Spontaneous Pneumothorax: Lung Lesions

Uh, this is more of a, a point of discussion and, uh, as, as Todd pointed out, um, trying to get an idea of, of, of various, um, modes of management. There is some disagreement in our own group and the literature, I don't think supports, uh, anything clearly. Uh, so, let's discuss a little bit primary spontaneous pneumothorax. So, uh, we'll start with a brief case presentation. If you would roll that slide over for me, please. Uh, no, uh, so, OK, so, I'll, oh, yeah, I'll do it for you. Hold on here. Yeah, I don't have a. Got it. Oh you went to. I did. Did I? Someone did. Oh yeah, yeah, yeah. OK, sorry, I'll take care of it, Stephan. I got it. You've spoiled everything. This will be brief, but 14 year old young man, uh, presents, uh, not uncommonly with acute onset left sided chest pain and shortness of breath. Uh, the young man has no significant past medical history, and his vital signs are, uh, stable, um, with, uh, um, heart rate of 92, respiratory rate of 24. He's in the emergency department on 2 L nasal cannula with 02 sats of 94%, and on, uh, physical examination, he has, uh, moderately diminished breath sounds on the, uh, left chest. So an X-ray, I'm not sure how well that projects, but I'll, I'll put some arrows just to outline, um, uh, probably a 20% plus minus pneumothorax on the left side. Uh, so we, we thought we would start the discussion. I'm having a hard time rolling that slide. I can do it. I got it. OK, uh, there you go. With just a polling question on how this would be managed across the board, with choices being number one, observation, admission with repeat chest X-ray within 24 hours, uh, tube thoracostomy in the ED, uh, tube thoracostomy under anesthesia in the operating room, or VATs with tube thoracostomy as a primary procedure, uh, and then we threw other out there to see. I OK, so, so while this poll is, uh, revving up, uh, it looks like we lost Liam's camera, but, uh, let me go to, um, Marcello. How would you handle this, Marcello? We would, uh, here in Argentina, uh, we would, uh, just, uh, uh, uh, do option two. We would just put a tube in the emergency room and wait. OK, uh, uh, Giovanna. Uh, in our country we use with us, uh, so limited thermothorax to wait 24 hours and then, so option one, option one, Alan, Steve, I would do option one. Option one, which is observation, Steve, observation with repeat X-rays 24 hours later. OK, but he has chest pain. He came to the ER, so, yeah, he, he would, it would be some version of option two. Does it matter what time of the night it was? That would give him more chest pain. With that pigtail catheter, probably. Pigtail catheter, does it matter what time of the day this is? Oh, I wouldn't put it in. Uh, Yama, what happens in Tokyo? Yeah, observation option one. OK. All right, very good. So it looks like from the audience it looks like 40 uh 50, it's pretty split between option one and 2, 54, so it's pretty split there, Mark. Interestingly, it's pretty interesting, right? Uh, interestingly though. I don't see what I, I look how, look what people wrote about option 3. So only 1% of those polled would, would actually do a VATS right now on this patient, an immediate VATS, uh, which is, I think, a point that I want to get to because that is actually what I always sought in general surgery was when these patients came in, we took them to the operating room for a VAT. So I, it's a, it's a great, where did you train on the moon. Uh, so, uh, let's, let's go to, uh, the, actually, hey Todd, one other question. Let's ask the, let's ask the group here, uh, uh, patients that undergo chest tube placement, let's assume now that the child doesn't improve his pneumothorax or is persistently symptomatic. And he's gonna need a chest tube of some sort. What percentage of those patients get a chest tube under local anesthesia or go to the operating, excuse me, yeah, local, or go to the operating room under general? Let's get a chest tube. Let's ask the, um, because that's driven a lot of our, our patient management here is, um, in the older chil, well, in the intermediate age children, um, we typically take them to the operating room to place a chest tube. Uh, which then makes progressive management with VATs more appropriate. All right. What is the, so, let's ask, uh, Marcello. I'm, I'm sorry. I'm sorry. I was talking, I'm sorry. You know what? You got to pay attention. Have a discussion here, but I was trying to get a beer. Wait, in Argentina it's wine though, right? So, all right, so Marcello, the question was, the question was, because what was your answer? I don't remember, you said you were putting a chest tube in in the ER. So the question is, of those who put a chest tube in, do you do it with anesthesia in the operating room? Do you do it with local at the bedside? If it's, uh, most of these kids are big, uh, kids, like 18 years old, so we would do it with local anesthesia, uh, just there. OK. Local anesthesia, and that's true. I mean, most of them are adolescents, right? Yes, yeah, so that's a good point. Uh, uh, Liam. Liam, Liam, the question is, I, I think in this case, I may have two options. The first one is I would like to perform a CT scan to know better the nature of the cause of, uh, of, uh, pneumothora. Otherwise, I will perform thoracoscopy to find the nature, the cause of pneumothorax, and based on CT scan, or based on thoracoscopy finding, I will decide what I