Spontaneous Pneumothorax: Update Course 2014

About this patient, 3-year-old female, she's been sick for 5 days. She's been febrile, productive cough, also has not been eating. Uh, I don't know why that showed up, sorry. I'm going backwards, there we go. So next step in this case, let, let me just kind of go through this at the same time because we want to talk about the pneumothorax stuff too. Um, so you get a chest X-ray. It shows an effusion, maybe left lower lobe pneumonia. You get a lateral decubi film. It shows no layering, OK. What would people do at this point? Anybody do a CT or go to ultrasound ultrasound ultrasound. OK, you do an ultrasound, let's say, and it doesn't show any layering or any oculations, OK? That's CTs too. OK, so you get the CT, yeah, yeah. What do you guys think about that? Is that necrotic lung? Looks like a lung. That's what it looks like to me. Yeah, so I think, I think the point I put this in here is because ultrasound can some, I think Todd said that early on, they can sometimes fool you, so you need to trust your ultrasound techs because in this case, this is all intraparenchymal disease, right? You don't, you don't want to do anything but treat this like Arnie said with antibiotics. It doesn't need an operation or anything, so you need to be comfortable that what the data you're getting from the diagnostic studies you're using is accurate. Thoughts about that? Well, the patient might need surgery, but it'll be a week or two later when that lung falls apart and you get an infusion and a fistula. OK, let's talk a little bit about, uh, pneumothorasis here. So spontaneous pneumothorasis specifically, uh, we're gonna avoid the traumatic stuff. So let's have a patient scenario here. I don't know if you guys can see this real well. It's a 15 year old male. He presents to the ER. He has minimal chest pains. He felt some crackles in his chest. He has no significant short of breath. Next step. Can you, can you see the X-ray or can't you? We can see it. What, what do you see? We don't see the pneumothorax. We're too far away for us. There you go. So there's an arrow there. You can see that little tiny kind of 5 10% pneumothorax in the apex. So I'd observe, I'd observe that. Would you, would everybody put him on oxygen? I do. Does anyone believe it does anything? No, I don't think it does at all. Absolutely. Yes, but I don't know how. So we, we all agree with that diffusion, put him on oxygen and not do anything else. Sorry. So those are the choices. What about simple aspirations? Anybody thought of that? Not for that. No reason to do that. Yeah, you'll cause more, cause more trouble. Get a bigger pneumo if you do that 30% pneumothorax, which one of these would you guys do? Chest, yeah, and again we do, we do a percutaneously saltinger technique, a little chest tube for air. So has anybody, anybody considered this last algorithm simple aspiration? No, so the only purpose of the, well, the two purposes, I guess, Dan, is that you're proposing that number 1, by having the lung opposed to the chest wall, it may seal faster, or number 2, to get rid of the symptoms. Would that be, well, no, I think when you put in a chest tube in a lot of these, you never see an air leak, right? But then there's no reason to aspirate point. My point is there's no reason to aspirate if they're. unless it's the symptoms you're trying, either the symptoms you're trying to get rid of, or that you think if there's a tiny hole, it may seal because otherwise, why not just leave it alone if you're going to aspirate it, I don't know if you're going to use a needle or not where you might stick the lung, but I mean you'll use a needle to get into the chest, but aspirate the air through the needle, or would you use like a Fermin or a blit catheter to. To aspirate if you're going to do that, why not leave it in overnight because a certain percentage of those patients will fail and you'll save people two procedures. If you have an apical pneumothorax that was small like you originally had and you put a needle in, you'll have a bigger pneumothorax, yeah, absolutely. So, uh, you know, and if you got a little one, just leave them alone. What do you do, Dan? So I, I have historically used the chest tube, but I bring this up because let's talk a little bit about some stuff here. Um, there's, you know, a 50% chance of, of, uh, failure with chest tube alone, right? And you have all these issues that go along with it. And if you go to primary vets, which I thought about doing for a long time, is that justified when it commits everyone to surgery when I just presented to you that 85% of people can avoid an operation with Eyhima. So that's why the question becomes, in my mind, is simple aspiration or reasonable management. If you could aspirate, watch them for 6 hours and send them home and not have them in the hospital. Now maybe that works. Maybe it doesn't. Here's some conflicting guidelines that give you some data for it. 2001 Adelphi consensus said there was no role for simple aspiration. British thoracic surgery 2010 simple aspiration should be first line therapy. These are adult studies, but as we know, most of these patients are teenagers approaching adulthood anyway. Then there's a Cochrane review in 2007 with only one randomized controlled trial looking at manual aspiration versus chest tube, OK. What that showed was that I've brought this up here just because the range included 16-year-olds, which is kind of where we are at with spontaneous pneumothorases. And it showed an immediate success rate of aspiration of 59%, which is what we can get with chest tube. Um, there were 11 failures. 