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4 PERFORMING ORGANIZATION REPORT IUMBER(S) 5 MONITORING ORGANIZATION REPORT NUMBERkS)

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6a N4AME OF PERFORMING ORGANIZATION 6b OFFICE SYMBOL 7a NAME OF MONITORING ORGANIZATION;SAF Sch-ool of Aerospace 1 (if applicable)

Med ic ine j PSAITSk'M/NG6 c ADDRESS (City, State, and ZIPCode) 7b ADDRESS (COt, State, and ZIP Code)

Aerosl a:ce MIeical Dvso ASC)Sno-,oks Air F-orce Bae X7235-5301

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-erosnace MIedicin jLASAN8c~ A DCR ES S (ir-y State, and ZIP Code) 10 SOURCE Or FUNDINC NU'vBERS

,e ros --,a ce M.edical Division (AF.-SC) PROGRAM PROjECT ITASK WORK UNITi oroc Is Ai r Force Base, TFX 78235-530Dl ELEMENT NO No NO ACCESSiON NO

ITiTLE (include Security Classification)

incrat--ou- --eurrj-thorax in thec U.SA- JAircrew Population: A Pe trospec ie tu

2 PERSONAL AUTHOR(S)-2t-acite, DF

13a TYPE OF REPORT 13b TIME COVERED 14. DATE OF REPOPT (year M~onth, Day) Ii D0 G E COUINTC: rrV' FROM 1"52 TO 1'-) 84 i- 2 ctober 11

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... cl)5ubMitteA t,-)Aviation, Space, and Environmental M-edicirje, 7 (l10 ptl) : -D3n)-049 VA

COSATI CODES 18 SUBJECT TERMS (Continue on reverse if necessary and identify by block number)E'D GROUP SUB-GROUP Spontaneous Pneumothorax (SP) , !-lIight Crews, Pvspnea,

Respiratory Oisi-i-,es, Pu-Iq,-a '1iea Plenrectoo

Surgery, Ch-est Painv Blobs, Bullae, Cysts

9 ABSTRACT (Continue on reverse if necessary and identify by block number),ontaneous, 7!ieu.mothorax (SP) is infrequently di-agnosed in aircrew personnel. liowe"- once

ii ~n~ed aircrew di pos it ion becomes a serious concern. Toevaluate thlis problem,-i Ii f rat fcr i re v iew was, conducted to nut the disease into proper rPersecot ive. A u-tinar

r.a t -r , ;'nt- t n a I I i .r'I tho Fozited 3 LaLes Air Force- -riye p ilc %-ho had su erd

or, -r t c)I in- a retp ro) . yg view of problems and situations ,, ficountered. The followingaIrea weoi stigated: recurrences hitweigjht, age., s~mokin~g history,, initial medicn,,l

manarni--ment n-'mpnomatology, activity at time of oc-currence, relationship to flight duties,_trtmen' ;ive n and personal/family hi story, of lung disease. A review of F'AA, mil itary, and

lsregjard tug personnel with a history of SDI was also done. it is concluded that........ :Oqnized hazard to ai rcrew personnel. Once an SD has been diagInosed in an

iv dua ,ne/eeshould be grounded from further flight duties until either ) years, have/.la:5.') iout i recurrence or there has been a bilateral parietal pleurectomv.

20 DOSTRIFIUTION 'AVAILABILITY OF ABSTRACT 21 ABSTRACT SECURITY CLASSIFICATION[9 UNCLASSIFIEDfIJNLIMITED 0l SAME AS RPT 0 DTIC USERS Unclassified

2'a NIAME OF RESPONSIBLE INDIVIDUAL ~22b TELEPHONE (include Area Code) 22c OFFICE SYMBOLJames P. Hickman, Jr. I s 2 536-2811 USAFSAM/NG

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Aerospace Mcdicai Association. Washineton. DC '

Spontaneous Pneumothorax in the USAF r "Aircrew Population: A Retrospective Study

91-10024 V MI. \OGE. .ID. M.P.H.. and R. ANTHRACrIT. M.D

I111tt li1I I~ 11 j~~ Navaol Hospital. Cosrpus Christi. Texas

%'cX;r %M. A1,TIIRACITE: R Spunioneoui PneumnIhnfal in fhr that population is composed of ounz. healthy males (4.L'SAFairrrer-apnulation arerrospecritevudi- Aviat. Space Environ CK9 bu uto vr () \oung men may have%lcd IV~t. 57 91t4"Y-J9).Aou otofeer

Spoto ,auus pneumnothoraat (SP) is inrvqently, dignosed in a history of SP (93). The actual incidence is probiblvaircrew peronnel. However, once it is dianased. coeo hieher than that reported since not all physicians reportclispoittion becomes a serious concern. To evaluate this pnDW1e, their cases of SP and, if symrptoms ..... mild, a patiento literaurwe review was conducted to ow owe disease ito proper may not consult a physician (28)l.perupecirre. A questionir~le was then sent to all aircrow in The frequency o f SP peaiks at two differentthe United Stts Air Force waiver file who had sufferied! SP iorder to gain a resietv vie of prl sadstain age group--nc large peak at age -0-'-9 years and a1encountered. The following areas were invsigated: recurrences, smaller peak at age 50-70 yecars (4.15.17.20.30.35,44,height, weight, age. smoking history, initial medical management. 46,.49.62.63,70.74.88.90.91.95. 9, 105). The youngersiymptomatology. activity aftlime of occurrenice. relationship to age group is comprised of voune. healthy males usua -llsflight duties. treatent given and personai/fosny history og asmdt aesfee utr fa pclsb~ualung disease. A review of FAA. military, and NASA guidelines asmdt aesfee utr fa pclsbluaregarding personnel with a history of SP was also done. It is bleb or bulla (3.6.9.12.1417. -0.24.-5. 2.30, 36, 48.62.concluded that SP is an unrecognized hazard to aircrew personnel. 63.64.70.77.83,91.95.109). There commonly is noOnce an SP has been diagnosed in an individual. he/sh, should prior history of disease, pulmonary or otherwise t62.be groundeds from further flight duties until either 9 years have 70) and occasionally no blebs are found at surgery (70).elapsed wihout arecurrence or there has beenoabilateral parietal Aia ulco lb r ut omni h eea

PO~tIWV~population (50) and are usually bilateral (24.:5.26.33.