will do. OK. So, we're going to get to that. I want to talk more about CT scans later in your. You bet. Right? That's the next point we're going. So, we're going to get to that, Liam, in a second. You're bringing up the next point. Um, I guess, but the question that, that Mark, because let me just tell you, let me preface it. The argument, why don't you make the argument on, on, or the why, why don't you answer why you're asking that question about anesthesia versus local? Well, because the majority of our children, um, elect to undergo general anesthesia and, uh, maybe we're spoiled regionally or nationally, uh, but most of the kiddos that we see don't want to undergo with their family at the bedside, uh, a local introduction of a, of a chest tube, so they default to the operating room, which is where we do almost everything at our children's hospital. Once we've exposed the child to general anesthesia and have made a 1 centimeter incision in the chest, uh, it's made a very good sense to me to put a scope in to define exactly what the problem is because these kids that, that, uh, either get chest tube placement or observation, 50% of those kids are gonna recur and need additional intervention. And if we've already exposed them to anesthesia, then I'm gonna stick a scope in, try to define a problem, uh, and if, if I do find blebs, then I'll address the blebs at the time. But the point you're making is that if you are a center that believes that you're putting a chest tube in under anesthesia, why not stick a scope in first and see if there's a bleb? That's the argument you're making, which I think is a valid argument if you're doing a job, but you're making an assumption that if they have blebs, they will recur. And that's not necessarily proven. It's not proven, but certainly if you, if you were to take all comers that undergo simple chest tube placement for a symptomatic pneumothorax, of those that have bleb disease, upwards of 50% will recur. Right. But I don't know of a study, maybe you do, that has taken the entire population. Separated out those that have blebs versus those that don't with spontaneous pneumothorax and determines the risk of recurrence for the two groups. No, most of the data is more retrospective looking at, looking at intervention and then, so overall they have a risk of recurrence of around 50%, right? Correct. Second recurrence of about 75s are not, and you can always treat them when they have a recurrence. So I'm not, I'm, I'm not criticizing your approach. I'm just saying, uh, I don't know that it's, it's based on objective evidence that if they have blebs, they're more likely to recur and you need to treat them in their first occurrence. So what study do you want to see? I want to see a study that separates out patients that on their first event, have blebs versus no blebs and look at the risk of recurrence of a second event. Which would be either done by having a CAT scan on everybody thoracoscopy. So, OK, well, and I believe in getting a CAT scan on everybody. Well, this goes to a point you do or do not. I do. OK, we're gonna get. So then, yeah, flip to the next slide because that's the question is when it's time, timing for the, uh, the CT because a lot of people wanted to observe these patients, but you're not going to get a very effective CAT scan of the chest with a partially collapsed lung, right. Uh, may I say one thing, Marcello? Yeah, yeah, go ahead. OK, um, when I say, uh, place of a chest tube, I, what I mean with the local anesthesia is that, uh, most of the times we would just place on that patient, uh, like a double pigtail, very, very thin, um, attached to a hemlich valve. Yeah. Not, not, not a, a, a big piece of chest. To just uh something uh percutaneous, right, I understand the position of it if you have to take it to the OR, if you're there, why not to scope it, and I understand the discussion. Just wanted to say that, yeah, yeah, yeah, but, uh, a question for you, and I, well, I don't want to jump ahead, but to answer you, we're gonna get to that point is I think that almost all of these do have bleb disease and so even if I don't see a bleb. I treat, treat, but we're going to, well, we're, that's actually you're, you're getting to my point, OK, which is, which is that you wait until they have a second recurrence recurrence, and then you treat all of them whether they have blebs or they don't. Correct. And I do the same, but we're going to go ahead cause we're, so here's the next poll question is role and, uh, timing of CT scan of the chest in these, in these children. OK. So, Mark, go ahead and pick on someone. Who do you wanna ask? Do you wanna ask, uh, Giovanna, who's sleepiest? Who, who, where, where is it 0300 in the morning? So I think, well, let's go, let's go to, I mean, so we already know Liam's answer to that, right? Uh, Liam says he, he gets a CT scan on everyone when they come in. Is that right, Liam? The patient is stable. If the patient is stable, and I prefer a CT scan first. OK. If, if he's still having pain, uh, Liam, do you, do you re-expand the chest before you get the CT scan? In other words, put a chest tube or a pigtail catheter in. So ask him again. Can you hear me? Yeah, Giovanna, go ahead. Oh, so I think that, uh, my attitude is to observe the patient for 24 hours, and if the pneumothola will improve, I prefer to perform a CT scan. So you have to decide to do, to put a chest drain or to perform