Scand J Thor Cardiovasc Surg 9: 281-286, 1975
SPONTANEOUS PNEUMOTHORAX F. Abyholm, G. Starren and 0. Geiran From Surgical Department IlI, Ulleudl Hospital, Oslo, Norway
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/20/14 For personal use only.
(Submitted for publication October 1, 1973)
Abstract. Patients with spontaneous pneumothorax, who were treated in this department during the period 1950-59, were reviewed in 1963. Since the treatment of this group of patients has changed radically towards a greater surgical activity in the form of suction drainage and thoracotomy, the patients from the next decade, comprising 229 episodes in 202 patients, have now been reviewed to evaluate the results of this attitude. The conclusion from the earlier review, that recidivating pneumothorax should be operated upon, is further supported, and in quite a few patients (9 %) thoracotomy had to be performed to control the first attack. Pleural rubbing, as an additional procedure to resection of bullae, seems as safe as partial pleurectomy in prevention of relapse. There were few serious operative complications. A rather protracted suction drainage has been practised in this series. One consequence of the experiences from the present review is that this time has been shortened.
In the present report, the primary and secondary forms of spontaneous pneumothorax are reviewed in connection with a presentation of a 10-year series of such patients from Surgical Department 111, UllevAl Hospital. Oslo. The series comprises 229 episodes of spontaneous pneumothorax in 202 patients. A series from the same department during the period 1950-59 has been presented earlier (Braband, 1963). Since our routine has changed, it would seem to be of interest to analyse the effectiveness of our present attitude, as related to earlier results, our own as well as those of others. Spontaneous pneumothorax occurs principally in two different groups of individuals. One group consists of young, otherwise healthy persons, with a strong preponderance in men, mainly in the age group 20-30 years. This type has been named primary spontaneous pneumothorax (Killen & Cobbel, 1968; Levy, 1966; Myers, 1954; Lynn, 1965; Hyde, 1963; du Bois, Price & Guilfoil; 1953). The other group, secondary spontaneous pneumothorax, consists mainly of patients with chronic bronchitis and secondary lung emphysema. 19 - 752915
In both groups, the direct cause of pneumothorax is rupture of subpleural bullae which communicate with the bronchial tree. Pneumothorax may also complicate a number of lung diseases, such as pneumonia with lung abscess formation, particularly when the pneumonia is caused by staphylococcus, cancer, and sarcoidosis. Bullae are best demonstrated by tomography of collapsed lung, and has been found by this method in 15% (Killen & Cobbel, 1968). By thoracoscopy, bullae have been diagnosed in 30-75% (Marrangoni, Storey & Geib, 1955; Crowther, 1955; Sochocky, 1966; Stanek, Wilson and Rogers, 1961). In patients operated upon for spontaneous pneumothorax, bullae have been found in 85-95%, while the frequency was 75% in a series which comprised primary as well as secondary spontaneous pneumothorax (Ramel, Briggs & Schultkings, 1963; Killen & Jackson, 1963; Shefts, Gilpatrick, Swindell & Gabbard, 1954; Baronofsky, Warden, Kaufmann, Whatley & Hanner, 1957). These series agree well with our own experience, since we diagnosed bullae by X-ray in 31 cases (14%) and found bullae in 47 (75%) of our 63 thoracotomy patients. The age distribution is shown in Fig. 1. The sex distribution and the side the of pneumothorax are shown in Table I. Diagnosis Spontaneous pneumothorax should be suspected with a history of sudden chest pain, noted either at rest or during physical exercise and sometimes accompanied by dyspnoea. Such a history has often led to false diagnosis of coronary disease, acute shoulder pains, perforated ulcer, acute gall bladder disease or pancreatitis. The pain usually subsides in the course of a few hours and the dyspnoea is then only noted after Scand J Thor Cardiovasc Surg 9
F. Abyholm et al.
282
Table 111. Previous manifestations of pulmonary disease
No. 100
r
93
Spontaneous pneumothorax Chronic emphysematous pulm. dis. Tuberculosis Sarcoidosis Bronchiectasia
85 31 15
1 1
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40
In a series from our department, during the period 1950-59 (Brabrand, 1963), the treatment of spontaneous pneumothorax was mainly conservative. Table IV delineates the treatment of this group of patients in our department during the last two decades. Table V shows the results of treatment in the present series.
20
10-20
Fig. 1. Age distribution of the patient series.
physical exercise, with major collapse of the lung and, especially with pressure pneumothorax, the dyspnoea may be dramatic. In our series, a number of patients were admitted to the medical department with a diagnosis of myocardial infarction. The diagnosis of spontaneous pneumothorax is confirmed by X-ray. The degree of lung collapse in our series is seen from Table 11. Previous lung disease One hundred and thirty-three of our patients had earlier manifestations of pulmonary disease (Table 111).
TREATMENT The trend in our treatment of spontaneous pneumothorax has been towards a greater surgical activity. Table I. Sex distribution and side
Group I: Bed Rest Only
Bed rest has been used as the only form of treatment when the pneumothorax has been slight and the patient has had no respiratory difficulty and no signs of progression. The normal course is absorption of the air and lung expansion during a period ranging from a few days to a couple of weeks. In our series, 24 patients were treated conservatively, i.e. 10.4%; All of them had a small amount of intrapleural air. Mean hospitalization was 7.5 days. In one patient, we had to resort to thoracic drainage with suction after a long test of conservative therapy, and in 2 patients the pneumothorax recurred during the hospitalization. Group 11: Exsufflation In this group, one must resort to radical methods more often than in the fiist group, probably because
Side of pneumothorax No. Men
Women
Right
Left
Bilat.
