the management of the spotaneous pneumothorax.pdf

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The Management of Spontaneous Pneumothorax

LTC Michael

G .

Seremetis MC USA

F C C P

The records of 155 patients with spontaneous pneumothorax seen at the

William Beaumont Army) General Hospital during the period 195 8 to

1968 were reviewed in retrospect with emphasis on effective management. The

recurrence rate was found to average 41 percent. It was 49 percent for pa-

tients treated with bed rest 40 percent for those treated

irst

with

bed

rest

and later with tube thoracotomy and 38 percent for the group treated pri-

marily with tube drainage. There was no recurrence after open thoramtomy

and plenrodesis, a procedure advisable after the second episode of pneumo-

thorax. The complication rate was low irrespective of therapeutic regimen but

hospitalization was considerably shorter after tube thoracotomy, which is pre-

ferred as treatment of choice for

initial

management.

B y defhition, spontaneous pneumothorax occurs

without demonstrable underlying pathology.

In reality, there is always a lesion, be it sub-

pleural bleb or other organic disease. The ap-

pellation spontaneous indicates either our inabil-

ity to demonstrate blebs clinically or their sponta-

neous development. Whatever the case may be, this

entity has attracted the interest of the medical pro-

fession, especially that of the military physician,

since it affects young, otherwise healthy individuals.

Many of the available reports in the literature came

from military

While pneumothorax was first described by Hard

in 1803, Laennec 1819) described spontaneous

pneumothorax very accurately and speculated as to

its relationship with preexisting emphysematous

blebs.1

The etiology of this disease, however, was not

elucidated until much later. Kjaergaard6 in

1932

established the fact that the majority of cases of

spontaneous pneumothorax are, in our era, non-

tuberculous.

'From the Thoracic-Cardiovascular Surgery Service, De art-

ment of Surgery, William Beaumont General ~ o s p i t a fEl

Paso, Texas. Present address: Department of Surge

Downstate Medical Center , State University of New YO^

Brooklyn, New York.

The Department of the Army has reviewed this material

and has no objection to its publication. The review does

not imply any endorsement of the opinions advanced.

The records of all cases of pneumothorax seen at William

Beaumont Hospital from January 1958 until the end of

March 1968 were reviewed. Onlv the true s~ ont ane ous

variety is included in this study. Neonatal, traumatic or

pneumothorax resulting from other causes were excluded.

To evaluate and compare the different ways of manage-

ment an effort was made to review retrospectively the

therapeutic measures taken after

n

episode

of

spontaneous

pneumothorax. Although all these patients were admitted to

William Beaumont General Hospital at least once, many of

them had their first attack elsewhere. Only pneumothorax

verified by radiographic means was taken into account. In-

formation regarding these

c ses

was already available in the

record of the patient an d was confirmed in most instances.

from the patients themselves.

A total number of 155 patients were seen and comprise

the material for this report. No attempt was made to classify

these patients by degree of pneumothorax.

hree distinctly

different modes of management were employed as the treat-

ment of the initial or recurrent attacks of these patients:

namely, bed rest with or without needle aspiration,

tube

thoracotomy and finally, open thoracotomy. Since some pa-

tients were first treated with

bed

rest and a few days later

with tube thoracotomy, this group was considered sepa-

rately. Tube thoracotomy was considered as primary man-

agement if canied out within

4

hours after admission of

the patient. In

a

few instances, it was preceded by needle

a~piration.

Hospital stay was considered as the time during which the

patient was in the hospital under treatment. Convalescent

leave or other administrative delays were not included.

s

complications of treatment only those resulting from t h ~

therapeutic measures themselves were considered. Persistent

air leaks or increased pneumothorax were not included, as

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66 MICHAEL

G.

SEREMETIS

these were considered the result of the evolution of under-

Tab le 1-Recurrence Rate

lying disease (hlehs) rather than complications of treatment.