39.48.57.77.95.113). Some feel that young. tall, thinSPONTANEOUS PNEUNIOTI-IORAX (SP) is an males mw~ have an -heritable*' dciect that is exacerbatedS entity of eytreme importance in the aerospace by the greater vertical length of the chest. making the

community. The condition may bring about sudden apex more vulnerable to gravitational stresses (26.107).incapacitation when least expected. SP is usually due to an underlying disease process in the

SP is a relatively common er:"ty in ta~l. th~n. ycung, older population (4.I7.09 - This older age gr~.'ohealthy males (17.43.70,90). The incidence rate ranges not be considered further.from 2-46 per 100.000 (18.48.70.77,112.113) and is felt SP appears to have a predilection for males. affectingto be increasing (17.27,32). This rate has been found to up to 5-40 times as many males as females (12.20.24.26.be higher in the military population. primarily because 4.6.55.60.70,91.95.105). Family history of pulmonary

problems or SP does not seem to be an indicator for_____________the subsequent risk of SP. although a familial incidence

This manuscript was received for review in June 1985 and was of 2% has been reported (70. 105). Activity level ataccpted for pubitcausot in Augus 1915. tetm fS osntse oaf

CDR V. M. Voge. MC. USN. is Head. Aviaaion Medione'Whitarr h ieo Pde o ee oafv::. iecMedmise Department of the Navail Hom- at Copu Cau rX i ot SP. About 75% of SPs occur dluang light or

s:ena rasi'n rr.cus to t-&JR Volle at Box M~. Ode.. TX 78370. sedentary activity or during sleep and are apparentlyThe opiuaons herein arm those of the suthori and not the USAF, unrelated to stress (16.17. 18.25.28.39.40.56.70.75.95.

*114vsflnof. Space, and EnronmwnuaI.Atrascuwu ocrotwr !WtA Q-IQ

RE OSpECvE STDY OF SP-V i & i r-

105.112). Some series relate a greater incidence of Pleurodesi is frequently used in recurrent SP (OR,

SP in smokers: up to 88% of those suffering SP 99). Pleurodesis may be mechamcai or chemical.

also smoke (14.20,25.80). Other studies disagree Both methods have their advocates and detractors.

(112). There is no predilection as to which lung Pleurodesis causes intrathoracic inflammation !o the

is affected (17.19,54.61.70.84.91,95,105, 112). About extent that the lung fuses to the thoracic wall obliterating

2% of all SPs are bilateral simultaneously (23,30,46, the pleural space (55). Many authors prefer mechanical55,70.91.95). Such a condition.even without associated pleurodesis to chemical pleurodesis because the former

pulmonary pathology.is potentially fatal (5.21.62.112). is less painful and -more effective- (20.52.91.99,105.The mortality rate from SP. overall, is less than 1% (18. 112). Others feel that chemical pleurodesis--{he insuf-

105). flation of a foreign substance into the pleural cavity--is

Svmptomatology of SP usually consists of a non- the most successful method of treatment (20.30.42). In

productive cough, pleuritic-type chest pain, and dysp- spite of the multitude of chemical agents used. none has

nea. which may or may not be persistent (14,17.18, proven satisfactory (1.2,7,8,13.18,20,30,35,42,47,53.25.35.70.75,94,95.113). The symptoms may be of 55.69.-70.71,79,90,92.97.98.102.104.108). The major

sudden onset, severe and life-threatening, with severe rea-.ons for chemical pleurodesis' unsatisfactory results

respiratory and cardiac insufficiency., in up to 10% of are that adhesions are either inadequate or produced

the cases,'(14.32.70.112). About 7% of SP patients do on the diaphragmatic and/or mediastinal surfaces where

not even notice symptoms which might alert them to the they are of little value (4.29,41). There may also be

possibility of an SP (17.18.70). Young individuals, even increased postoperative morbidity (8,17.24._9.30.36.

with the total collapse of a lung. may not appear sevecely 42.-4,.54.58.70,79,102.108). In spite of its morbidity.

ill (46). Symptoms are more likely to be present if the chemical pleurodesis cannot be guaranteed to prevent

SP is bilateral (46). further recurrences (10).

On physical examination, the patient may appear Many thoracic centers have abandoned pleurodesis !n

to be in no distress or may be in acute respiratory favor of parietai pleurectomy because of pleurodesis'

distress (75.113). There is usually no elevation in body high recurrence rate (97). The recurrence rate

temperature or of the erythrocyte sedimentation rate after parietal pleurectomy is 0-1% (4.20.30.70.90.95)(70) It would appear that thoractomy with resection or

The diagnosis of SP is confirmed by chest X-ray (38). obliteration of blebs and parietal pleurectomy provide

There is no radiological evidence of pulmonary disease the best protection against both persistent air leaks

in about S0% of cases. and no evidence of a previous and recurrences Sl,. inu. Siultaneous bilateral

SP in well over half of the cases (12.17,30). Patients thoractomies are a major insult to any patient but.since

are most frequently misdiagnosed as having the flu. an the contralateral recurrence rate is so hgiti. it is oni,

acute URI. a "circulatory disturbance."or a myocardial prudent to repair both sides simultaneously (6.77) or

infarction (46). separately.

The treatment of SP may be conservative or surgical. Panetal pleurectomy is feb by many to be the

Conservative therapy consists of bed rest and/or treatment of choice in persistent or recurrent SP

needle aspiration (thoracocentcsis) and/or a chest tube. for those who are sufficiently fit to undergo a

Surgical treatment consists of chemical or mechanical surgical procedure (4.35.42.65.91.95.96.112). Parictal

pleurodesis. paretial or complete panetal pleurectomy, pleurectomy creates a uniform inflammatory surface

andlor surgical excision of bullac and blebs (62). There with secondary adhesions of the lune to the endothoracic

is no consensus as to %hich therapy is the best for fascia (20). This procedure is felt to he the best

nonaviation personnel. in spite of voluminous literature chance for a permanent cure and that it should he

on the subjcct (99.102). performed early (4,77,95). Even though thoractomv

Conservative therapy is unacceptable in the aviation and pleurectomy are major surgical procedures. the

community because of the high SP recurrence rate after morbidity and mortality are no greater than that for

such treatment (27,42.2.113). chemical pleurodesis (42.95). The complication rate

Surgery for SP is usually indicated when the lung is extremely low (4%). Some studies report no

fails to reexpand after 3-10 d, recurrent SP. tension compiications, to include recurrences or deaths (..20.

pneumothorax. chronic unexpanded pneumothorax. 29.30.95.96). Postoperative pulmonary function tests

hemopneumothorax that fails to respond to aspiration, have been routinely reported as being normal even

bilateral pneumothorax. fistula. or the presence of after bilateral Frocedures (3.4.20,29,30,96). 'arietalthin-waleed. air-containing cysts on chest X-ray (11. pieurectomy is net a radical procedure since there14.20.23.24,65.66,70.,3.%bi.3.99,102.112.113). The is little additional trauma compared to mechanical or

goal at operation should be to remove the ,tu sative chemical pleurodesis. The pleurectomy may be partiallesion and/or to obliterate the pleural space by the or complete (4.,2O.^'S

simplest possible technique (20.63). Surgery may be The most common and important complication of

performed through a large thoracotomy or median SP. recurrence, needs special consideration (14.29.30.sternotomy (buateiai uScb .. Ii" JA' : ":..i ./ ' . 71. ;7, l166) Moubt .,.nts :.ucv -,:SP ,-,,1

parietal pleurectomy) or a small lateral incision in the have a recurrence (71). The time between recurrencesfifth or sixth intercostal space (24.77.82). It is generally is usually less than I year. (17.39.48.62) and two-

agreed that surgical siviphysis does not interfere with thirds of recurrences will appear within the first 2

lung function (17). years after the initial occurrence. The average interval

040) ,afw" ~ee.'. E-t .' ' mall'frdicjne"O r -[006 9

Lh1-,, .. .. . .. ___. ... . -

RETROSPECTIVE STUDY OF SP-VOGE & ANTHRACITE

between SPs is about 2.3-3.1 years (17.18.42.74). The onset of SP is more likely aunng n'nfl.'ng