Table 11. Degree of lung collapse judged by frontal projection No. Small Moderate to severe Total collapse
Scand J Thor Cardiovasc Surg 9
60 86 83
Table IV. The change in therapy towards greater activity from the decade 195060 to 1960-70 (percentages in parentheses) Brabrand 1950-1959 No treatment Exsufflation Suction drainage Pleurodesis exsufflation Pleurodesis suction drainage Thoracotomy
58 (43.6) 38 (29) 12 (9) 13 4 8 (6)
Total
133
+ +
Own series 1960-1970 24 (10.5) 8 (3.5) 134 (58.5) 63 (27.5) 229
Spontaneous pneumothorax
283
Table V. Methods and results in the present series Prev. pneumothorax
No.
Treatment
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Bed rest Exsufflation Suction drainage Thoracotomy
24 8 134 63
Men 20 7 105 49
Women
same side
4 1
7 3
29 14
31
17
exsufflation is naturally used with larger amounts of intrapleural air and thus larger air leakage from the lung surface. The report by 14 authors on treatment of 146 patients with spontaneous pneumothorax by exsufflation showed that resort to other forms of treatment became necessary in 39% of the patients. The mean period for complete lung expansion was 20 days (Killen & Cobbel, 1968). In our series, 8 patients, all of whom had a small air leakage on admission, belonged to this group. Mean hospitalization was 13 days (2-21). There were no hospital relapses, but two occurred after discharge. Eleven other patients were primarily treated with exsufflation. In 10 of them suction drainage had to be instituted and one had a thoracotomy. Group ZZZ. Suction Drainage
This form of treatment has been more extensively used in the course of the last 20 years. With this procedure, a rapid expansion of the lung is usually effected and maintained, and blood or other fluids are effectively drained. One drain is usually sufficient, but in some cases two or more drains may become necessary, probably because of adhesions which cause trapping of the air in loculi. The reports by 16 authors on altogether 605 patients treated by drainage show that the method was successful in 91.3% of the cases (Killen et al. 1968). In our series this treatment has been used in the largest group (134 patients). In 123 patients suction drainage was instituted on admission. One patient was primarily treated conservatively, and 10 patients were primarily treated with exsufflation.
other side
bilat.
2 0 10 2
3 0 2 8
Hospital stay
Mortality
7.5 d. 13 d. 20 d. 26 d.
0 1 4 1
The interval from initiation of symptoms until suction drainage was applied is listed in Table VI. In 17 patients the lung was found to have expanded only partially after one day of suction. The time prior to complete lung expansion varied, as shown in Table VII. Duration of suction drainage
The recommended duration of suction treatment varies greatly, but it seems that 12-24 hours after complete lung expansion and cessation of any signs of air leakage may be a safe routine. In our department, the thoracic drain has always been connected to suction with hypopressure of 15-20 cm of water. Even when the lung has expanded completely, the leakage of air has sometimes lasted for a relatively long time. Only during the last few years has air leakage been routinely controlled by means of a water-seal bottle; 24 hours after the cessation of all signs of air leakage, the drain has been successively clamped for increasing periods and with X-ray control to diagnose relapse. The duration of drainage is seen from Table VIII. In addition to these 134 patients, 20 patients who were primarily treated by suction drainage later had a thoracotomy. The drain was removed without having been clamped for control of leakage in 19 patients. In 22 patients, pneumothorax recurred after clamping and in 11 after removal of the drain. In 6 of these latter patients a new drain was applied, whereas 5 patients were left to spontaneous expansion. In 19 patients two drains had to be applied to obtain complete expansion of the lung. Mean hospitaliza-
Table VI. Time from the start of symptoms before application of suction drainage
Table VII. Time from application of suction drainage until complete lung expansion
Time @-6 h. No. of patients 1 0
Days No. of patients
6-12 h. 12-24 h. 2-4 d. 9 44 61
>4d. 10
1 86
2 10
3 3
4 2
5 15
6 1
Scand J Thor Cardiovasc Surg 9
284 F. Abyholm et al. Table VIII. Time from application of suction drainage clamping, resp. removal of drain
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Days Clamping of drain Relapse after clamping Drain removed Relapse after removal
6 13 3 1 1
7 17 1 8 1
8 9 22 21 4 2 6 1 7 1 2
10 15 5 6 1
tion was 20 days. This is a rather long time compared with other reviews, which report a of 6 1 2 days (Carpathios & Bogedian, 1963; 1966; Withers, Fisback Kiehl & Hannon, Lynn, 1965; Aust, 1961).
