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Pneumothorax
Key Points: 1. Spontaneous pneumothoraces are either primary or secondary, depending on if there is underlying lung disease. 2. Spontaneous PTXs <15% can be treated with oxygen and those >15% can often be treated with needle aspiration alone. 3. Secondary PTX often require tube thoracostomies and pleurodesis. Pleurodesis should be avoided in CF patients awaiting transplant or TB patients prior to 6 weeks of medical therapy. 4. Tobacco, as always, is a huge risk factor.

Primary Spontaneous Pneumothorax

--a pneumothorax that occurs in the setting of normal lungs, although further investigations have revealed that many of these patients actually have subpleural blebs Risk factors: Tobacco is the largest risk factor with relative risk in males 7-102 depending on amount smoked, and up to 68 in females. Presentation: Usually occurs at rest, in patients under 40 yo. Pts present with acute SOB and chest pain. Exam reveals hyperresonance on affected side, decreased breath sounds. Treatment (as recommended by British Thoracic Society and American College of Chest Physicians): <15%: Give supplemental oxygen and observe. Expected resorption rate without O2 is 1.25% per hemithorax/day. Oxygen increases this rate 6-fold. >15%: Needle aspiration: In one study this was 80% successful (in another 56%) and decreased length of hospital day from 4.5 to 2 days in comparison with thoracostomy tube. Can either a) extract air and observe, or b) insert catheter with stopcock, extract air and close stopcock, observe for 4 hours, reshoot CXR, withdraw tube, observe for 2 more hours, and d/c. Thoracostomy tube (a small one): Use if withdraw >4 Liters air from chest with needle and no resistance felt, or if needle aspiration is unsuccessful. Pleurodesis: Recommended to use a tetracycline (doxycycline is preferred agent because it causes less pain). In a study of 229 pts, recurrence rate decreased from 41% to 25% if pleurodesis performed. Thoracoscopy: Pleural abrasion with dry gauze (mechanical pleurodesis) or stapling. Thoracotomy: Only for refractory cases. Recurrence rate: 25-50% will have recurrence, usually within first year. Decreased recurrence if stop smoking, so this should be primary goal. Females and tall people are also at greater risk of recurrence. One study showed that recurrence when treated with needle aspiration vs. thoracostomy tube was 17% vs 28%, respectively, although a recent study showed no difference between the two.

Secondary Spontaneous Pneumothorax:

--pneumothorax that occurs in the setting of abnormal lungs. Important Lung Diseases: COPD: rupture of blebs in apical portion of lung. Symptoms more severe than in primary PTX because less pulmonary reserve. CXR may be harder to interpret because emphysematous portions of the lung may obscure the visceral pleural line outlining the collapsed lung PCP: incidence of 4-30%. Often seen in pts with prior PCP, recurrence, or on inhaled pentamidine. Carries poor prognosis, with in-house mortality of >25% and median survival 3months. 65% will have recurrent ipsilateral or contralateral PTX.

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TB: occurs in 1-3%. See rupture of TB cavity into pleural space. Has even been reported in miliary TB, although rare. CF (cystic fibrosis): incidence 8% of all patients and 20% for patients who reach 18 yrs of age

Treatment: Similar recommendations as for primary PTX except needle aspiration less successful and recurrence rate is not decreased, so generally suggested to use tube thoracostomy with pleurodesis. Avoidance of recurrence important because can be a life-threatening situation. Tube thoracostomy: will see lung expansion in 7 days in over 80%, but without pleurodesis, recurrence rate 50% in next 3 years. Doxycycline pleurodesis: recurrence rate cut in half from thoracostomy alone. Thoracoscopy stapling: 5% recurrence If bronchopleural fistula persists after 3 days or incomplete lung expansion, should proceed to video assisted thoracoscopy for stapling and mechanical pleurodesis. Special Considerations: *In PCP: try insertion of catheter into pleural space with valve. Can send patient home. If lung does not reexpand, often need thoracoscopy with stapling of blebs. *In CF: avoid any kind of pleurodesis if pt is candidate for lung transplant. *In TB: often need prolonged duration of chest tube. Should not consider pleurodesis until pt has received 6 weeks of anti-TB treatment. Interesting side-note: In women with recurrent pneumothoraces around time of menstruation, consider catamenial pneumothoraces due to thoracic endometriosis!!! Over 100 cases reported since 1960s. Most also had pelvic endometriosis; most are right sided PTXs. Difficult to diagnose, but CT can help, CA-125 may be elevated, and cytology may show endometrial cells. First line treatment is with hormonal suppression (ie OCPs), but may need pleurodesis.
References: Noppen, et al. Manual aspiration vs CT drainage in 1st epidsodes of PSP: a multicenter prospective randomized pilot study. Am J Respir Crit Care Med. May 2002. Onuki, et al. Thoracoscopic surgery for PTX in older patients. Surg Endosc Feb 2002. Mert, et al. Spontaneous PTX: a rare complication of miliary TB. Am Thorac CV Surg. Feb 2001. UpToDate 10.2 and other articles