First time: 91 patients (59)

RESULTS

Second time: 7 patients

Third time 21 patients :~gn~e

Variations on the year-to-year incidence were

~ our t hime: 4 patients (64 patients)

significant but without clear-cut pattern. The age

Fifth time: 2 patients

254 Episodes

distribution showed that 146 patients were less than

40 years old and only nine were over that age. The

majority 84 patients) were between 21 to 30 years

old. Only 18 women were included in this series, a

fact reflecting mainly the composition of our mili-

tary population. There was a pronounced difference

in race incidence, most of the patients 147) being

Caucasians. Only seven were Negroes and one ori-

ental. The military personnel contains a more sub-

stantial percentage of Negroes.

Like others4 we were unable to find any seasonal

tendency in the appearance of the attacks. These

occurred with almost equal frequency during all

seasons. The side of the chest involved was more

often the left 58 percent). Bilateral pneumo-

thorax was found to occur in low percentage 6

percent or 9 patients) and tension pneumothorax

even less often 3 percent or

4

cases). Simultaneous

bilateral pneumothorax was seen only twice. The

presence of clear or sanpineous fluid in the chest

was reported in 16 instances.

In considering the factors that may precipitate an

attack, smoking was found to be the most common

denominator 130 patients); common colds with

chronic cough 13 patients) and heavy effort with

or without minimal trauma 12 patients) were

found to be less commonly implicated in triggering

the mechanism for the appearance of pneumotho-

rax.

Pain was by far the most common symptom

140 patients). Shortness of breath was present in

33 and cough in 16 instances. General malaise, with-

out other symptoms was seen in five patients and

ten experienced no symptoms at all; their pneumo-

thorax was found in the course of routine physical

examination or during unrelated diagnostic work-

up. It is interesting that 18 percent of the patients

admitted 28 cases) had symptoms for over a week.

This fact is important bedauie in the military serv-

ice patients, as

a

rule, seek medical advice soon,

if

not too soon.

The initial episode of pneumothorax was treated

with simple bed rest in 44 patients. Some of them

were in addition subjected to needle aspiration.

The group that was initially managed with bed

rest combined later with tube thoracotomy is made

of another 29 patients. The majority of patients

81) underwent tube thoracotomy and finally only

one patient had open thoracotomy as initial man-

agement for uncontrollable tension pneumothorax.

The overall recurrence rate in this series was 41

percent or 64 patients Table 1 .Of these, 37 pa-

tients had only a second attack while 21 had a third

one, four had a fourth and two had a fifth episode.

The total number of episodes that the entire series

of 155 patients suffered was 254. The average time

interval between the initial and the second attack

was 17 months range of four to 35 .The interval

averaged only 11 months between the second and

third episodes range 2 to 22 months).

Of patients initially treated with bed rest 49 per-

cent 21 out of

44

patients) developed recurrence.

The combined group of bed rest and tube thorac-

otomy showed a 4 percent recurrence rate 12 pa-

tients out of 29) and the group of primary tube

thoracotomy patients

38

percent 31 cases out of

81) Table 2).

The hospitalization averaged 18 days for pa-

tients treated with simple bed rest with a range

from 8 to 29 days. Those treated with bed rest first

and tube thoracotomy later stayed in the hospital

for an average of 12 days range 7 to 19) while the

group managed primarily with tube thoracotomy

was hospitalized for an average of only four days

range three to six). The lung reexpanded fully in

the great majority of the tube thoracotomy group

within one to three days. The tube was usually re-

moved 24 hours after full expansion. Only three

patients continued to experience air leak after

several days of tube application. Suction was

used in a very few cases.

Open thoracotomy was performed 31 times and

the indications for it are listed in Table 3. The main

problem is recurrence. Treatment failure includes

patients who either continued to have air leak

Table 2-Ma~gement/Res ults

of

First Episode

(155

Patients)

Hospital

Stay

Recurrence (Avera e,

Treatment No. Patients Rate ~ a y s y

Bed rest only 44 49 21)O 18

Bed rest and

tube later 29 40 12)' 12

Tube thoracotomy 8

38

31)' 4

Open thoracotomy none

'Number in parentheses-patients.

CHEST VOL. 57 NO. 1 JANUARY 1970



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MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX

7

Table

3-Indications

for Surgery (31 Patients

Recurrent attacks

2nd

tim 6

3rd

tim

11 22

more

5

Tension pneumothorax 1

Bilateral pneumothorax

5

Persistent air leak

despite tube

31 patients

despite several days of tube drainage or even

progressed in the degree of collapse. None of the

surgically treated patients developed pneumothorax

again on the side operated on. The average follow-

up of these patients was 3 years.