11 12 13 7 8 3 2 3 8 1 6 1 6 4 1 1
when mean Levy, 1964;
Group I V: Treatment Thoracotomy Thoracotomy becomes necessary when suction drainage is insufficient because of continuous leakage of air from the lung surface. Operation may also be indicated in cases of recurrent pneumothorax and of haemopneumothorax. The patient’s respiratory reserves greatly influence the choice of treatment. In some cases, this reserve is marginal and in those patients a pneumothorax can only be tolerated for a limited time. This is especially so in patients suffering from chronic emphysematous bronchitis. Thoracotomy has been widely accepted as the treatment of choice for recurrent pneumothorax, based on a knowledge of the pathological anatomy of these lesions. The primary aspect of the operation is, apart from the resection of the diseased lung tissue containing the subpleural bullae, to obtain a n adhesion formation between the visceral and parietal pleura. This has been accomplished by rubbing of the surfaces, pleurectomy or installation of various remedies which act by local irritation. The effectiveness of the operative treatment in prohibiting relapse seems satisfactory, since in 21 authors’ reports of altogether 950 patients treated with thoracotomy only 4 recidivated. In our series 63 patients (27.5%) were thoracotomied. The indication for thoracotomy is seen from Table IX. The operative findings may be seen
Table IX. Indications for thoracotomy Failure of exsufflation Failure of suction drainage Recid. pneumothorax Bilat. pneumothorax Thoracotomy prim. treatment Scand J Thor Cardiovasc Surg 9
1 20 42
14 9 2 2 1
15
16
17
18
19
20
~ 2 0
6
5
4
1
2
1
11
in Table X, and the operative procedures are listed in Table XI. Eight patients were admitted with bilateral pneumothorax. The complications are listed in Table XII. In the thoracotomy group mean hospitalization was 26 days. Complications Pressure pneumothorax is caused by a valve formation allowing air to enter the pleural cavity during each inspiration and trapping it there. The dyspnoea is more serious and may be dramatic, and a cardiovascular collapse may result. X-ray shows deviation of the trachea. mediastinum and heart towards the
Table X. Operative findings in the 63 thoracotomy patients Bullae Fibrous tissue in apex Bronchial fistula Leakage from apex Haemopneumothorax Atelectasis No pathology
47 (75 70) 5 1
2 3 2 3
Table XI. Operative procedures in the 63 thoracotomy patients Resection of bullae, rubbing Resection of bullae, pleurectomy Pleurectomy Suture Pleurectomy lobectomy Pleurectomy + evacuation of hemothorax Lobectomy
+
34 8 10 4 1 3 3
Table XII. Postoperative complications in the thoracotomy group Pneumonia Wound infection Protracted pleural exudation Atelectasis and pleural fistula (later thoracoplasty) Postop. resp. failure, tracheostomy, respirator Contralateral pressure pneumothorax
2 5 1 1 1
1
Spontaneous pneumothorax 285
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Table XIII. Review of the 6 male patients who died during the treatment Time from symptoms to death
Clinical death diagnosis and findings a t autopsy
No.
Age
Earlier lung disease
Treatment
1
58
Chronic emphysematous bronchitis
Exsufflation Suction drainage Thoracotomy
9 months
Pneumonia. Respiratory insufficiency Mesothelioma pleurae Coronary disease
2
67
Pneumonia
Suction drainage Tracheostomia
2 months
Bronchopneumonia Emphysema pulm. Bronchiectasis Bronchitis chr.
3
58
Asthma
Suction drainage
3 days
Status asthmaticus Emphysema pulm.
4
78
Chronic emphysematous bronchitis
Suction drainage
5 days
Bronchopneumonia Emphysema Bronchitis chr.
5
80
Chronic emphysematous bronchitis
Suction drainage Tracheostomia Respirator
10 weeks
Bronchopneumonia Emphysema Bronchitis chr.
6
67
Tbc. pulm.
Exsufflation
2 days
Bronchopneumonia Asthma bronchiale Emphysema pulm.
contralateral side and variable collapse of the lung. Instantaneous relief of the hyperpressure is mandatory. In this series pressure pneumothorax was diagnosed in 42 patients. All patients, in whom air was expelled with force at thoracocentesis, have been included. Haemopneumothorax is a rare entiry and is reported in 2-5% of hospitalized cases of spontaneous pneumothorax. ‘The condition is characterized by accumulation of air and blood in the pleural cavity. The bleeding is caused by tearing of vascularized adhesions at the moment of lung collapse. The vessels lack musculature and normal retraction is prevented. This factor, together with the negative intrathoracic pressure, are responsible for the continuous bleeding in these cases (Deaton & Johnston, 1962). The symptoms are the same as with spontaneous pneumothorax, with the addition of symptoms caused by the blood loss, which may be considerable. Blood loss of up to 8 OOO ml in the course of 18 hours has been reported (Mills & Baisch, 1965). Treatment of haemopneumothorax is surgical, by effective drainage, blood transfusions, and in selected cases thoracotomy. In our series 5 patients (2.2 %) had haemopneumothorax. Mean blood loss was 1 500-2 OOO ml @byholm & Straren 1973).
