Spontaneous pneumothorax

Spontaneous pneumothorax in its commonest form is a disease of young adults, occurring more frequently amongst males than females, and is due to rupture of a bleb. These are usually found at the apex of the upper lobes and, although their origin is still obscure, they probably follow minor infection with patchy fibrosis and contraction of areas on the surface of the lung creating blebs in between. Rarely, they may occur in women at the time of menses and may be associated with Marfan's syndrome, Pneumocystis carinii infection, particularly in patients with AIDS, granulomas and lymphangio-leiomyomatosis. It is commoner amongst smokers and seems particularly prevalent at times of sharp barometric change.

In adults with emphysema, the cause is a ruptured bulla and continuing air leaks are often a significant problem. The bullae are distinguished from blebs in that they are surrounded by lung tissue (Fig. 18.13).

The clinical presentation of spontaneous pneumothorax is a sudden onset of pleuritic chest pain and breathlessness. It is often confused with a myocardial infarction but the diagnosis becomes apparent by the absence of breath sounds on one side and is confirmed with a chest X-ray.

If the pneumothorax is shallow, it may be aspirated and the patient observed; otherwise an intercostal catheter should be inserted. Of patients having their first episode, 80% will not have any further problems, but if a recurrence occurs then the likelihood of further episodes is of the order of 50% and increases with subsequent recurrences. Whilst spontaneous pneumothorax is rarely fatal, excepting in the rare event of a tension pneumothorax or simultaneous bilateral pneumo-thoraces, it accounts for significant use of hospital beds and loss of time from work. Early definitive treatment can save much subsequent morbidity and the introduction of VATS has allowed for aggressive early management leading to minimal periods of hospitalization and reduction in the likelihood of troublesome postoperative neuralgia. The management of the apical blebs by ligation or excision alone is insufficient as they may recur and a pleurodesis should also be performed. In young patients, this is best done either by a



Spontaneous Pneumothorax Surgery

formal pleurectomy or abrasion, but in older patients talc can be used as an irritant, as the possibility of long-term induction of tumour caused by the irritant is not relevant.

A plan for the management of spontaneous pneumothorax is:

• pneumothorax <15% - aspirate and observe,

• pneumothorax >15% - intercostal catheter with suction. Indications for surgery are:

- tension pneumothorax,

- bilateral pneumothorax,

- recurrent pneumothorax,

- haemopneumothorax,

- continuing air leak >5 days.

- occupation,

- availability of medical care.

A rare variant that is best operated on at the time of diagnosis is spontaneous haemopneumothorax. This occurs when an adhesion which is usually apical is torn as the lung deflates and there is continuing bleeding with consequent hidden blood loss. The blood needs to be evacuated and the adhesion fulgurated.

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