Blebs, intact or leaking, were found in most of the

patients operated on

(28

out of

31).

Oversewing or

excision of these areas was carried out in 17 pa-

tients. Pleurodesis aimed at prevention of recur-

rence was performed in all patients operated on.

Two procedures were utilized, pleurectomy in six

instances and scarification in 25.

The complications of treatment are listed in Ta-

ble 4. None of them was serious. There was no

mortality in the entire series.

The recurrence rate following one episode of

spontaneous pneumothorax is high, irrespective of

treatment, short of open thorac~tomy.~nitial and

recurrent attacks should be considered as two stages

of the same disease, calling for different therapeu-

tic approaches.

During the last decade the pendulum of manage-

ment of initial attack has definitely swung from ex-

pectant bed rest treatment to more active measures.

As in many other situations, management should

be individualized. The degree of the collapse, its

progressing or regression, presence of air leaks

and/or tension phenomena, the previous history of

the patient, and his particular job must all be con-

sidered before choosing the right treatment.

It is certain that many cases of pneumothorax

will eventually reexpand and improve by simple

bed rest. The great disadvantage is the length

of time required for full reexpansion; even a

50

percent to 60 percent collapse usually takes three to

Table 4-Complications

o Treatment

Tube Open

Bed Rest Drainage Thoracotomy

Infection 2 1

Atelectasis or

pneumonitis 3 3

Space prohlem

Total

four weeks. Needle aspiration does not seem to has-

ten the recovery and may even delay it by in-

ducing new leaks with repeated punctures of the

lung. It should be used rarely,

if

ever. Bed

rest still has its place for minimal collapse, that is to

say a

5

percent to

10

percent pneumothorax or mere-

ly an apical collapse. It was employed in

22

per-

cent of the cases at William Beaumont General

Hospital during the period 1958 to 1962 while its

use dropped to 13 percent in the last five years.

Since

1963

only patients with minimal pneumothor-

ax were treated by bed rest and as a result the

average hospital stay for these patients was only

seven days.

Closed (tube) thoracotomy is the main therapeu-

tic approach in the great majority of pneumothorax

case~ .~>~-Onderwater drainage without suction is

much preferred to suction. It is simple procedure

and,

if

properly done, carries minimal risk. All gen-

eral surgeons, even in smaller hospital facilities,

should be able to apply this method without great

difficulty. Tube drainage shortens the hospitaliza-

tion period, but is not, of course, definitive treat-

ment. Recurrences after closed thoracotomy still

occur in a high percentage of cases.

The only definitive treatment to prevent further

attacks is open thoracotomy and pleurodesis. The

main indication for it is not the &st episode of

spontaneous pneumothorax but a recurrence.' While

in the past a third recurrence was used as a yard-

stick for surgery, there is a positive trend today to

advise earlier thoracotomy, that is after the second

episode of pneumothorax. This is probably more in-

dicated for military patients. Of course, tension

pneumothorax and/o r simultaneous bilateral pneu-

mothorax first needs vigorous emergency measures

either in the form of large needle aspiration or

better, the immediate insertion of a tube into the

chest. Open thoracotomy is then carried out later

as an elective procedure. Surgery is advised after

only one episode of pneumothorax on both sides,

even if not simultaneous.

The aims of open thoracotomy for spontaneous

pneumothorax are two: namely, control of the pres-

ent leak and secondly, prevention of future attacks.

The latter is accomplished by pleurodesis which is

a principal choice of either ple ur e~ to my l~ .' ~r scar-

ification. Both procedures are apparently effective

in preventing recurrent pneumothorax. Scarification

is simpler, less bloody, and does not make a poten-

tial later thoracotomy difl ic~l t.' ~

As for other ways to prevent or even to predict

possible development of spontaneous pneumotho-

rax, we simply do not have any idea how fast and

by what mechanism is the underlying bleb devel-




4/4

MICHAEL G. SEREMETIS

oped. There is no diagnostic procedure that can tell

us beforehand which lung is more liable to develop

blebs and how we can detect them once they are

there. For this reason, this condition is very impor-

tant in the military because it affects otherwise

healthy, young soldiers. It is potentially dangerous

and it may even be fatal if

neglected. At the same

time, each attack should be treated promptly with a

complete diagnostic workup, especially for patients

with a first episode. Surprise diagnoses may appear

from time to time.