Pneumomediastinum and subcutaneous emphysema Pneumomediastinum has been diagnosed in 1.5 % in series of spontaneous pneumothorax (Stenek et a]., 1961; Hyde, 1963; Killen &Jackson, 1963; Schecter, 1963) and subcutaneous emphysema is usually also present in these cases. The air spreads to the neck and head, upper chest and upper extremities. In our series 5 patients (2.2%) had this complication. Bronchopleural fistula wlw-0. emphysema These complications occasionally occur in severe and long-term leakage from the bronchial tree to the pleural cavity. Suction drainage and antibiotics should be tested, but thoracotomy with decortication, resection or even thoracoplasty may become necessary if the fistula persists. Mortality Six patients (2.6%) died in hospital. They were all men in the age 58-80 years. One was treated by exsufflation only, 4 by suction drainage and one was thoracotomied. Three of the patients who died belonged to the chronic emphysematous bronchitis group. A detailed review of the patients is given in Table XIII. CONCLUDING REMARKS Our attitude to the treatment of spontaneous pneumothorax has changed from the period 1950-59 Scand J Thor Cardiovasc Surg 9
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286 F. Abyholm et al. to the period 1960-69. In the first period, 72% were treated either without any surgical activity or with exsufflation, versus 14% in the period 1960-69. Suction drainage is at present applied in all cases with an amount of air which on a frontal X-ray measures more than about one inch. Suction is continued until leakage has stopped, shown by continuous complete expansion of the lung after increasing periods of drain clamping. This clamping has been started after about 9 days and the drain removed after 12 days. We have not found from the present review of this series that early clamping and removal have resulted in increased frequency of lung collapse. We have not routinely used under water seal for discovery of air leakage. As a consequence of our experiences from the present series, we have started to use such a control and crossclamp the drain as soon as the air bubbling stops. As soon as two or three X-ray controls in the course of 24 hours have shown that the leakage is sealed, the drain is removed. It was concluded from the series 1950-59 (Brabrand, 1963) that recurrent pneumothorax constitutes an indication for thoracotomy with resection of bullae and pleurodesis. These principles have led to the relatively large number of thoracotomies in the later period. Pleurodesis is now effected by means of rubbing of the pleural surfaces with dry compresses, instead of pleurectomy, to make possible future thoracotomy for other unrelated pulmonary lesions.
REFERENCES Aust, B. J. 1961. Spontaneous pneumothorax. Postgrad Med 29, 368. Baronofsky, J. D., Warden, H. G., Kaufmann, J. C., Whatley, J. & Hanner, J. H. 1957. Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Surg 34, 3 10. Bernhard, W. F., Malcolm, J. A., Berry, R. W. & Wylie, R. H. 1962. A study of the pathogenesis and management of spontaneous pneumothorax. Dis Chest 42, 403. Brabrand, G. 1963. Spontaneous pneumothorax. J Oslo City Hosp 13, 3-10.
Scand J Thor Cardiovasc Surg 9
Carpathios, J. & Bogedian, W. 1963. Spontaneous pneumothorax. Experience with fifty cases. Amer Surg 29, No. 8. Carr, D. T., Silver, A. W. & Ellis, F. H. 1963. Management of spontaneous pneumothorax: With special reference to prognosis after various kinds of therapy. Mayo CIin Proc 38, 103. Collins, H. A., Daniel, R. A. Jr & Diveley, W. L. 1963. Parietal pleurectomy for spontaneous pneumothorax. Amer Surg 29, 844. Crowther, J. S. 1955. Spontaneous pneumothorax. Tubercle (London) 36, 265. Deaton, W. R. &Johnston, F. R. 1962. Spontaneous pneumothorax. J Thorac Cardiov Surg 43, 413. Du Bois, H. M., Price, H. J. & Guilfoil, P. H. 1953. Spontaneous pneumothorax: Medical and surgical management. Analysis of 75 patients. New Engl J Med 248, 1. Hamel, N. C., Briggs, J. N. & Schultkins, T. A. 1963. Thoracotomy in the treatment of pneumothorax. Amer Rev Resp Dis 88, 55 1. Hyde, L. 1963. Spontaneous pneumothorax. Dis Chest 43, 476.
Killen, D. A. & Cobbel, W. G. 1968. Spontaneous pneumothorax. J. & A. Churchill Ltd., London. Killen, D. A. & Jackson, L. M. 1963. Management of spontaneous pneumothorax. J Tenn Med Ass 56, 439. Levy, I. J. 1966. Spontaneous pneumothorax. Treatment based o n analysis of 170 episodes in 135 patients. Dis Chest 49, 529. Lynn, R. B. 1965. Spontaneous pneumothorax. Dis Chest 48, 251.
Marrangoni, A. G., Storey, C. F. & Geiv, P. 0. 1955. The management of spontaneous pneumothorax. Amer Rev Tuberc Pulm Dis 72, 257. Mills, M. & Baisch, B. F. 1965. Spontaneous pneumothorax. Ann Thorac Surg 1, 286. Myers, J. A. 1954. Simple spontaneous pneumothorax. Dis Chest 26, 420. Ramel, Briggs & Schultkins. 1963. Schecter, M. M. 1963. Spontaneous pneumothorax. Some special features and a program of therapy. J FIorida Med Ass 50, 203. Shefts, L. M.,Gilpatrick, C., Swindell, H. & Gabbard, J. G. 1954. Management of spontaneous pneumothorax. Dis Chest 26, 213. Sochocky, S. A. 1966. A simple spontaneous pneumothorax. Br J CIin Pract 14, 12. Stanek, R. G., Wilson, J. L. & Rogers, W. L. 1961. Spontaneous pneumothorax. A review of 71 cases. Dis Chest 40, 391. Withers, J. N., Fisback, M. E., Kiehl, P. V. & Hannon, J. L. 1964. Spontaneous pneumothorax. Amer J Surg 108,772. Abyholm, F. & Steren, G. 1973. Spontaneous haemopneumothorax. Thorax (in press).
