 10 minutes. Thanks again for listening and until next time, remember knowledge should be free.