9 of them got chest tubes, and only 2 of them went on to VAT, and they avoided hospitalization in 50% of the patients with no difference in overall hospital stay or recurrence rate or timed recurrence. So it raises the question of, of, is this something that should be done in children? It's not very well studied in children. Uh, because there isn't a lot of patients, a lot of patients that occur in that under 16 years old, so I think that there is a need for a quality study to look at this possibility in children that are minimally symptomatic. I'm not saying you take a child who's got excruciating chest pain and, and, um, uh, you know, shortness of breath and on oxygen. That's not, that's not where I'm saying we should go. But we don't, we don't see this in children. We see it in teenagers and adults. If you've done, if you've been in, uh, adult thoracic surgery, every one of these patients has blebs on the top of the lung, and so you can't just say we're going to treat it with a chest tube and get away with it because it's gonna come back again because of the blebs. So you're committed to tell you to set me up like this, Ernie, because I really, really appreciate it. What's that? You, you set him up for his next question. Did I, did I actually tell you to set me up like that? The where I wanna go with this. So the next patient scenario, a 15 year old male presents to the ER. He has significant chest pain, feels crackles in his chest, and he has significant shortness of breath, and you can see this big pneumothorax here on the right side. Next step, I think all of us would agree that we would treat that with a chest tube to begin with. Do we, is that what people would say? Yeah, the other thing you want to look carefully at that chest X-ray, that's a classic chest X-ray of these kids that have it. They're very authentic. Uh, they, they got a sort of a very thin, chest capacity, and every one of those ends up with blebs in the, uh, in the upper part of the lung. So would anyone here do a primary vats? OK. So we get a chest CT and exactly what what Arnie's talking about. You can see these blebs up here. At this point, would people just treat this with a single chest tube, or they would go, they go after that with the vets? That's, vets. Well, wait, hold on. So why did we get the CT? To see the blebs. Why? So you can prove does everyone get a CT? You want, you want to prove that they have blebs. I know they have blebs. No, not 100%. I've not had a patient that has not had them. You want to get a CT because you want to see the other side. Yeah, I don't want to see the other side. Oh, I do want to see the out of sight out of mind. I don't want to know about it because I'm going to fix you look at the other hernia side too. We'll talk about that later. I, I, I want to see what I'm dealing with on the other side because I'm either going to. Tell the family they have an incidence of something developing on the other side, or I'm gonna schedule the kid and do something elective on the other side. OK, so what are you gonna do? So they come in, this kid's got, I'm just saying you got a CT, OK, you got getting a CT on these kids. Fine. So, but you're getting it because you're going to change your management. So now you have your CT and you see blebs on both. You see your pneumo on the one side and blebs on the other side, right? You're going to do bilateral vats at the time, you'll do one side at a time. I'll do one side and then I'll, and then what, then I'm gonna do the other side. So you bring him back without it, without him getting a pneumothorax on the other side. Absolutely. Well, if you look at the adult thoracic literature, that's not usually the paradigm. You, you fix the side with the blebs that's symptomatic. You verify that the other side has blebs, and then if they get one pneumothorax, that's the indication to go ahead because they don't always get a pneumothorax. I see. So now that's finally an argument that I could maybe go to my partner Dr. McCallum's technique, which is this is what we argue about because I don't get scans. But that makes sense. So I won't necessarily treat that side, but if they come in, I don't need to waste time with the chest tube. I go straight to bats. So I would argue the first time out, if you're just gonna put it on the first time out, put a chest tube in, doesn't matter even if you see a little bleb or not, or does it? Well, you know, you do a primary vats if you see a bleb on a first timer. I think in this day and age we do. Before the era of, of, uh, vats and, uh, thoracoscopy, it was a thoracotomy you had to do. So the rule of thumb was I was a thoracic resident was you waited for a second pneumothorax and then you went in and did a little anterior thoracotomy, took out the blebs, and roughed up the pleura. Today I think that paradigm is a little more aggressive by doing it the first time, but I don't think anybody. Can I don't think it makes a lot of sense to say you're going to prophylactically do the other side. I think, I think that's, I think in some kids you do. I think you have the discussion with the family and the child. I mean, I did a girl a few summers ago who spent 2 months hiking in the backcountry. That was her plan. She was, but that's a, that's a little bit different. But, but I think you still, you, you can have that discussion with the family. You have to, you know, talk to them about it. I have to, I don't, I don't think it's wrong to have that discussion, but I think it's reasonable to one minute left. One minute left, Dan. So do you have any, uh, I think this is a big controversy and I don't think this is near as controversial as I would. I think that has a role that we should be thinking about picking picking a pneumothorax size, you know, we're estimating 25% in simple aspiration. This, I don't think is near as controversial in terms of what we do with this. I would agree