SPONTANEOUS PNEUMOTHORAX F. Abyholm, G. Starren and 0. Geiran From Surgical Department IlI, Ulleudl Hospital, Oslo, Norway
Scand Cardiovasc J Downloaded from informahealthcare.com by University of Newcastle Upon Tyne on 12/20/14 For personal use only.
(Submitted for publication October 1, 1973)
Abstract. Patients with spontaneous pneumothorax, who were treated in this department during the period 1950-59, were reviewed in 1963. Since the treatment of this group of patients has changed radically towards a greater surgical activity in the form of suction drainage and thoracotomy, the patients from the next decade, comprising 229 episodes in 202 patients, have now been reviewed to evaluate the results of this attitude. The conclusion from the earlier review, that recidivating pneumothorax should be operated upon, is further supported, and in quite a few patients (9 %) thoracotomy had to be performed to control the first attack. Pleural rubbing, as an additional procedure to resection of bullae, seems as safe as partial pleurectomy in prevention of relapse. There were few serious operative complications. A rather protracted suction drainage has been practised in this series. One consequence of the experiences from the present review is that this time has been shortened.
In the present report, the primary and secondary forms of spontaneous pneumothorax are reviewed in connection with a presentation of a 10-year series of such patients from Surgical Department 111, UllevAl Hospital. Oslo. The series comprises 229 episodes of spontaneous pneumothorax in 202 patients. A series from the same department during the period 1950-59 has been presented earlier (Braband, 1963). Since our routine has changed, it would seem to be of interest to analyse the effectiveness of our present attitude, as related to earlier results, our own as well as those of others. Spontaneous pneumothorax occurs principally in two different groups of individuals. One group consists of young, otherwise healthy persons, with a strong preponderance in men, mainly in the age group 20-30 years. This type has been named primary spontaneous pneumothorax (Killen & Cobbel, 1968; Levy, 1966; Myers, 1954; Lynn, 1965; Hyde, 1963; du Bois, Price & Guilfoil; 1953). The other group, secondary spontaneous pneumothorax, consists mainly of patients with chronic bronchitis and secondary lung emphysema. 19 - 752915
In both groups, the direct cause of pneumothorax is rupture of subpleural bullae which communicate with the bronchial tree. Pneumothorax may also complicate a number of lung diseases, such as pneumonia with lung abscess formation, particularly when the pneumonia is caused by staphylococcus, cancer, and sarcoidosis. Bullae are best demonstrated by tomography of collapsed lung, and has been found by this method in 15% (Killen & Cobbel, 1968). By thoracoscopy, bullae have been diagnosed in 30-75% (Marrangoni, Storey & Geib, 1955; Crowther, 1955; Sochocky, 1966; Stanek, Wilson and Rogers, 1961). In patients operated upon for spontaneous pneumothorax, bullae have been found in 85-95%, while the frequency was 75% in a series which comprised primary as well as secondary spontaneous pneumothorax (Ramel, Briggs & Schultkings, 1963; Killen & Jackson, 1963; Shefts, Gilpatrick, Swindell & Gabbard, 1954; Baronofsky, Warden, Kaufmann, Whatley & Hanner, 1957). These series agree well with our own experience, since we diagnosed bullae by X-ray in 31 cases (14%) and found bullae in 47 (75%) of our 63 thoracotomy patients. The age distribution is shown in Fig. 1. The sex distribution and the side the of pneumothorax are shown in Table I. Diagnosis Spontaneous pneumothorax should be suspected with a history of sudden chest pain, noted either at rest or during physical exercise and sometimes accompanied by dyspnoea. Such a history has often led to false diagnosis of coronary disease, acute shoulder pains, perforated ulcer, acute gall bladder disease or pancreatitis. The pain usually subsides in the course of a few hours and the dyspnoea is then only noted after Scand J Thor Cardiovasc Surg 9
F. Abyholm et al.
282
Table 111. Previous manifestations of pulmonary disease
No. 100
r
93
Spontaneous pneumothorax Chronic emphysematous pulm. dis. Tuberculosis Sarcoidosis Bronchiectasia
85 31 15
1 1
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40
In a series from our department, during the period 1950-59 (Brabrand, 1963), the treatment of spontaneous pneumothorax was mainly conservative. Table IV delineates the treatment of this group of patients in our department during the last two decades. Table V shows the results of treatment in the present series.
20
10-20
Fig. 1. Age distribution of the patient series.
physical exercise, with major collapse of the lung and, especially with pressure pneumothorax, the dyspnoea may be dramatic. In our series, a number of patients were admitted to the medical department with a diagnosis of myocardial infarction. The diagnosis of spontaneous pneumothorax is confirmed by X-ray. The degree of lung collapse in our series is seen from Table 11. Previous lung disease One hundred and thirty-three of our patients had earlier manifestations of pulmonary disease (Table 111).
TREATMENT The trend in our treatment of spontaneous pneumothorax has been towards a greater surgical activity. Table I. Sex distribution and side
Group I: Bed Rest Only
Bed rest has been used as the only form of treatment when the pneumothorax has been slight and the patient has had no respiratory difficulty and no signs of progression. The normal course is absorption of the air and lung expansion during a period ranging from a few days to a couple of weeks. In our series, 24 patients were treated conservatively, i.e. 10.4%; All of them had a small amount of intrapleural air. Mean hospitalization was 7.5 days. In one patient, we had to resort to thoracic drainage with suction after a long test of conservative therapy, and in 2 patients the pneumothorax recurred during the hospitalization. Group 11: Exsufflation In this group, one must resort to radical methods more often than in the fiist group, probably because
Side of pneumothorax No. Men
Women
Right
Left
Bilat.