The recurrence rate after the fist episode of

spontaneous pneumothorax is high 41 percent)

with either bed rest 49 percent) or tube thorac-

otomy (38 percent). The latter is preferred as treat-

ment of initial attack, mainly, because it shortens

considerably hospitalization and it is safe. The only

effective treatment to prevent further recurrences is

open thoracotomy and pleurodesis, best achieved

by

scarification of the pleura.

1 DRISCOLL,. J., AND ARONSTA~I,

.

M.: Experiences in

management of spontaneous recurrent pneumothorax,

I

Thorac. Cardiovasc. Surg., 42:174, 1961.

2 HICKOK, . F., AND BALLENGER,. P.: The management

of spontaneous pneumothorax due to emphysematous

blehs, Surg. Gynec. Obstet., 120:499, 1965.

3 HYDE,

L.:

Benign spontaneous pneumothorax, Ann. In-

tern. Med., 56:746, 1962.

4 MILLS, M., AND BAISCH,B. F.: Spontaneous pneumo-

thorax: a series of 400 cases Ann. Thorac. Surg., :

286, 1965.

5

THOMAS,. A.: Spontaneous pneumothorax, Milit. Med.,

124: 116, 1959.

6 KJAERCAARD, .: Spontaneous pneumothorax in the

apparently healthy, Acta Med. Scand., 43 (suppl):l,

1932.

7 CBBBEL, W. G., JR., RHEA,W. G., JR., NELSON, . A..

AND DANIEL, R.

A.

JR.: Spontaneous pneumdhorax,

J

Thorac. Cardiovasc. Surg., 46:331, 1963.

8 KLASSEN,. P., AND MECKSWORTA,.

V.:

Treatment of

spontaneous pneumothorax: prompt expansion with con-

trolled thoracotomy

tube

suction, J.A.M.A., 182:1, 1962.

9 LEVY, . J.: Spontaneous pneumothorax: treatment based

on analysis of 170 episodes in 135 patients, Dis. Chest,

49:529, 1966.

10 THOMAS,.

A.

AND GEBAUW, . W.: Recurrent pnen-

mothorax and bullous emphysema, results and compli-

cations of pleurectomy, I. Thwac. Cardwuasc. Surg..

39:194, 1960.

11 BEARDSLEY,. M., AND PARIGIAN,

.

M.: Scrubbing the

pleura in the treatment of chronic and recurrent spon-

taneous pneumothorax, Surgety, 30:967, 1951.

12 KINSELLA, .

J.:

In discussion of paper by Gobbel et nl,

Ref. 7.

13 KAUF~IAN,

.

A.. HANNER, . M., AND BARONOFSKY,

.

D.: Spontaneous pneumothorax: review of experience

at a large naval hospital, Western 1. Surg., 66:73, 1958.

Reprint requests: Dr. Seremetis, 4737 36th Street,

NW

Washington, D.C. 20008

1970

ALFRED

R RICHMAN

ESSAY

ONTEST

The American College of Chest Physicians announces the 1970 Alfred A. Richman

Essay Contest for undergraduate medical students.

First

rize

500

Second

Prize

300

Third Prize 200

The primary objective of the Alfred A. Richman Essay Contest is to encourage and

stimulate medical students:

to broaden the scope of their interest in circulation, respiration and related

disciplines

to

explore and investigate problems of all disciplines relating to diseases of the

chest

to

summarize and present their

fin ings

in open competition for the benefit of

other students and investigators.

Application forms may be obtained by writing:

The American College of Chest Physicians

112 East Chestnut Street

Chicago, Illinois 60611

Students must complete the application forms and mail them with their manuscripts

before

March

31, 1970.


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the management of the spotaneous pneumothorax.pdf

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