EVIDENCE BASED REPORT

Emergency Surgery for Spontaneous Hemopneumothorax

Cumhur Murat Tulay and Mert Aygün

ABSTRACT
Emergency management of spontaneous hemopneumothorax patients was retrospectively analysed in this study. From
November 2009 to August 2012, 221 patients with spontaneous pneumothorax were treated in the thoracic surgery clinic.
Among them, 9 (4.07%) were diagnosed with spontaneous hemopneumothorax. Chest X-ray and computed tomography
were the diagnostic tools. Emergency thoracotomy was performed for 7 of 9 patients because of massive hemothorax and
continuous bleeding from the chest tube. Massive hematoma was documented in 2 of 7 patients at tomography. Bridging
veins and torn pleural adhesion between parietal and visceral pleura were the source of bleeding determined at
thoracotomy. Hematoma evacuation, resection of bullae, ligation of pleural adhesions and apical pleurectomy were
performed. Spontaneous hemopneumothorax is an emergency due to massive hemorrhage and hematoma formation.
Early surgical treatment is recommended for patients with spontaneous hemopneumothorax.

Key Words: Bridging veins. Bullous lung. Pleural adhesion. Spontaneous hemopneumothorax. Emergency surgery.

INTRODUCTION than 1000 ml of blood drainage was accepted as

Spontaneous hemopneumothorax (SHP) is a rare
disorder, complicating 0.5 - 12% of patients with spon-
taneous pneumothorax.1-3 Simultaneous accumulation
of air and blood in the thoracic cavity without underlying
trauma or obvious causes is named as spontaneous
hemopneumothorax. Bleeding usually occurs because
of vascularised adhesions, consisting of aberrant
vessels between the parietal and visceral pleura. These
adhesions are torn as the lung collapses following
pneumothorax. Rapid progression of symptoms can be
seen because of blood loss which may cause
hypovolemic shock. The initial treatment of spontaneous
hemopneumothorax is chest tube drainage.4
However, in cases with continuous or massive bleeding,
emergency surgery must be performed. Thoracotomy or
video assisted thoracic surgery are surgical inter-
ventions. In this study, retrospective analysis of the
surgical experience is reported for massive hemorrhage
because of spontaneous hemopneumothorax.
METHODOLOGY
Retrospective analysis of spontaneous hemopneu-
mothorax patients was done in this study from
November 2009 to August 2012. Accumulation of more
than 400 ml of blood in pleural cavity associated with
spontaneous pneumothorax was accepted as
spontaneous hemopneumothorax.1,5,6 Chest X-ray and
computed tomography were the diagnostic tools. More
Department of Thoracic Surgery, Sanlıurfa Teaching and
Research Hospital, Sanlıurfa, Turkey.
Correspondence: Dr. Cumhur Murat Tulay, Sanlıurfa
Teaching and Research Hospital, Thoracic Surgery
Department, Sanlıurfa, Turkey.
E-mail: cumhurtulay@hotmail.com
Received: April 30, 2013; Accepted: December 12, 2013.
massive hemothorax. Parameters for deciding to
emergency surgery were as follows: (a) 1000 ml or more
blood drainage at time of chest tube insertion and
continuous bleeding, (b) massive hematoma at
computed tomography, and (c) clinical state of shock
after excluding other causes.6 Informed consent was
taken from all the patients.
According to the criteria, thoracotomy was performed to
patients who had massive hemothorax. Hematoma
evacuation, resection of bullae, ligation of pleural
adhesions, apical pleurectomy were performed.
Bleeding bridging veins were controlled by using
hemoclip. Bullae formations were resected by linear
stapler. Chemical pleurodesis was not done because of
apical pleurectomy.
Results were expressed as frequency percentage and
measures of central tendency and dispersion.
RESULTS
Two hundred and twenty one patients with spontaneous
pneumothorax were treated. Among them, 9 (4.07%)
were diagnosed with spontaneous hemopneumothorax.
All the patients were male, aged between 16 and 69
years with mean age of 43 years.
None of the patients had history of trauma. Patient
number 5, 8 and 9 had used mediave for chronic
obstructive lung disease and also these patients had
bullous lung diagnosed from previous tomographic
images.
The affected side was the right side in 5 and the left side
in 4 patients. A patient with left side hemopneumothorax
with hematoma formation had pneumothorax on his right
side and chest tube insertion was done to the right side
before surgery. Hypovolemic shock was determined in
3 of 9 patients (Table I). Massive hemothorax was
determined in 7 (77.7%) of 9 patients who needed

Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (6): 435-437 435
Cumhur Murat Tulay and Mert Aygün

Table I: Spontaneous hemopneumothorax patients’ characteristics.