Table 11. Degree of lung collapse judged by frontal projection No. Small Moderate to severe Total collapse
Scand J Thor Cardiovasc Surg 9
60 86 83
Table IV. The change in therapy towards greater activity from the decade 195060 to 1960-70 (percentages in parentheses) Brabrand 1950-1959 No treatment Exsufflation Suction drainage Pleurodesis exsufflation Pleurodesis suction drainage Thoracotomy
58 (43.6) 38 (29) 12 (9) 13 4 8 (6)
Total
133
+ +
Own series 1960-1970 24 (10.5) 8 (3.5) 134 (58.5) 63 (27.5) 229
Spontaneous pneumothorax
283
Table V. Methods and results in the present series Prev. pneumothorax
No.
Treatment
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Bed rest Exsufflation Suction drainage Thoracotomy
24 8 134 63
Men 20 7 105 49
Women
same side
4 1
7 3
29 14
31
17
exsufflation is naturally used with larger amounts of intrapleural air and thus larger air leakage from the lung surface. The report by 14 authors on treatment of 146 patients with spontaneous pneumothorax by exsufflation showed that resort to other forms of treatment became necessary in 39% of the patients. The mean period for complete lung expansion was 20 days (Killen & Cobbel, 1968). In our series, 8 patients, all of whom had a small air leakage on admission, belonged to this group. Mean hospitalization was 13 days (2-21). There were no hospital relapses, but two occurred after discharge. Eleven other patients were primarily treated with exsufflation. In 10 of them suction drainage had to be instituted and one had a thoracotomy. Group ZZZ. Suction Drainage
This form of treatment has been more extensively used in the course of the last 20 years. With this procedure, a rapid expansion of the lung is usually effected and maintained, and blood or other fluids are effectively drained. One drain is usually sufficient, but in some cases two or more drains may become necessary, probably because of adhesions which cause trapping of the air in loculi. The reports by 16 authors on altogether 605 patients treated by drainage show that the method was successful in 91.3% of the cases (Killen et al. 1968). In our series this treatment has been used in the largest group (134 patients). In 123 patients suction drainage was instituted on admission. One patient was primarily treated conservatively, and 10 patients were primarily treated with exsufflation.
other side
bilat.
2 0 10 2
3 0 2 8
Hospital stay
Mortality
7.5 d. 13 d. 20 d. 26 d.
0 1 4 1
The interval from initiation of symptoms until suction drainage was applied is listed in Table VI. In 17 patients the lung was found to have expanded only partially after one day of suction. The time prior to complete lung expansion varied, as shown in Table VII. Duration of suction drainage
The recommended duration of suction treatment varies greatly, but it seems that 12-24 hours after complete lung expansion and cessation of any signs of air leakage may be a safe routine. In our department, the thoracic drain has always been connected to suction with hypopressure of 15-20 cm of water. Even when the lung has expanded completely, the leakage of air has sometimes lasted for a relatively long time. Only during the last few years has air leakage been routinely controlled by means of a water-seal bottle; 24 hours after the cessation of all signs of air leakage, the drain has been successively clamped for increasing periods and with X-ray control to diagnose relapse. The duration of drainage is seen from Table VIII. In addition to these 134 patients, 20 patients who were primarily treated by suction drainage later had a thoracotomy. The drain was removed without having been clamped for control of leakage in 19 patients. In 22 patients, pneumothorax recurred after clamping and in 11 after removal of the drain. In 6 of these latter patients a new drain was applied, whereas 5 patients were left to spontaneous expansion. In 19 patients two drains had to be applied to obtain complete expansion of the lung. Mean hospitaliza-
Table VI. Time from the start of symptoms before application of suction drainage
Table VII. Time from application of suction drainage until complete lung expansion
Time @-6 h. No. of patients 1 0
Days No. of patients
6-12 h. 12-24 h. 2-4 d. 9 44 61
>4d. 10
1 86
2 10
3 3
4 2
5 15
6 1
Scand J Thor Cardiovasc Surg 9
284 F. Abyholm et al. Table VIII. Time from application of suction drainage clamping, resp. removal of drain
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Days Clamping of drain Relapse after clamping Drain removed Relapse after removal
6 13 3 1 1
7 17 1 8 1
8 9 22 21 4 2 6 1 7 1 2
10 15 5 6 1
tion was 20 days. This is a rather long time compared with other reviews, which report a of 6 1 2 days (Carpathios & Bogedian, 1963; 1966; Withers, Fisback Kiehl & Hannon, Lynn, 1965; Aust, 1961).