However. the interval for first recurrenc can be as hours (28.39.94). There have been reiativelv few

lone as 10-ZI years (17,74). The reponca recurrence case:, -eported during flight (12%) or in low-pressure

rates very widely. This wide variance is usually due chamoers (LPC) (4,17.25,28,34,39.4851.102).to a) length of follow-up, b) whether the SPs are Conservative therapy is not appropriate for aircrew

suspected or radiologically proven, r) interpretation personnel because of the known high recurrence rz'te

of interval history., d) inclusion or noninclusion of of SP and its attendant dangers at altitude (27.62.113).

contralaterai episodes, e) noninclusion of previous Some authors feel surgical correction is the treatment of

episodes before treatment-an -initial episodc may choice, even in those who have not experienced an SP

not be a patient s first SP. f) type of therapy given but who have significant bleb formation with expansionfor the SP. and g) size and composition of the study at altitude (39).group (25,49). Each recurrence significantly increases Return to flight status after an SP should be basedthe chances of another episode (25.49,62). First on a thorough aeromedcal evaluation and examinationrecurrence rates with conservative therapy vary from 10- (28). lThe civil aviation and militarv recuiations60 (17.',S.2-4.29.30,34.37.41.45.49.51.57.59.62.70. governing the treatment/disposition of an aircrewman73.80.85.87.89.90.95.97.101.102.105).and tend to be with an initial episode of SP vary greatly (31.67.72.high because the blebs that originally caused the SP are 100.103).still present. Thc frcqucncy of second recurrence afterconscrvatiie therapy is 17-80% (14.42.73) and for third METHOD

and fourth SP ,. 9O-100% (1-4. 18.24.30.73). Of patients A retrospective questionnaire stud% was carried out

with SP. lt-2tW% will develop SP in the contralateral by reviewing the cases of 147 aircrewmen with a history

side (17.30.61.7S.S0.90.97) and 2-3% will experience a of SP in the USAF Waiver File at the LUS. Air

simultaneous bilateral SP (30.45). It is generally agreed Force School of Aerospace Mcdicine. Eighteen-item

that patient,, with one or more recurrent SPs should questionnaires were sent to each involved aircrewman

hi|ve some form of ,urgical treatment since recurrence to ascertan the peculiarities of his expericnce.

rsk i% No high (2t1.32.62.76). Chemical or mechanical We conducted a literature search for general infor-

plcurodeci, hase hich recurrence rates varying from G-. mation. signs. symptoms. incidence, complications.()r; (17 ').30.42). treatment modalities, and recurrence rates of SP

From this we hoped to determine the most reliableAeromedical Aspects therapeutic modality to ensure nonrccurrence in the

SP ma, be innocuous at ground level. It is neither aircrew population. In conlunction with this. we

common nor important statistically for the ground reviewed the U.S. Navy, U.S. Air Force. U.S. Army.

armed forces. The problem is more serious for NASA. and the FAA Rcgulations concerning the

aircrew members exposed to the added hazards and disposition of aircrewmen suffcring SP (Tiblc I

risks of fn ing. with the possibility oi incapacitation RESULTSand subsequent inability to control the aircraft (25. Of the 147 individuals identficd in the USAF Wkaiver

27.28.68. SP can cause JistraCtion because of ches_.t File as having suffered SP. 2 wkere excluded Irom thepain. dvspnea. and hypoxia (28.42.68). In flight it can survey for administrative reasons. 2 wkere deceased. andcause an aviator to reiinquish his duties or to abort I refused to answer the questionnaire. easing a possiblethe mission. or can cause a serious mishap or a malor 14. Of these..1 were excluded because they suffereddisaster. In single-scat aircraft. SP may cause loss of life a . t hese. pn e eo exoua e er th a s uffered

or loss of the aircraft. The cause of the mishap may be a traumatic pneumothorax rather than a spontaneous

erroneously labeled as "unexplained" or due to "human responded to the questionnaire for an 81 creturn rateerror." Therefore, one should take a conservative Of these aircrewmen. 411% are still actisely flying. Theattitude when grounding aviators with blebs. bullac. follow-up time vaned from less than 1-32 ,ears with ancysts, or a .hstcrv of SP (27.28,39).

The etiology oi SP in aircrew personnel appears to be average follow-up time of 10 yers.

similar to that of the general population, the predispos- Recurrence

ing pathology being more important than environmental There werc 151 episodes of SP in the 112 aircrewstresses (28.39.94). Others feel operational flight may members responding. Of these 112. 287% experienced ainduce SP in an individual with preexisting pulmonary first recurrence. 23% of this 28% experienced a secondmalformations. e.g. blebs. This is of concern since recurrence, and 14% of this 23% experienced a third,he individal with malformations is exposed. over the recurrence for a total recurrence rate of 35%. No oneyears. til high G, rapid decompressions. pure oxygen in our retrospective study reported more than four SPs.brel'ihir;! e ,i.... - .... al The average :e ors, c-jrren': -A-7 2' ,-:.s. v fistforces. and/or chest restriction due to anti-G suits (27. recurrence 31 years, at second recurrence 34 years. and86. 11!). The concern is that. at altitude, the involved at third recurrence 36 years.lung ma! collapse completely and/or form a tension The time interval between initial SP and recurrencepneumothorax (27.42). 1 one continues to fly with a was skewed toward somewhat longer intervals comparedSP. further compression of the lung with mediastinal to other series (17.18.39.42.48.62.7.0. Of all recur-suft and/or sudden death may occur. Air embolism is rences. 56% occurred within 2 years. 77% within 6also felt to be a danger (39). years. and 95% within 9 years of the preceding SP.

•tarum Dare. .dvl Eriviranw ntal tai ctLe . ;c:'orr, '04M 041

RETROSPECT STUDY OF SP-VOGE & ANTHRA=iT

TABLE 1. RULES AND REGULAMINS GOVERNING SPONTANEOUS PNF3UMOTHORAX.