Patient Age Side Amount of bleeding Treatment Shock situation Source of bleeding
1 16 Right 450 ml Drainage and follow-up No No surgery
2 22 Right 1500 ml Thoracotomy No Bridging vein
3 32 Left 1100 ml + hematoma formation Thoracotomy No Torn pleural adhesion
4 41 Right 800 ml Drainage and follow-up No No surgery
5 44 Left 2000 ml Thoracotomy Yes Bridging vein
6 51 Right 1000 ml + hematoma formation Thoracotomy No Torn pleural adhesion
7 52 Left 1700 ml Thoracotomy No Torn pleural adhesion
8 64 Right 1700 ml Thoracotomy Yes Bridging vein
9 69 Left 2500 ml Thoracotomy Yes Bridging vein

The possible causes of spontaneous hemopneu-

Figure 1: Bullous lung with bleeding point which was attached to the thoracic
wall by bridging vein (black arrow).
urgent surgery. Chest tube drainage and follow-up
period were effective and curative for 2 (22.2%) of
9 patients. Massive hematoma was documented in 2 of
7 patients at tomography. Bridging veins and torn pleural
adhesions between parietal and visceral pleura were the
source of bleeding in the majority, which was determined
at thoracotomy. An unusual bleeding point originated
from torn diaphragmatic adhesion in one patient
(Figure 1). All bridging veins and bleeding parietal pleura
from the torn adhesions were controlled directly. The
amount of hematoma which were evacuated from
intrathoracic cavity changed from 1000 to 1500 ml in 2
patients. Intercostal nerve blockage was done to all the
patients. One chest tube was placed intraoperatively at
the end of surgery.
Patients were discharged from the hospital within 6 - 10
days with full lung expansion. There was no intra-
operative or postoperative mortality. Patients were re-
evaluated at 10-day interval for first month, and then
monthly with chest X-ray. No recurrence was observed.
DISCUSSION
Spontaneous hemopneumothorax is an uncommon
condition which can cause shock and death. It occurs in
about 0.5 - 12% of spontaneous pneumothorax
cases.2,8,9 In this study, it was observed to be 4.07%,
occurring in 9 among 221 patients.
mothorax are torn pleural adhesions or aberrant vessels,
bridging veins, rupture of vascularised bulla and
underlying lung parenchyma.1,2,5,9-12 In this study, torn
adhesions and rupture of bridging veins caused the
massive hemothorax in spontaneous pneumothorax
cases.
Bulla formation and torn adhesions are usually seen
around the apex of the lung and this region is accepted
as the major site of bleeding.3,8 Apex of the lung is
accepted the most common site of bullous formation and
surgeon especially looks into the apex. In one patient, it
was observed to be unusual bleeding site from
diaphragmatic adhesions. It shows that the thoracic
surgeon has to evaluate the whole pleural face to
determine possible adhesions and bleeding points.
The condition can be life-threatening due to progressive
blood loss into the pleural cavity leading to hypovolemic
shock. In addition to fluid resuscitation and stabilisation
of vital functions with medical approach, surgery is an
appropriate treatment to minimise complications,
especially for hemodynamically unstable patients. In this
series, 7 of the 9 patients had massive hemothorax and
2 of them had intrathoracic clot formation on tomo-
graphy. Massive hemothorax and continuous bleeding
was associated with spontaneous pneumothorax which
needed emergency surgery. In 2 of the 9 patients, chest
tube insertion and follow-up were curative, but
thoracotomy had to be done for 7 of 9 patients.
It is considered that pressure hemostasis at the site of
bleeding can be obtained by reinflation of the collapsed
lung. However, insufficient expansion of the lung can
not apply pressure to bleeding point. In cases of
spontaneous hemopneumothorax, lung expansion may
not be obtained which may lead to massive hemorrhage
and/ or hematoma formation. Massive hemorrhage-
hematoma formation prevents lung expansion. To
prevent this paradox, surgery should be done at an early
stage of spontaneous hemopneumothorax.
In the present cases, thoracotomy was the commonest
procedure performed for surgery. VATS is an useful
surgical skill for many of thoracic pathologies. In elective
surgeries, VATS is generally performed for bullous lung
or pneumothorax. However, massive hemorrhage and

436 Journal of the College of Physicians and Surgeons Pakistan 2014, Vol. 24 (6): 435-537
Spontaneous hemopneumothorax
shock conditions were needed to perform thoracotomy
in these cases, because of faster and better visualisation
of bleeding point. Removal of hematoma by suction
requires time using thoracoscope. This can be done
rapidly in emergency conditions with thoracotomy.
Resection of bullae and apical pleurectomy leads to
more adhesions formation and recurrences can be
prevented.
CONCLUSION
Spontaneous hemopneumothorax is important due to
massive hemorrhage and hematoma formation. The
goals of treatment include resuscitation, hemostasis,
and re-expansion of the lung. So the authors emphasize
the importance of early recognition and prompt surgical
intervention.
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