11 12 13 7 8 3 2 3 8 1 6 1 6 4 1 1
when mean Levy, 1964;
Group I V: Treatment Thoracotomy Thoracotomy becomes necessary when suction drainage is insufficient because of continuous leakage of air from the lung surface. Operation may also be indicated in cases of recurrent pneumothorax and of haemopneumothorax. The patient’s respiratory reserves greatly influence the choice of treatment. In some cases, this reserve is marginal and in those patients a pneumothorax can only be tolerated for a limited time. This is especially so in patients suffering from chronic emphysematous bronchitis. Thoracotomy has been widely accepted as the treatment of choice for recurrent pneumothorax, based on a knowledge of the pathological anatomy of these lesions. The primary aspect of the operation is, apart from the resection of the diseased lung tissue containing the subpleural bullae, to obtain a n adhesion formation between the visceral and parietal pleura. This has been accomplished by rubbing of the surfaces, pleurectomy or installation of various remedies which act by local irritation. The effectiveness of the operative treatment in prohibiting relapse seems satisfactory, since in 21 authors’ reports of altogether 950 patients treated with thoracotomy only 4 recidivated. In our series 63 patients (27.5%) were thoracotomied. The indication for thoracotomy is seen from Table IX. The operative findings may be seen
Table IX. Indications for thoracotomy Failure of exsufflation Failure of suction drainage Recid. pneumothorax Bilat. pneumothorax Thoracotomy prim. treatment Scand J Thor Cardiovasc Surg 9
1 20 42
14 9 2 2 1
15
16
17
18
19
20
~ 2 0
6
5
4
1
2
1
11
in Table X, and the operative procedures are listed in Table XI. Eight patients were admitted with bilateral pneumothorax. The complications are listed in Table XII. In the thoracotomy group mean hospitalization was 26 days. Complications Pressure pneumothorax is caused by a valve formation allowing air to enter the pleural cavity during each inspiration and trapping it there. The dyspnoea is more serious and may be dramatic, and a cardiovascular collapse may result. X-ray shows deviation of the trachea. mediastinum and heart towards the
Table X. Operative findings in the 63 thoracotomy patients Bullae Fibrous tissue in apex Bronchial fistula Leakage from apex Haemopneumothorax Atelectasis No pathology
47 (75 70) 5 1
2 3 2 3
Table XI. Operative procedures in the 63 thoracotomy patients Resection of bullae, rubbing Resection of bullae, pleurectomy Pleurectomy Suture Pleurectomy lobectomy Pleurectomy + evacuation of hemothorax Lobectomy
+
34 8 10 4 1 3 3
Table XII. Postoperative complications in the thoracotomy group Pneumonia Wound infection Protracted pleural exudation Atelectasis and pleural fistula (later thoracoplasty) Postop. resp. failure, tracheostomy, respirator Contralateral pressure pneumothorax
2 5 1 1 1
1
Spontaneous pneumothorax 285
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Table XIII. Review of the 6 male patients who died during the treatment Time from symptoms to death
Clinical death diagnosis and findings a t autopsy
No.
Age
Earlier lung disease
Treatment
1
58
Chronic emphysematous bronchitis
Exsufflation Suction drainage Thoracotomy
9 months
Pneumonia. Respiratory insufficiency Mesothelioma pleurae Coronary disease
2
67
Pneumonia
Suction drainage Tracheostomia
2 months
Bronchopneumonia Emphysema pulm. Bronchiectasis Bronchitis chr.
3
58
Asthma
Suction drainage
3 days
Status asthmaticus Emphysema pulm.
4
78
Chronic emphysematous bronchitis
Suction drainage
5 days
Bronchopneumonia Emphysema Bronchitis chr.
5
80
Chronic emphysematous bronchitis
Suction drainage Tracheostomia Respirator
10 weeks
Bronchopneumonia Emphysema Bronchitis chr.
6
67
Tbc. pulm.
Exsufflation
2 days
Bronchopneumonia Asthma bronchiale Emphysema pulm.
contralateral side and variable collapse of the lung. Instantaneous relief of the hyperpressure is mandatory. In this series pressure pneumothorax was diagnosed in 42 patients. All patients, in whom air was expelled with force at thoracocentesis, have been included. Haemopneumothorax is a rare entiry and is reported in 2-5% of hospitalized cases of spontaneous pneumothorax. ‘The condition is characterized by accumulation of air and blood in the pleural cavity. The bleeding is caused by tearing of vascularized adhesions at the moment of lung collapse. The vessels lack musculature and normal retraction is prevented. This factor, together with the negative intrathoracic pressure, are responsible for the continuous bleeding in these cases (Deaton & Johnston, 1962). The symptoms are the same as with spontaneous pneumothorax, with the addition of symptoms caused by the blood loss, which may be considerable. Blood loss of up to 8 OOO ml in the course of 18 hours has been reported (Mills & Baisch, 1965). Treatment of haemopneumothorax is surgical, by effective drainage, blood transfusions, and in selected cases thoracotomy. In our series 5 patients (2.2 %) had haemopneumothorax. Mean blood loss was 1 500-2 OOO ml @byholm & Straren 1973).