a. So, uh, this is my attitude. So I think that CT scan is important for you to first surgical option, uh. Can I answer, uh, uh, and then I want to go to Alan. I just don't understand. I'm curious cause I'm going to prep this. I don't understand how a CT scan would ever help me. So, I'm just curious because I go by clinical, like if they recur again, I go back in and I resect the apex, whatever I see. So, I'm curious how you want to see, I agree. It doesn't change your management, but it may give you insight into how much disease the person has. So, they may have contralateral blood disease as well. They may have superior segment of the lower lobe blood disease and upper lobe. They can have a variety of Interesting. Things that you can see on CT scan. How often have you seen the lower lobe, uh, labs? You have seen them? Yes. Yeah. I, well, I, CT scan, Often, the way I use it is to help the patient or their parents make an informed decision. Like I had a kid who came in spontaneous pneumothorax. We watched it, didn't do it, didn't get, you know, it didn't completely resolve, and she was going away on a, you know, outward bound kind of thing where she was going to be up in the hills for 6 weeks away from medical care. We got a CT scan and it showed she had bilateral blebs. So, you know, you make an, make an informed decision. In her particular case, the risk of being out in the wilderness and getting a tension pneumothorax is higher than if she was in the city. You know, doing it. But I think, um, in general, I'm not sure it, it makes a, a huge role in the, in the change of management. Um there's a question about how sensitive is the CT scan for blebs. It's pretty good, actually, from what I've seen. I don't know. Once you get the lung reexpanded, yeah. Right. You got a comment you wanna make, I, I think there's a recent study out from Saint Peter in, uh, in Kansas City that looks at just that how, how, uh, how accurate is a CT scan of defining blood disease, and he found it was very, very poor, uh, whenever he looked at that in comparison with subsequent thoracoscopy. So I think we're missing, like you said, almost all these kids, I think, are gonna have blood disease whether we define it early or not, or, or whether just because they have blood disease they recur. Maybe they don't, but I think the majority of them do have some degree of blood disease. But that's my point. Blood disease doesn't necessarily mean recurrence. No, but if I were given a choice, if I had an active kiddo like Doctor Rothenberg pointed out, who's gonna be on, so would you treat blood disease before a second recurrence based on the presence of bloods? Yes. Yes, uh, well, I would discuss it with the family, but, but the, the idea I think of, of a, of a, a child at a football game or on a trip or at school, this is a big issue for these kids, acute onset pain, it changes their schedule. They rush to the emergency room. Well, you treat them on the admitted 24 hours. You're gonna be doing, uh, potentially a number of unnecessary phlebectomies and. Um, Pleurectomies, right? The scope is going in. We have to define whether they have the labs. Right, and if you treat every kid that has blebs, and you say that most of them will have blebs, then you're doing a 50% rate of unnecessary. If you do 100% of kids, you know. Present to you, your, your point's well you're doing a lot of unnecessary the flip side of that is you're saving 50% of kids from an untimely recurrence, uh, of a potential, but they usually don't recur when they're off on, on top of a mountain somewhere on an outward bound trip. They usually with Doctor Roth and they usually recur when they're at home. Have you ever seen someone come in in extremists? I haven't. No, I don't think I have. Pain. They usually come on pigtails, yeah, but not, uh, from an outside extremist extremists. And by the way, guys, out in, uh, everywhere else, chime in, be, uh, interrupt us, be rude. We don't, don't wait for me to call on you. I'm trying to be rude. Yeah, I mean, sometimes you got to just yell to shut us up, so we're just going to keep talking unless you say something. Uh, OK, OK. All right, I'm getting told to, to hurry along. So let's, let's go on, um, Mark, uh, so we'll go to the next slide here. And we'll just hurry this up. OK. Let's make the assumption then that the patient does have blood disease based on a CT scan. Uh, the approach with VATs for unilateral blood disease, uh, As far as panel goes, uh, is anybody doing single port surgery? Uh, far and away the majority, uh, are doing multi-port, but there are some articles written about single port and its efficacy. Yeah, I, I've done one case and reported it and I've never done it since I did my own report. OK, we, we, we, we've done a couple of cases, uh, not with single port but reducing the number of ports by placing a magnet, uh. So we grab the blade with a magnet and just uh move it all over the place and just uh in this way we, we would just say to put uh another 5 millimeter port so we can perform. Um, one of these resections just with 15 millimeter port for the camera and then a 12 millimeter port for the scope for the stapler and and and just that. Marcello, you're so predictable. I knew you were going to say you're going to use magnets somehow. Uh, all right, um, any comments about this before we go to the next slide from anybody? OK, let's go to the next one here, Mark, which is. This here