with. With Arnie in that unless there was extenuating circumstances such as Steve's kid going hiking or somebody's traveling to sub-Saharan Africa, I would probably not do anything on the left side in this. So rapid fire, what do you, what do you do like for the contralateral, no, no, asymptomatic, no, no, no, for the vats. How do you do the vats for a pneumothorax? What, yeah, so yeah I do, I do an apical wedge with, you know, thoracoscopic apical wedge and then rough up the, the pleura, and then depending on if this kid's been out and had a couple of chest tubes, then I would probably also consider top pleurodesis. OK, Lou, we just rough it up, rough it up. Say no talc yet. Yeah, no, yeah, no, no tal, right. Remove the blebs and rough up the plural with a scratch pad. Yeah, I remove the blebs and I do twel. Would anybody do doxycycline? I did before. No, I mean, the, the talc lap thoracoscopically just snows so beautifully everywhere. So what do you do? But I do talc, but I want to try tis seal. To seal goes away. Yeah, yeah, well, they, they, they, they say that if you rough up the edges and then you apply to seal it, it might, they're not advocating that, but I, it's just more expensive than, yeah, Jay. I usually just rough the edges, mechanical, mechanical, mechanical, but I also mechanically do the visceral pleura as well as the, the parietal pleura. Oh, that's different. You're gonna get a lot of air leaks. Well, I, I don't go to town on it, but, but clearly there's an, there's an abrasive process that I think improves. I, I've gone back on some kids that have had that have been recurrent pneumos that have had the pleural roughed up, and it looks like no one was ever there. See, I quit doing. I'm the one who quit doing it. It's as if no one's ever, if I see blebs and I get the blebs and staple them, I don't do pleurodesis. Has anybody, has anybody operated on somebody who had talc put into his chest and had to go back in for a thoracotomy? OK. Would you describe that as funny or not funny? Can I, can I ask, this is the that argument, this is the argument I don't get about that. Are we doing it or not? So I get that no pleurodesis. I get. Pleurodesis, but what's this half pleurodesis? Like? I want it to sort of stick, so I'm not going to do something where it's going to really stick. I want the top third of the chest, not the entire chest, it probably doesn't work. That's the OK, so you only do pleurodesis on the apex, 4th and costal space up, OK. The way you do a pleurodesis with a scratch pad is you see little blood, you know, blood vessels becoming prominent on the. Floura, when you've got to that point, then it'll stick, but to pull talin in this day and age is, I think, absolutely wrong. This might be my second management change today. Yeah, but you know what are you, what are you doing really, because we're, we're saying that these are congenital blebs in these kids and we've resected them. So you're looking at the top of the lung and you're saying there's no more pathology there. But you, but the question is, is that you don't see the blebs, and if you've resected the pathology, why are you doing something? Your lungs collapsed. Are you sure you resect so I've done what you did before when I saw there's a whole school of thought that agrees with that. Just take out the blebs. My question is, can you be sure you removed all your blebs? That's the only question. Well, I deflate the lung and then have watch as it comes, reinflates, have anesthesia do that a couple of times, picked up blebs, particularly on the edges of the lower lobe in that way. I, that's actually what I do. You seal the blood. I seal them. I don't you put a stapler because then you get away with a 3 or 5 millimeter incision, although now they're 5 millimeter staplers, so you can do it, but uh you can seal it and get the same millimeter sealer, and then just boom, you're done. I remember I put chest tubes in? Yeah, yes, OK, so we got, we're on break now, right? We got a break. Yeah, although, although we did a study to show that you don't need to, so we did a combined study showing that there was known for, I think, how many patients did we have? 350 patients without a chest tube, and there wasn't a single I mean those were just so that you put chest tubes in or no this was in a. I This is in a staple cohort. These weren't necessarily pneumothorax patients. These were, these were not patients. They were not spontaneous, those were for lung biopsies. They weren't pneumothorax. We're talking to a worldwide audience and in your institution and your institution, you're going to catch. Teenager that's dipnik at 2 in the morning, but that's not everywhere. Good point. So if you are, I mean, all of us go different places. So if you're not gonna, if, if the nursing care is the kid's mom who's asleep and tired from everything that's going on, you can't reliably say, OK, fine, my nurse is gonna catch it. So you have to be a little bit careful. I mean, the nursing care is phenomenal. Would you do them at the same time? Do one side, slide them over, and then do the other side. I don't think so. I mean, for the contralateral side, yeah, no, OK. So, but, but my only argument about the, the talc is it's like you were saying, why do a half it's like if you're there to do if you ever need to go back in that kid's chest when he's an adult, it is, it is if you've never gone into a towel chest, it is, it's awful. In fact, you can't get back in. They're gonna go. For a plural to get back in. So, so I had the conversation with our adult thoracic guys, and, uh, and they, they said, they said it's OK. It's not. I spent, I spent a year. No, it's hard. No, I know, I know it's hard, and I tell you, it's, it's miserable. They said it's not easy, but it's doable.