Pneumomediastinum and subcutaneous emphysema Pneumomediastinum has been diagnosed in 1.5 % in series of spontaneous pneumothorax (Stenek et a]., 1961; Hyde, 1963; Killen &Jackson, 1963; Schecter, 1963) and subcutaneous emphysema is usually also present in these cases. The air spreads to the neck and head, upper chest and upper extremities. In our series 5 patients (2.2%) had this complication. Bronchopleural fistula wlw-0. emphysema These complications occasionally occur in severe and long-term leakage from the bronchial tree to the pleural cavity. Suction drainage and antibiotics should be tested, but thoracotomy with decortication, resection or even thoracoplasty may become necessary if the fistula persists. Mortality Six patients (2.6%) died in hospital. They were all men in the age 58-80 years. One was treated by exsufflation only, 4 by suction drainage and one was thoracotomied. Three of the patients who died belonged to the chronic emphysematous bronchitis group. A detailed review of the patients is given in Table XIII. CONCLUDING REMARKS Our attitude to the treatment of spontaneous pneumothorax has changed from the period 1950-59 Scand J Thor Cardiovasc Surg 9
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286 F. Abyholm et al. to the period 1960-69. In the first period, 72% were treated either without any surgical activity or with exsufflation, versus 14% in the period 1960-69. Suction drainage is at present applied in all cases with an amount of air which on a frontal X-ray measures more than about one inch. Suction is continued until leakage has stopped, shown by continuous complete expansion of the lung after increasing periods of drain clamping. This clamping has been started after about 9 days and the drain removed after 12 days. We have not found from the present review of this series that early clamping and removal have resulted in increased frequency of lung collapse. We have not routinely used under water seal for discovery of air leakage. As a consequence of our experiences from the present series, we have started to use such a control and crossclamp the drain as soon as the air bubbling stops. As soon as two or three X-ray controls in the course of 24 hours have shown that the leakage is sealed, the drain is removed. It was concluded from the series 1950-59 (Brabrand, 1963) that recurrent pneumothorax constitutes an indication for thoracotomy with resection of bullae and pleurodesis. These principles have led to the relatively large number of thoracotomies in the later period. Pleurodesis is now effected by means of rubbing of the pleural surfaces with dry compresses, instead of pleurectomy, to make possible future thoracotomy for other unrelated pulmonary lesions.
REFERENCES Aust, B. J. 1961. Spontaneous pneumothorax. Postgrad Med 29, 368. Baronofsky, J. D., Warden, H. G., Kaufmann, J. C., Whatley, J. & Hanner, J. H. 1957. Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Surg 34, 3 10. Bernhard, W. F., Malcolm, J. A., Berry, R. W. & Wylie, R. H. 1962. A study of the pathogenesis and management of spontaneous pneumothorax. Dis Chest 42, 403. Brabrand, G. 1963. Spontaneous pneumothorax. J Oslo City Hosp 13, 3-10.
Scand J Thor Cardiovasc Surg 9
Carpathios, J. & Bogedian, W. 1963. Spontaneous pneumothorax. Experience with fifty cases. Amer Surg 29, No. 8. Carr, D. T., Silver, A. W. & Ellis, F. H. 1963. Management of spontaneous pneumothorax: With special reference to prognosis after various kinds of therapy. Mayo CIin Proc 38, 103. Collins, H. A., Daniel, R. A. Jr & Diveley, W. L. 1963. Parietal pleurectomy for spontaneous pneumothorax. Amer Surg 29, 844. Crowther, J. S. 1955. Spontaneous pneumothorax. Tubercle (London) 36, 265. Deaton, W. R. &Johnston, F. R. 1962. Spontaneous pneumothorax. J Thorac Cardiov Surg 43, 413. Du Bois, H. M., Price, H. J. & Guilfoil, P. H. 1953. Spontaneous pneumothorax: Medical and surgical management. Analysis of 75 patients. New Engl J Med 248, 1. Hamel, N. C., Briggs, J. N. & Schultkins, T. A. 1963. Thoracotomy in the treatment of pneumothorax. Amer Rev Resp Dis 88, 55 1. Hyde, L. 1963. Spontaneous pneumothorax. Dis Chest 43, 476.
Killen, D. A. & Cobbel, W. G. 1968. Spontaneous pneumothorax. J. & A. Churchill Ltd., London. Killen, D. A. & Jackson, L. M. 1963. Management of spontaneous pneumothorax. J Tenn Med Ass 56, 439. Levy, I. J. 1966. Spontaneous pneumothorax. Treatment based o n analysis of 170 episodes in 135 patients. Dis Chest 49, 529. Lynn, R. B. 1965. Spontaneous pneumothorax. Dis Chest 48, 251.
Marrangoni, A. G., Storey, C. F. & Geiv, P. 0. 1955. The management of spontaneous pneumothorax. Amer Rev Tuberc Pulm Dis 72, 257. Mills, M. & Baisch, B. F. 1965. Spontaneous pneumothorax. Ann Thorac Surg 1, 286. Myers, J. A. 1954. Simple spontaneous pneumothorax. Dis Chest 26, 420. Ramel, Briggs & Schultkins. 1963. Schecter, M. M. 1963. Spontaneous pneumothorax. Some special features and a program of therapy. J FIorida Med Ass 50, 203. Shefts, L. M.,Gilpatrick, C., Swindell, H. & Gabbard, J. G. 1954. Management of spontaneous pneumothorax. Dis Chest 26, 213. Sochocky, S. A. 1966. A simple spontaneous pneumothorax. Br J CIin Pract 14, 12. Stanek, R. G., Wilson, J. L. & Rogers, W. L. 1961. Spontaneous pneumothorax. A review of 71 cases. Dis Chest 40, 391. Withers, J. N., Fisback, M. E., Kiehl, P. V. & Hannon, J. L. 1964. Spontaneous pneumothorax. Amer J Surg 108,772. Abyholm, F. & Steren, G. 1973. Spontaneous haemopneumothorax. Thorax (in press).
