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SPONTANEOUS PNEUMOTHORAX AND INDICATIONS FOR PLEURODESIS Rishabh Shah, MD Seattle Children’s Hospital October 31, 2013 OBJECTIVES Case report-CW Discuss classification, presentation, and symptoms of spontaneous pneumothorax Discuss operative management Discuss factors complicating operative intervention CASE REPORT-CW 16 year old male presents to outside ED with sudden onset of left sided chest pain, without shortness of breath Transferred to SCH after chest xray demonstrated left pneumothorax, treated with ketorolac History of recurrent right sided pneumothorax requiring with talc and mechanical pleurodesis HISTORY PMH-recurrent right-sided pneumothorax, FTT requiring G-tube, eosinophilic esophagitis, ADHD, insomnia PSH-VATS RUL wedge resection of bullae, talc and mechanical pleurodesis, G-tube placement, myringotomies with tube placement FH-bipolar disorder, emphysema(PGF), no history of connective tissue disorders SH-denies cigarette use EXAM Vitals: T: 37˚, HR: 53, BP: 109/59, RR: 16, O2: 100% on room air No increased work of breathing Reduced lung sounds in anterior and apex of left lung field CHEST XRAY MANAGEMENT Taken to OR for VATS bleb resections and talc pleurodesis 24 French chest tube placed intraoperatively and maintained on 20 cmH2O suction for 48 hours Stable chest xray after being placed on water seal Discharged post-operative day 3 SPONTANEOUS PNEUMOTHORAX Primary-spontaneously occuring pneumothorax in an individual without evidence of underlying lung disease Occurs primarily in tall, thin males (male-tofemale ratio of 1.9-10:1) Average age range of 13.3-16.5 In adults, smoking history important, but less so in pediatric poplation CONTINUED Secondary –related to underlying disease, which can cause weakening of the connective tissue of the lung Causes range from primary lung disorders, such as cystic fibrosis, asthma, etc. to systemic diseases such as connective tissue disorders and autoimmune processes to infectious and malignant processes Less male dominance (1.4-4.3:1 male-to-female ratio) PRESENTATION Presents most commonly with sudden onesided chest pain and dyspnea Less often, anxiety, cough, and fatigue Secondary pneumothoraces present with more severe dyspnea due to underlying reduced lung function MANAGEMENT Initially, placement of chest tube for first occurrence of primary spontaneous pneumothorax If failure to resolve pneumothorax (persistent air leak), proceed to pleurodesis PLEURODESIS Method to obliterate pleural space Promotes scarring between parietal and visceral pleura INDICATIONS American College of Chest Physicians Delphi Consensus Statement, “Management of Spontaneous Pneumothorax,” recommends surgical intervention following: second occurrence of a primary spontaneous pneumothorax first occurrence of a secondary spontaneous pneumothorax. persistent air leak for greater than 4 days. RELATIVE INDICATIONS high-risk occupations (i.e., airline pilots, divers) a contralateral pneumothorax, bilateral pneumothoraces, AIDS MODALITIES Chemical-can be introduced through nonoperative and operative methods Talc and tetracycline derivatives most common agents utilized Operative approach provides added benefit of resection of affected lung tissue as well as ability to assess lung expansion Mechanical-create raw surfaces that further produce inflammation Scrubbing pleural surface with a rough gauze pad or stripping of pleura can be done CONTRAINDICATIONS Patients with trapped lung and incomplete lung expansion Severe inflammatory disease in which further inflammation would compromise pulmonary function WHEN TO QUESTION USE OF PLEURODESIS If successful, pleurodesis causes strong scarring of visceral to parietal pleura with obliteration of pleural space In patients who are eligible for lung transplant, these strong adhesions cause great difficulties for transplant surgeon MINI CASE REPORTS HC-23 year old female with tuberous sclerosis with history of multiple left and right pneumothoraces finally treated with mechanical pleurodesis in 2012 and 2013 CONTINUED KS-47 year old female with severe bronchiectasis secondary to cystic fibrosis leading to spontaneous right pneumothorax in 2008 treated with mechanical pleurodesis, bilateral lung transplant in 2013 with multiple morbidities in the postoperative phase REFERENCES Dotson, K., Johnson, L. Pediatric spontaneous pneumothorax. Pediatr Emer Care. 2012;28: 715723. Cameron, J. Pneumothorax, Current Surgical Therapy, 9th Ed. 2008:2428-2432. Light, R. Primary spontaneous pneumothorax. Uptodate. April 2013. Langenburg, S., Lelli, J. Childhood Lung Disorders. Seminars in Pediatric Surgery. 2008;17: 30-33. Baumann, M., et al. Management of Spontaneous Pneumothorax. Chest. 2001;119(2): 590-602. QUESTIONS?