Yes, as Doctor Flake pointed out earlier, one of the reasons I think CT scan is useful, uh, is, is diagnosing blebs on the contralateral side. And so that brings up the question, if you do have a patient with bilateral bleb disease, uh, and, uh, for argument's sake we'll say second recurrence or first recurrence, second episode, um, how are you going to address that? Um, one stage or two stage procedure and then timing, uh, of the second procedure. I mean, I, I do symptomatic side only. I don't know what you do. Uh, I would do both sides. If they, if I saw blood disease on both sides and I'm doing an operation. Same time. Same time. I would, I would Discuss it with the family, but I would do both sides. Yama on the symptomatic side. OK, Liam. Uh, we're not hearing you, Liam. Go ahead. Uh, I, I will do bilateral patch. OK, bilateral, which seems like we're having a split here. Giovanna? I do bilateral because I did in the past the symptomatic side only and I had a recurrence on the contralateral side during the immediate post-operative period, so I prefer to do bilateral now but I am looking to the importance of the lesion at the CT scan before. OK, so this, I mean this just, this makes the argument for getting a CAT scan if you're gonna do that because without a CAT scan you would never know that there was contralateral plebs, Marcello. I would, um, just treat the symptomatic one. we just have a patient like this right now at the hospital. If, if the patient is symptomatic, it's just the, that side. If it's just a CT scan, uh, observation and he's asymptomatic, we send him home with a, with a blebs. Unless he has a pneumothorax, then we will treat it bilateral. OK. It looks like, uh, 70% of the audience, uh, would do the symptomatic side only. Someone had a comment? Yes. Thought I heard someone say something, OK. Um. Mark, do you have another, let's see what the last, I think this is additional workup. We probably don't need to touch on that much more, but I, I would, I would be curious as well, uh, technique. More and more people are using chemical pleurodesis instead of the mechanical pleurodesis and finding better results, shorter OR times as well as decreased recurrence rates, and still there's a pretty high recurrence rate even after VATs with blebectomy and mechanical and or chemical pleurodesis. So, um, are people reinforcing staple lines? Are we using talk? Are we using, uh, um. A mechanical abrasion. Can I start with this one and then we'll go? I, so I learned from initially I used to use the little bovi pad thing which I don't think, I think it's fun, but I don't think it does anything. Steve, you taught me, I don't know if you still do this, where you actually really do a pleurectomy. You actually apical pleurectomy, apical pleorectomy, which. I loved and did for the last 5 years where I just would score it and pull it down caused a lot of pain. I don't know if you found that. Maybe it's my technique, but it seemed like when I would do that they would be hurting more than if I used talc. And when Scott Bollinger, my partner when I was at Rainbow, taught me this uh aerosolized talc. Do we have that here? Yeah, we've started to use and you just put the chest tube in, squirt it down the chest tube. It snows inside the chest, and you're done. It takes a second. I'm curious what, you still do that or? Oh, I don't, I don't like talc. OK. Cause I think you're doing a, a random massive, Chemical pleurodesis and you don't know if anybody's ever going to be, need to be in their chest again. But then what's the purpose of your apical pleurectomy? Because it's only the apex. The apex of the lung. Oh, interesting. And I think. Putting talc in a kid is a bad idea. OK. Yeah, I save talc if I have a recurrence with the other approach. Right. But, which is, um, I actually use a hydrostatic pleurectomy. So, you can basically, this is a very cool technique. OK. So, you make a little, uh, incision in the pleura. OK. Um, and you put a suction irrigator into the opening. Yeah. And you, you seal the pleura around your suction irrigator. Yeah. And you irrigate. And it basically dissects the entire pleura. How does that help? And then you can grab it and, and you rotate. You just roll it up and you can basically dissect the whole pleura, OK, you know, even, even more than an apical pleurectomy. You get like a hemi. Thorax, pleura. Why is that better than talc? Uh, I don't know that it, uh, I think talc's probably better, but I think I agree with Steve, you know, you do talc in there and if you ever need a thoracotomy for anything, you're really solidly adhesed. Don't you think it would be with what you're doing too? Uh, uh, I don't know, not as much, I would hope. OK. And it wouldn't be the entire pleural space, you know, it's more the upper component of the lung. OK. Steve, when you do the apical pleurectomy, how far down? How many rib spaces down do you go? Oh, it's just a few. I mean, if it's just a, if I really see apical blebs, I'm only going down to like the third inner space. What if you get in and see no blebs at all? Your scope's in there and then no blebs at all. That's a tough problem. I always take the apex. So, yeah, I seal the apex with a ligature. Um-hum. Oh, really? And then I do an apical plenectomy, yeah. Wait, so you just come across the apex with a ligature? I don't, I don't cut anything out. I just seal it. He, he can't resist ligature. Yeah. OK. You, oh, is there,