Entrv Into Flitht Proeram Retention In Flitht ProtaFederal Av~tuon Spontaneous pneurnothorax, spontaneous pncumotfsorax is disqualifying for aiiation dutyAdminiustration (31) is disqualifying for

aviation duty-unless resolved radio- -unless resoilved radiograpically and no underIvine disease is

graphically and no presentunderlying disease ispresent

U>S \as (67) Spontaneous pnicumnothoraia -if reccurrent by haitorvas disqualifying foraviation duty-if present within 3years of examination:-unless sur,callycorrected if no significantresidual disease or deformit%exists and pulmonary functioni-us~ arc normi~al

U S Arm . X Spontaneous pneumothofax is Samcdisqualifying for aviationduty.if present within 3years of examination-unless surgically correcicdif not significant residualdisease or deformity existsand pulmonary function testsarc normal

L' S -kr Fiircc 1 01 Spontanecus pneumothorix is -h% histors. ciccrit j %inric rpsidt: mas hi: .ji ci rT compictc

disqualifying for aviation rcmvery with full lung clipinmn.duty norrn3t pulnionar% functiorn tcsts. ind nil-by history undcrliane diseas

unless successful pleurodecsis pet-firmcd and rorrnil puirnonamt

funtijon tests. After ns monath% of ot,%crm Sioit

I requires hs'pobaric chamlser eviluationi '

NASA\ Spontaneous pneumrothorax iii -unlcivs surgicills corrccted %ithout rccurrcncc for vs months

disqualifying for acro-space duty-by histcry-unless surgically correctedand without recurrence for

Syears

The follow-up interval after an initial SP at which theprobabilitv of recurrence becomes negligible is about 9years. The mean irterval between SPs was about 3 yearsin all cases.H

Height. Weight. Age

The average height of our study group was 71.7 in andthe average height of those currently actively flying is73.4 in. The average weight of all respondents was 173.6lbs, (Fig. 1). The average age was 43.4 years overalland 40 vears for those still actively flying (Fig. 2). Ofall respondents. 41% were under 40 years cf age, and ., 0 1011 I i48% of all airtrcw in our population currently flying are *1111 a-aunder 40 years of age.

Smoking

Of the aircrewmen in our series. 79% ' have a positive Fi. 1. Height and weight of all aircriew and those cswwwtwly

smoking history, with an overall averagec of 30.75 pack- flu.

4: 4-ionop. Snect. and Enviwonmirniii,atilen - Ociobetr 19*

RETROSPECMIVE S TUDY OF SP- VOGE & ANINRACITT

~.. 3

77'. .. .

Fig. 2. Age otoccurtonceof SPToand curetage of Poppaton. 1 ______

years. There is no direct relationship between pack- Fig. 3. rime delayp in seekcing medical attenion cher .xp~r.vears per individual and number of recurrences. We did iincng SPIT.not obtain data on whether the aircrewman is a currentsmoker or not. Of aircrewmen under 40 in our studygroup. 65'r arc nonsmokers. However, only 31c-, of knife-like, dart-lIke, similar to a 'pulled mnunc~e.-current livers, undcr .40 years of agc in our group are cramp-like, like a 'steel band" on chest. poin onnonsmokers (Tablc 11). bending over. moving. or with exertion: and in s.arious

Inuita Treatment locations such as shoulder blades. shouldcr. back upperchest, under rib cae. in arm. etc. Some patierns

Only 82i7% of patients with SP were seen by , flight expenriced no pain. Other individuals experienced%urgeon The dclay in seeking medical attention varied pain so severe it caused then to double over andfrom ( -336 h with a mean of 24.6 h. a median of 4 h, almost lose consciousness. T%4o individuals claimed noand a mode of 01.5 h (Fie. 3). Of the patients. 3217 symptomnatology. stating that their SP wxas discos ered onwiiaited I h or less and 544 waited 4 h or less to see a a'routine examination.phvsician: -'I 7% waited more than 24 h to see a physician. Actit it%All but one of those with a second or third recurrencesought medical attention within 3 h of occurrence, the There was no relationship h~v-'een actiuit% ee andlatteir waiting 12 h. The reasons given for delaying the occurrence of SP-24%7 were sleeping. 3%s.emedical trcati-;nt were fear of grounding. distance from participating in minimal effort activities (sitting at desk.or availability of medical servict's. and/or the lack of eating. etc). 28%7 were involked in moderate cffortsev ernity of symptdms. activities (getting in and out of car. A~alkinc, c!ci. and

S,%.Mptms I1I% were involved in great effori actis ities (rac~ziriall.Symptomslogging. tennis. etc). Five pr.:ceni of the indisiduals

The most frequently reported symptoms were pain could not remember what they ,%ere domne at the time(89%r). dyspneca (61%). difficulty moving nght or left of symptom occurrence.arm (6 1). fatigue (6%1), near loss of consciousness Fih eairsi(6%). and URI-tvpe symptoms (617). Other symptoms Fih eawstmentioned were sore throat, cvanosis, heartburn. Of those answenng the questionnaire. 70%- havecough. -thought was having an Ni." nausea. audible flown military aircraft within the last .4 years ( 198(0-S3)heart beat. dizziness, increased pulse rate, audible (Fig. 4). Only 3% last flew prior to 197 .0. Thirty-sevenpleural -knock.- difficulty running or jogging. choking. percent of aircrewrnen admitted to havine flown %sithindiaphoresis. weakness, cramps. fainting. paleness. fear, the 24 hours before or after their SP. Of ths 37c. 63%-"didn't feel like smoking." and tachv.pnea (Table 111). had been flying "straight and level"* profiles and 37%-The pain had many different characteristics. such as high-G or rapid-change-in-altitude profiles. Of those

TABLE It. SMOKING HISTORY OF AIRCREWMEMBERS AiTH SP.

56"7c of non-smokers are currently flying24%e of ct,'rent flyers are non-smokers"re. of all flyers are non-smokers1717c of former flyers are non'smokers6517 of those under 40 years of age are non-smokers and 411-c of aimmrwmemnbcrs

are under 40 years of age31 le of current flyers under 40 vears of are are non-smokers

RETROSPECT IE STUDY OF SP-.-VOGE & ANTHRACITE

TABLE 1HI. REPORTED SYMP4TOMATOLOGY WITH SPONTANEOUSPNEUMOTHORAX (n = 112).

SYMP TOM NUJMBER (%) SYMPTOM NUMBER (~

Pain 100 (89) tactivcardia 2 12Shortness of breath 68 (61) chokin5s 2 (2)Difficulty moving (61 pleural kj-'2 (2)

arm or leg sensation of -something 2 (2)'..*ar losa of 6 (5) mnoving in chest caviry"

consciousn~ess diaphoresis 2 2Tired-fauigue 6 (5) diff6cuii- jogginig! 2 (2)LURI svmptoms 6 (5) runningC~sannIsis (4s) Wcakflcss (1)Sore throat (3) cramps 1 (1)Loss of consciousness 3 (3) fainting 1Nausea 3 (3) paleness 1 (1)Heariburn- 3 (3) fear I (U)

Cough 3 (3) -didn i fel like IThoueht was hav ing 2 (2) smokine"

%1t. tacnvpnea IAuditbfr heart tei( 2 2)Dizziness 2 (2 1

3c. The reported scveraN of svmptorns rqnnl inot coincide with the aircrewmembers evaluations ofthe symptom%' effect on flight safety or incapacitation.

x] (Table IV).Treatmen!

