Professional Documents
Culture Documents
Essentials in Cardiothoracic Surgery Management of Pneumothorax and Bullous Disease For SCRIBD
Essentials in Cardiothoracic Surgery Management of Pneumothorax and Bullous Disease For SCRIBD
Essentials in Cardiothoracic Surgery Management of Pneumothorax and Bullous Disease For SCRIBD
Management of Pneumothorax
Background Management of primary spontaneous pneumothorax Management of secondary spontaneous pneumothorax Management of iatrogenic pneumothorax
References
Background
Terms
Primary spontaneous pneumothorax (PSP) Secondary spontaneous pneumothorax (SSP) Iatrogenic PTX Tension PTX Catamenial PTX
Recommendations
SSP higher morbidity / mortality than PSP Strong emphasis on smoking cessation, to minimise the risk of recurrence PTX is not usually associated with physical exertion Symptoms in PSP may be minimal or absent Symptoms are greater in SSP, even if PTX is relatively small in size
The presence of breathlessness influences the management strategy Severe symptoms and signs of respiratory distress suggest the presence of tension PTX
Diagnosis
X-ray
Standard CXR upright in inspiration are recommended, rather than expiratory films It is currently recommended that a diagnostic PACS workstation is available for image review CT scanning is recommended for uncertain or complex cases
In defining a management strategy, the size of a PTX is less important than the degree of clinical compromise The differentiation of a large/ small PTX CT
Most accurate PTX size calculations Not neceassary
Size of pneumothorax
3 dimension estimation
Volume of Pneumothorax
9.5 cm 12 cm
SSSC7
Sizing PTX
ACCP
< or > 3 cm apex-tocupola distance
BTS
< or >2 cm lung margin lateral chest wall
PT
Either ACCP or BTS
Treatment
The distinction between PSP and SSP should be made, to guide appropriate management Breathlessness indicates the need for active intervention The size of PTX
determines the rate of resolution relatively indicates active intervention
PSP
Conservative/ ambulatory care Active interventions
Medical Surgical
Management of pneumothorax
Observation Needle aspiration Small-bore catheter drainage Tube thoracostomy (ICD) for surgery, only Unfit Chemical pleurodesis Surgery
Observation is the treatment of choice for small PSP, without significant breathlessness
SSSC7
Treatment for Observe asymptomatic small PSP,
ACCP
Observe
BTS
Observe
PT
Observe
PT = Author
Pt with significant breathlessness, whatever size, should undergo active intervention ICD is required for tension or bilateral PTX A large PSP, but without significant breathlessness, may be managed by observation alone.
2009
Cochrane review
1239 publications 6 studies only one eligible for inclusion No significant between NA and ICD
Immediate success rate Early failure rate Hosp stay One year success rate No of patient requiring pleurodesis in one year
Needle aspiration?
SSSC7
Role of needle Delayed aspiration asymptomatic (NA) PSP, < 30% PSP Fail NA
ACCP
May consider in enlarging PSP after observation
BTS
Initial treatment for non-tension PSP Small bore catheter chest drain. NA should not repeat.
PT
May consider in delayed asymptomatic PSP Small bore catheter chest drain. NA should not repeat.
SSSC7
Significant PSP (>30% PSP) with symptom, initial treatment ICD, 20Fr, with water seal drainage system
ACCP
Small bore catheter (<14Fr) or medium bore tube (1622Fr), Heimlich valve or water seal
BTS
NA is procedure of choice in most cases
PT
Small bore catheter (<14Fr) or medium bore tube (1622Fr), Heimlich valve or water seal Not recommend
Not Not recommend. recommend May use in BPF, or patient with positive pressure ventilation
SSSC7
Suctioned drainage system
ACCP
BTS
Should not be routinely used. May consider if persistent air leak > 48 hr
PT
Should not be routinely used. May consider if persistent air leak or lung is not completely reexpanded after 48 hr
If the lung is If lung fails to not completely reexpand reexpanded. quickly with water seal system
SSSC7
Medical chemical pleurodesis
ACCP
Acceptable in high risk patients or wish to avoid surgery
BTS
PT
Same as ACCP Should only be used o high and BTS risk patients or wish to avoid surgery
BTS 2003
Persistent air leak/failure of the lung to re-expand, early (3-5 days) thoracic surgical opinion Open thoracotomy + pleurectomy lowest recurrence rate Minimally invasive procedures, VATS, pleural abrasion, and surgical talc pleurodesis - effective alternative strategies
ACCP 2001
Patients with air leaks persisting > 4 days should be evaluated for surgery
Patients should not undergo the placement of an additional chest tube or bronchoscopy to seal endobronchial sites of air leaks.
Although the relative value of VATS compared to a limited thoracotomy has not been clearly defined, the panel selected VATS as the preferred management.
SSSC7
Persistent air > 5 7 days leak requiring surgical intervention
ACCP
> 3 5 days
BTS
> 5 7 days
PT
> 3 5 days
SSSC7
Surgical approach VATS is preference. Experience with minithoracotomy has been favorable.
ACCP
VATS (based on panel s practice preference)
BTS
PT
Open limited VATS or posterolateral axillary thoracotomy thoracotomy has lowest recurrence rate while VATS is better tolerated.
Bleb/bullae management
Bullectomy should be performed by staple bullectomy/ hand sewing Options include electrocoagulation, laser ablation
Depending on institutional expertise and experience
Secondary pneumothorax
Open thoracotomy is the recommended approach. VATS procedures should be reserved for those with poor lung function.
Secondary pneumothorax
All patients with SSP should be admitted to hospital for at least 24 hours Most patients will require the insertion of a small-bore chest drain Those with a persistent air leak should be discussed with a thoracic surgeon at 48 hours
Medical pleurodesis may be appropriate for inoperable patients Patients with SSP can be considered for ambulatory management with a Heimlich valve
ACCP
Most members of the panel recommend an intervention to prevent pneumothorax recurrence after the first occurrence. *** Medical or surgical thoracoscopy is preferred. *** a muscle- sparing (axillary) thoracotomy is an acceptable alternative. A standard thoracotomy is not appropriate therapy for most patients. ***
Recurrence prevention
Pleural abrasion pleurectomy surgical chemical
pleurodesis
Catamenial PTX
Catamenial PTX
Catamenial PTX is underdiagnosed in female PTX patients A combination of
surgical intervention (include diaphragmatic resection or plication of the fenestrations seen) hormonal manipulation - gonadotrophin-releasing hormone analogues
Iatrogenic PTX
The majority observation alone
Traumatic pneumothorax
The indication of VATS included:
Persistent PTX On-going bleeding in stable patients Retained hemothorax/ infected pleural space and collections Evaluation of the diaphragm in penetrating injuries and management
Surgical indication
Symptomatic patients Giant bullae occupying over one third of a hemithorax Mediastinal shift Bullae complications
Pneumothorax, infection, and enlargement with time
Treatment options
Surgery VATS/ thoracotomy
Bullectomy Modified Monaldi technique
opening the bulla, placing a purse-string suture at the neck of the bulla
Talc is a, natural, hydrated magnesium silicate that has the approximate chemical formula of Mg3(Si2O5)2(OH)2.
aerosol (insufflation) in a suspension (slurry)
The most common approach - bilat VATS lateral decubitus position, with side-changing Or supine position, modify the sites of the trocars,
2 on the anterior axillary line 1 on the midclavicular line/ 2nd ICS