While 67%c of patients were treated initially witha chest tube alone or in combination with otherprocedures. 1917 were given "no treatment" (bedcrestl.':1 Aftcr the first recurrence. only four patients weretreated surgically while three injividuals were given -notreatment" bedrcst). After the'second recurrence. 71%-were treated surgically. After the third recurrence.100% had surgery (Table V). Only 357c of the aircrcw-

bit .orf a .4uyf~igfo ~hmembers still living have been surgically corrected.

fus U1 MeAll but three were surgically corrected after one ormore recurrences of SP. The treatment modalities were

Fig. 4.Lsyero ci*dtfligfrec icemn reported by the patients and we cannot verify them.

FaritY ndPersonal Hwiorv

There is no correlation betwcen expenencing an SPwho suffered an SP within 24 h of flying. 30% suffered and a personal history cf lung disease. Immediate bloodit during flight. Several individuals elected to fly relatives seem to have a higher incidence of lung diseaseimmediately after the appearance of symptomatology. and SP compared to the general population, however.Seven percent of the aircrew had been in a low- This has not been reported previously.pressure chamber (LPC) within 24 h of their SP. AllCretArceUtnadhad experienced rapid decompression during their LPCCrrnAicwSadadflight, and 86% of these experienced their SP during the All agencies reviewed (civilian and military) haveLPC flight. Of thcse. 80% experienced their SP during unique dispositions for aircrew members who haveihe rapid decompression phase. suffered an SP. Grounding periods vary from none

The question -Could the symptoms have com- for a single episode to 5 years following surgicalpromised flight safety had they occurred in the air?" was correction (Table 1). NASA (72) has the most stringentanswered affirmatively in 28 cases (1W%' and "maybe" requirements, dictating a 5-year grounding period afterin 27 (18%). Thus, 37% of aircrewmen reported surgical correction after an initial SP episode. The FAAthat the symptoms would or could have compromised (31) requires only that the SP be resolved radiologicallyflight safety had they occurred in the cockpit environ- and that there be "no underlyng disease." Thement. The question "Were you incapacitated by the three military services (67. 100.103) dictate that SP issvmptoms?- was answered po:,itively by 27 (18%) and disquahifing for aviation duty if the individual is an"maybe ' by 7 (55o) of the aircrewnien. for a total of applicant for a flight program. However. once in the

944 A vaann Space. a Enva'u'onnvngni Medim - October. I 9M6

RETROSPECTIV,-E STUDY OF SP-VOGE & AiNTHRACIT

TABLE IV, AIRCRZEwMEMBERS' RATINGS OF REPORTED SP SYMPTOMIATOLOGYAs To WHETHER SYMPTOMS AFFECTED FLIGHT SAFETY OR

CAUSED INCAPACITATION.

F~i Safety Ir anaC'ittiofl

Left s houlder 2nd arm pain: thought he no n0

was htvine dt M.LDeep chest discomfort, aching pari, no 10

poitional mild dvspneaPain in left lung: difficultv breathinc; yes ito

left arm pain: dizzinessLecft-sided pain: could not take full breath, no no

crushing sensationExtreme pain in upper chest; -thought I wast mnasnc no

hasing an N.I7"Cold S'^eat. Pale. shortness of breaih. -' ILX); i

oxsgcn and one good lung would he

sulfCiccnt to fly*

Sharp pain in collar bone: could ovik brcatrrc rash'&ith back rigid

Rapid and yhallow breathing with sham nopain on deep inspiration in chest andright shoulder blade

Shirr chest pain; slight weakness in left nitiarrn sanosis. fatigue

shirp pain in lower left back, not 'citcrc A A

.nt'uen to immobilize, troubic stiienicnincu:p

Paiin ct chest. shortness of hreath. '.ers it) r

uncoritlortahlc. tlhinkirg it was indigestion

I Iqst A anied to get on the ground-I trcmec pain in sternum and became item tired

,oilme %horinc, of breath; ' ifficuaiis inmining right armn (limited movcroentii

Sharr biurning pain in chest; -1 felt no no

impairmcnt sA thought or coordinationSpain. shorinin of breath. '* had chest no

rain -nd could not take a deep breath. btutI ias able ito move about. ncrc tit

cinsctiolusnes% or felt like wa% going ito

lo,,e conscioutses,

TA91LE VREPORTED TREATNIEN1TS OF SPONTANEOU'S PNELMOTHRlN(OF THOSE WHO RESPONDJED 1 n = 15 11

I st -nd 3r d

TRF NT\IFFNT ncCLRRFNCF nCCIVRRFNrF flcCItRRF\CF

Chest tube k

Surgens

0xsgenNeedle aspirationNont 21 3Chest tube plus surgeryChest tube plus oxygen 9Clhest tube plus needle aspirationINeedle aspiration plus oxygen 3Needle aspiration plus surgeryChsest tube. oxygen, and sufer'

program. there are no firm guidelines regarding aviation rates were lower than those reported for the generalduty after an SP. population (17.18.24.29.3O.34.3-7.41L4S.49, 1.S'.59.

DISCUSSION 62.7O.73.8O.8S,87.89.9O.95.97.11O12.1O5 , Severalreasons for thts may be: a) those who did not respond to

SP may be a serious. incapactating mnalady in the the questtonnaire may oe a unique croup. b) the atrcrewavilatton envsrcnment. We found USAF recurrence populatton may underreport symptoms. the number of

RETROSPECT'E STUDY OF SP-VOGE & ANTHRAC'TE

occurrences , or the number of recurrences. c) some 'he time of their SP. Many arirew members r.portedof the aviators had a very short follow-up period at stopping smoking after their initial SP. Of inte.est isonls I year. and d) c snviusions drawn from such a the lack of correlation between the individual pack-sma l study group are uaccrtaiti. The length of time year history and the number of SP recurrences. Nobttween recurrences ir, our populatn was similar to correlation existed between smoking and SPs occurringthat reported elsewhere (17.18.39.42,48.62.74). This in an LPC or in a high-G environment. An interestinghelps support the contention of underreporting by our project would be to study SPs in future populations topopulation. We did not calculate SP incidence rates. determine whether the incidence of SP decrea-ses with. aWe feel only a portion of SPs which actually occurred decrease in the number of cigarete smokers.are reported in the Waiver File. This may be t,"e We found a relatively high occurrence of SP infor many reasons. Principle among the..e are: a) the iamily members This relationship has not beensvm.ptoms were not severe enough to cause the aviator previously reported. although it has been consideredto seek medical aid. b) the aviator may have sought (70,105). Lacking other information on the involveCaid in the civilian community, c) if the aviator sought family members, we can make no further observatic is.aid. the SP may not have been recognized. ar;d d) if The aircrew members having family members with SPthe SP were recogenzed. it may not have been reported. were taller than our popu!ation's mean. however.It setms safe to assume that the recurrence rate in Our population tended to seek medical attentionthc USAF aircrew population should be at least that much more quickly than its civilian counterpart (14.reported by others. 17.70). This action may have several explanations: aj

The mean age of those suffering SP in our group was the military aviator is conditioned to seek medical aidgreater than that found in other studies '4.15.17.20.30. when he does not feel well. b) those Aho had symptoms35.44.46.49.62.63.71).74.88.90,91.95.97.105). There were sufficiently frightened by them to seek mcdicimas be two reasons for this. After prolonged periods attention, c) we only have infc-'mation on those %Nhoot G-sutt positive pressure breathing. O, breathing, sought medical atte:ition from military physicians. ntand G stress, the lungs may hecorr more susceptible on those who sought aid from ciiiian physicians,. d)to an SP (2" .86.1Il). More reasonable is that the many of those with minimal symptoms may not ha)eaircr:% population is a skewed population as far as age sought medical attention for fear of grounding or fadiurcis concerned. Very few individuals become aviators to appreciate the significance of the %ymptoms. Thein their teen years or during their early 20s. This individual who waited 12 h to seek medical aid after aCarl% period is usually a time for college preparation recurrence of SP was on a campinr tip in the wilderness.,nd decision planning. Those who enter the militarv He could not have sought medical attention soonera, iation commumty more frequently are in their middle- He dii admit to seeking civilian medical attention andto-late '_0s. Inose who suffered an SP before reaching neglecting to inform his flight surgeon or the milh:ars ofthi, point in their livcs would have been rejected from the SP recurrence.the aviation program because of the almost universal Most of the symptoms elicited were similar to thosedisqualifying clauses regarding a previous SP. previousli reported (14,17. 18.25.35.".5.YS.95. 1.

The study group population is taller than the general 113). Our group also reported many symiptoms notpopulation. Thosc with a history of SP currently flying previously found in the literature. These "unusual"are ,ouneer than and an average of 1.7 in taller than our symptoms were occasionally the only vmptoms experi-entire SP population, although population norms have enced. e.g. sore throat. Ho ,ever. the SP mas bebeen getting taller ever the years. The overall height incidental and unrelated to the -unusual" symptomsof the study population helps to confirm the general One must always consider SPin any young, tall malefeeling that SP occurs in tall. healthy r ales (22.40. with a positive smoking history and chest symptoms.42.43.78.90.110) and that SP may be due to traction even with no temperature or ESR elevation (70)on the apical regions of the lungs causing formation Symptom severity is not of assistance in the diagnisisof bullac and/or blebs with eventual SP (26.107). We of SP for the symptoms may be of any degree. Otherdo not have information on the SP patients' weights studies report a 10% rate of severe symptoma':olog,at the time of their SP experience and, consequently, with SP (14.32,70) while 28% of our group reportedcannot make accurate statements regarding the rweight severe symptomatology--primanv pain and/or severeof individuals experiencing an SP. However, the mean shortness of breath. The seventy of our group'sweight of current flyers is 6.5 lbs less than those not reported s.mptoms further indicates that many of thosecurrently on flying status. At the time of occurrence of with minimal symptomatology may not have reportedan SP. an dviator would be more likely to be thinner to military physicians. It must be remembered that thisthan our data presently indicate, and tall. is a retrospective study and that the patients are most

Some studies report a high incidence of smokers in likely to remember the symptoms that were the mosttheir SP population while others do not (14.20.25.80. distressing to them at the time, forgetting about other112). Our data agree with the former. Smokers made symptoms.up 79% of our population. The exact mechanism for Incapacitation is not the only danger of an in-flight SP.this relationship is unknown unless it is related to the Just the stress of one's body malfunctioning may be thechronic irrtative qualities of cigarette smoke along with cntical factor in high-performance aircraft maneuvennga facilitation of emphvsematous pockets. We have no or in an aircraft mishap. Such added stress is espectallyinformation on the pack-year history of the smokers at critical in single-seat aircraft where no one can take

4 viaton. Soace. and Enva'onmeneu Medicine • Octooer 19,

RETROSPECTI7VE STUDY OF SP- 'OGE & ANTHRACI TE

over for an ailing aircre',,ran. Even in dual-piloted 61.73.7-t.80.90.97). The requircmtnt for a comp~etcaircraft, insufficient time may be available to correct ~i bilateral parietal ple ;rectomy is exemplified by one ofdeteniorating situation dunng critical maneuvers. ou aircre-- members who had a partial (apical) bilateral

Our data ageree with thse literature in that well over panetal pleurectoznv. Hei subsequently experiencedhalf of our population was either sleeping or exercisingz a recurrent spontaneous pneumotilorax in t..e basa!minimally at the time of the SP (16.18.25.28.39.40. portion of one lung. The only viable alternative56.70.75,95.105.112). The time of SP occurrence has to complete parietal pletirectomy is to observ- e.Icn

ttle. ianything. 1o do with activity. The only detractor airci-ewman for a period of time sufficient to ensureto t!.is gen. ral statement is :he relatively high number that his risk of experiencing another SP is minimal 19of SPs occurring during R~s or pressure changes. vears). For all practi-., purposes. an aircrew memberThis relationship has not been previously reported (4. experti.encing an SP !.a.st either opt for comnlete

1.2;.28.33.39,48.51.105S)_ Although significant when bilateral parietal Dlcurectomy or must seek a new careerconsidered as a percentage of all Slas experienced, the field. Since the incidence of SF is lo%& (18.118.7 '''/I . I12.relationship is not significant when one considers the 113). such a requirement would not prese-,: a nard~hiventire 3IrCres4 population. It would be difficult to devise to mnilitary or civilian agencies. "Caus. Lt-deirnined'a 's ' stem to scrcen out RD-provocable SP individuals, or -hajrnan error- mishaps occur frequent;%. We hatecWe do riot know %Nhcther these individuals had bullae no %% %- of knowing how many of these mishaps ha'e SP

orhlcbs radioloviczliv at the time of thei. RD or as a contributing factor. The 6.5. rn.:itarN services andh)Amanv RDs they had ex~perienced betore their first civilian agencies need to make chanes in their current

prcumothorax. An interesting area for investigation retculations regarding atrcre..men vkijh an intil SP%%ould be to study the RD relationship .o SPs.

We iound no correlation bctwccn iight expericrnce RlErERENCES'ithin 24 h (if an SP and its occurrence,. Che: Aidcr RH A WiaC po~der acri,"'t rn! f~r "c 'c mIn I1.- ocition of SP with flicht seem' to be coincid,.ntal. recurrent spuneous pricumiiTh,,ix~ Ann 7'n-r >urc :nfiowcver. one-third of SF's did (czcur within 2, h if 474i11 :it uuts and 3(I' of these a ,iutors were actually And-ercri 1. Niimcn H Result'i, ofis flt!Jt 2cuI J.flsmnc at the time of iheir SP The danger of in A Wontanfcou~ pncumniiothra Di' C~c't F~v~

ncapatiain~ evnt ~s 2rcent n rh~ indviduas Afdcru~in IL. RPitcn T Sutei lrc~imrnl 4 tiicuincpactatng vct %% Reset i tc~cIndvidal. flncumothorax. Ati Chir %'sj nj 1" i " H iNhcn he proxicmity- of in SP to a flight experience A~c AR Pancial ricurcctiim\ fr rccirre n pcImii~r.o, coupled with the finding! that over one-third )f ?hc Bt J Surg 19Th. 63 20i3-5 ti(ridscaircrew member, feel thcir SP experience could have Ausi JR. Spontancou% pnecumrithota< P.i(rJ c.'r

compromised nigh-. 'sacts . t% icczmcs apparent that we hBjronohsk%-ID. o) Btlaier~j thcrNs ii, u;nfljt!.) ii nfi.inctiumust try to prevtcnt SP in night. The large number of pricunolisorat. I Thoitfc C rU,'s11 Sure Ili,alr~rc%%mcr rcporting that iheir SP could have had an lOcnjrij E, Mcvcr A Trcjimeni oi ni,nfliuI,,CreIiuN ','fI.,nctiusads erse effect on flight safety is protably factitiously r~ncumnothorax Di% (Ches0i - I Y4 641loA when one considers that many .ndividuals failed to .R~cthumc N. Pleurat poudaeec-a nc i tbniuuc tor the jct-w~rzt:recognize or apprcciate the %escrity of their smt % irmiuciof of pleural a4dhr- tins a,' rcriinir\ io r

s~ptmsI Thctrac Surp 103<.--(T.anle IV) The sjme observations may be applied to Hi rttci RC Rccurrcni ind chri'nc 7it~f~zu unitthe responses received regarding incapacitation. One Thorax 190i. 3 SXQuarter of *hosc rcsponding felt that they may have been 11) Bromiev 11. The manseevrrni i! ''trtnvou, -nno~itnoir:sincapacitated h their svmptoms: not I "mp aired.- but Thorax 1967. 2.49-

Thi isa sron tstionylw irc~ It Brnooks JW Oren thoracoioms, n hc rnjrtjrcm,:,T ,I r-ni'ncapacitated."Ti sasrn etmn yarrY tafleots pnicurrothorax Ann !tUte N" -'members thcmsels s on the dar'-er of inflight SP. :' 8rnon TS. The chesi X-r3,, in 1" paluCn; -1,h rrcumoitr,4

Once an individLal has experienced an SP, he should Bnt J. Clin. Prac. 197'. 11 IA",iSprevented from pursuing aircrew duties as long as t3 Cattanco S. Sirak H. Klasn K~ Rccrrcnt Prnzincou%

there is a reasonable risk that he will experience another intrcuirl qia ihe high nsk Ciirw. manicn Nsi1SP The literature states that conservative therapy is m 4h7-71I.neither appropriate nor adequate in the treatment 14 ClarK TA. etal. Spontaneous pricmot hor 3 It AMIsure 19-:.of airerew members with SP (27,62.113). Opinions 1:4 .8&31.regarding chemicail and mechanical pleurcxlesis vs I! Cohen S. Kinsman JIM. Noin-traumnatic stxnlaneous pnieu-parietal pleurectomv are not as well delineated (42.4. mthorax among military personnel N Enei I Sled IY1h99. 102). Pleurodesis is not the surgical method of choice 16 Cox PA. Keshishian Al. Dcfiniii'e surgical tre3tient ofbecause the recurrence rate after pleurodesis can be spontaneous pneumothorax. Acrosp Sled MW- 1 62-as high as 3051% (10.17.20). no method of pleuroidesis 17 C,2n IR. Rumbail CA. Surve'*. of spontarieous pricumothorax inhas been demonstrated as the method of choice (20.24. the Rov.x; Alf Force. Thorax. 1967. -' 62'

-).3.42.2.5.70.9.9,95.9.10.10.112113. an ISCurtis P. Spontaneous pnew.., thorax-& dilemma of manaec73.6.4.5255.0.7.9195.9.l2.lS.12.13) ndmciii. 1. Fain. Prac. 19M -S36-7pleurodesis carries high morbidity. Parietai pleurectomv. 19 Dermirstan G. Lamb LF. Spontaneous pricumothorax in ir'-has a ver-y low recurrence rate'of 0-1% (4,20.30.70. parenist healthy- 1lvingpersorinti Ann t nt. Mled. 1959. 5I 3990.95) and very low morbidity and mortality (20.42. ZO Deilauners J. et ll/. *Transaxitlarv pleureesom t Inr treatment o!95.96). Parietal pleurectorny must be done bilateral- Finospiuohri.AnTo uei":359since there is a contralateral recurrence rate of up to ~.Dna-,ple LG. Cox WA. Simultanecus bilateral spontaneous20'c. and the pieurectom% must be complete (6.17.30, pnewnothorax. Mil. Med. 19741 :9bq.i

ii ariott )pace. and Emironmrnwi %t,'uicrr , ciionn- Qs,1

RETROSPECTIVE STUDY OF SP-VOG= & M4IRA(fl=

=2 Editorial- Brit. Med. 1. 1958: 1.1347. 57. 1t~i AM*-~C SPoawsec Pw- Kirax Br me., 1. !%a:23. Ellia FH Jr.. Caff DT. vsrg z of spontaneous pcesnosisorzat 1:720.

11-. Gin. N. Am. 195-. 18:1065. 58. Lead4ing Article- Spontaneous prerohrx Br. Med. I- 197f.'4t Fergi % LS. Imne '2W. H.~dsu- S. Excsion of builac without 2 -526.JPTetnto otnouPICII-ectsffv In Patients wit. spontaneous pnewnousorax 3nt. 59. L.Fetnne A,,,, oi-fm ET Lynch J.Teteto pnaeuJ. Surg. 1981:- 53:211-6. priurhithorax. .. A.M.A. 1956: 162:622.

25. Flux ki. Dille R. Inflight spV itaneous pneumiothotax: a case 60. Legrand M, Cbemrouille E. Spontaneous pricumnothorax n.'nor. Aerosp. Med. 1969; #0:660.-2, womnen. Semn. Hop_ pdrns. 1976: 52:2471-6,

25. Forg P Stature in iitimlle ewcunoth-rax. Thorax 1967. 221481. 61. Levy IF. Spontaneous pneumothOrax. Treatment based on-. FuCh- hs. Idiopathic -xntaneous Pnbeurncthorax and flying. anlss f10 psd on 135 patients. Dis. Chest. 1966.

Aerosp. Meoc. iyu/: A8128--. 49:(2937-28 Fuchs HS. Incidence .. spontaneous pneumathorax in apparent'v 62. Uichter 1. Long-term follow-up of planned treatment ol' spon.

healthy airerew. Acrosp. Med. 1967; 38:1286-, t.netctis pneumothorax. Thorax 1974: 29-32-7.N9 3cisner .EA. arietal pleureetonty for re...arent spot.:aneous 63 Lichter 1. Gvwynne IF. Spontaneous pneumnothoraxt in %ounr

pncurnothorax. Surg. Gyriecol. Obstet. 19.56:' 102_.93, subjects- A clinical anid pathological study. Thorax 1971!.30 Golt*-i WNG Jr., er al. Spontancous pricumnothorax. J. Thorac '76:409-17.

3i arudior asiati muedia 1963. miners. 6-4 Lindskog GE. Halasz A. Spontaneous prcurnothorax: considcra-Ocid Io satn meiaIxmnr Washington. DC. FAA.. tion of pathogenesis and management with ai review ofO:Hnc IL ercor9$!rohoa raedb aca hospitalized Lases. Arias. Surg. 1957:' 75:693.

3: ancn o-iL. Refractr 1 n976. ora treated5 bypnea 5 Mcformack rUM. ihe manaement of s~on,ancous, pnecupicuolsis Tora 196. 3:65-S.mothorax. Thorax 1967: 21:492.

1 ' Hayshi I Uchcr totliehen pneucnothorax durch it. .,t aud 66. MAaassen W. Spontaneous pneumrothoras. Chir. Ther. Thcra..-- rsvscma Frankfurt Ztschr. F. Path. 1915:* 16: 1. piewoche 1974. 24:214.

34 H-ath Em Spontaneous pneumothorax in healthy Young adiIts 67 Mlanual of the me'dical department. U.S. Nay", 25 No% l~xf0-ih pa~licxslar reference to the aetiological role of aerial Chap 151-20 par2 2K. Chap 15-70 pars.-

.i~~~~~cni~~~ Am e.Se.14:21: 1 l artovits AS. Philipps RB. Lune collapse it. aviation ],A %I ASHcrnr %IA. Chronic pneumrothorax with recurrent a..ute 1957, 6.~6~1

cs.1ccroatic..'s. Md. State Mcd. J. March 1976, 65-7 69. Mlatsumotit T,.-, :1. Cvanoacrmiate tis,uc adhesives in il-3, Hcrrn~n SI. Oricamp GC. Weibrad GL Pulmonar, kaolin treatmcni of rccurTcn* spsontaneous pricumothorax. Surccv-.rar ulomas. 1 .. in. As%. kidiol. 1982. 3327-XOU 1967: e)!573 -5.

3- Hicr. D. Ballenger FIX The maunaltement of spontaneous 70. Matitla S. and Kostiaincni- Spontaneous * ricurnothoran. Sclirdpineumothorax due to cmphysematous blcis. Surg Gvnec J. Thor. Cirdinvasc. Surg. 19777 11 L9-4i3.Obict. 1965. 120AWV-50' 71. Mlaiwell I The production of picurai adhicsions by kaolin~Is Hinshiaw HC. Garland CH. Diseases of the '.t.Philadelphia in~cctson. Thorax 1954. Y 1U'A B. Saunders, 1956:' 2 72. '. Medical cvaluation and 'tandird, for astronaut scircion

ly Ho B-L. A case repot of spontaneous pneumothoraix during Washington. CC: NA A. ]an 1977 4 5 1flight Avijit- Space Environ. Med 1973. 44.K41. 73. Mcrcter C. et at Outpatient mnan.azcmcnt of~ interaistai tut~c

01' Holier H'., Hor\%itz 0 Spontaneous pricumnothorax produced h\ drainage in spontaneousi rrnumothovas Ann Thor Surgiscent in airplane. I.A.M.A. 1945. 127:519 1976. 22:163-5.

41 Hopkirk JAC. Letter to the Edttor. Aviat. Space Environ lie, 74 MeycrJ,\. Sirnplc spont1ncoks rncumt,thtiix. Di, C'-st ';s,;992. 53. 1 K3, ':4:0.

42 Hopkirk JAC. Pullen M.J. Fraser JR. Pfeurode' s. .he result% -15 Meverson RNI Spontaneous pnournmthorix ciiniczl studs of !(X!of treatment for spontaneous pneumohorax in the Rovai Air consecutive cases. N Enfl J Mcd 1Q.s. 2'38 4h1Force Aviat. Space Environ. Med. 1983. 54 158-410 76. Nandi P Rcc..rre,it spcntaneous pncumotmorax Chest 19N).

4~ Hsde L. Benign spontaneous iineurnothoraa. Ann Intern Med 77:491i-5.962. 56.74h.51. -Neal.IF. erat. Biiateral bleb encision through rdiin sicmoturms

-H\sIc L. Spontareous pneumo'whorax. Dii. Chest, 1963. 3.1 47#s- Am. J. 5.urg. 1079: 13$ 79.4--"AV ~7t Nissen H Prieumothoax spontaneous MIurksgaard Co,cn.45 lovnt GHC. Laire RC. Treatment of spuntaneous pneumothorat hagen (thests in Danish %ith an English tumrnarvl 196y

%ith kaolin Ca.. Chest. 195C: 34:1-7. 79 Oforgbu DO. PI..urodesis for spontaneous pneumrotrioraii. ci-.1h Kalnins 1. Torda TA. Wnght IS. Bilateral simultaneoul pentie with tntrapieural ulise oil in high risk paticnts -\rm

pleurodesir by mediaii stetnosomy for spontaneous 1. Surg. 1980: 140:6N_81Ipineumothoraa. Ann. Thor. Surg. 1973; 15:2021-6 80. Pagec A. ec al. Spontaneous pneu.-io'ho-,a outpatient manare-

47 Katrwinkel J.. irt al. l'strapicural instillation of quinaenine for inent with intercostal tube .ur age Car.. Mel. Ass. 1 1971.reeurrent Pneutsotsoral. J.A.M.A. 1973; 226:557-9. 1H: 707-9.

48 Klaergaard H. Spontaneous pneurnothorait in the apparently 81. Pecora DV Chemical pleurodiesis Cciest 0482. 82.514healthy. Acta Med. Scand. Suppi. 1932: 42:1. 92. Penagaluru JR. Spontaneou; pneumnothorax Ann. Thor. Sure

4 0 Killen DA. Gobbel %WS' Spontaneous pneumnothorax. London. 1976: 21:85Churchill. 1968. 83. Perimt OM. Spontaneo-.. 7neumnothoraxl. A clinical study of 16650. Kletnerman J. Cowdrey CR. Stem HM. Unpublished data case;. Ann. Char. Gs'sueeol. (Suppl 1196. 160:7-61.prtiented at the 1968 annual meting. Amenican Thoracic 84 Perry KMA. On spontaneous pneumothorax. 0. J. Med. 1919-Society. Houston: Pediatric Herald. 1968- 9:5. 8.*1.

51 Kruetzer FL. Bimz lara LG. Rogers WL_ Treatment of spon- 85. hIole GW. The management of spontaneoui pneun-.othsorax.taneous pneuminthoraz by means of continuous ttstrapleural Thorax 1967. 22:482.suction. Dis. Ches. 1952. 21:663. 86. Ra.,n H. Farsi LE_ Gaseous environment and atelciasis. Fed

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4agallon. Space. ind Enivirorimn'nal %fruic'.' 'v *~~Q(3