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Coping with Pneumothorax

Michael F. Reed, MDDivision of Thoracic SurgeryUniversity of Cincinnati College of MedicineApril 21, 2007

Caveats

Medicine is both science and art

Sometimes there is more than one way to address a problem

Background

Lymphangioleiomyomatosis (LAM) is a rare lung diseaseLAM primarily affects women of child-bearing ageCharacterized by proliferation of smooth-muscle-like cellsFormation of thin-walled pulmonary cystsProgressive decline of lung functionDevelopment of pneumothorax or chylothorax

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Definition

pneumothorax (nu-mo-tho’raks)[G. pneuma, air, + thorax]. The presence of air or gas in the pleural cavity.

Symptoms

Pain

Shortness of breath

Cough

Hypoxia

Pneumothorax: Chest Film

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Pneumothorax: Chest CT

LAM Complications

PneumothoraxLifetime incidence 39-81%Almoosa, et al:

66% experienced pneumothorax82% had 1st pneumothorax before LAM diagnosed

ChylothoraxIncidence around 30%

Spectrum of Treatment

ObservationAspirationChest tube (tube thoracostomy)Chest tube + pleurodesisVATS + pleurodesisThoracotomy + pleurodesisThoracotomy + pleurectomy

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Chest Tubes

9 French (about 3 mm diameter) 28 French (about 10 mm diameter)

Chest Tube Insertion

Small-bore tubes

Sedation

Pain Control

Pneumothorax Recurrence

Pneumothorax recurrence (Almoosa, et al)73% had at least one recurrence

71% had recurrence(s) on same side74% had recurrence(s) on opposite side

Recurrence rate 66% after no therapyRecurrence rate 27% after chemical pleurodesisRecurrence rate 32% after surgery

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Definitions

Pleurodesis (ploor-od’ĕ-sis) [pleuro- + G. desis, a binding together]. The creation of a fibrous adhesion between the visceral and parietal layers of the pleura, thus obliterating the pleural cavity.

Methods of Pleurodesis

ChemicalTalcBleomycinDoxy/tetracyclineBlood

Mechanical (Pleuroabrasion)

Performing Pleurodesis

AwakeSedationEpidural analgesiaVia chest tube

Operating RoomGeneral anesthesiaEpidural analgesiaVATS or thoracotomy

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Chest Incisions

VATS (video-assisted

thoracoscopic surgery)

Thoracotomy

VATS Wedge Resection

VATS Mechanical & Talc Pleurodesis

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Recommended Treatments (Questionnaire to Lung Transplant Centers)

First pneumothorax:97% selected minimally invasive procedures

First recurrence:41% selected minimally invasive procedures16% chemical pleurodesis via chest tube31% VATS procedure12% open procedures

Subsequent recurrences:13% selected minimally invasive procedures13% chemical pleurodesis via chest tube33% VATS procedure40% open procedures

Lung Transplantation

Post-transplant survival of patients with LAM equivalent to that of transplants for other diseasesThe major complication of lung transplantation for LAM is potentially fatal hemorrhage due to prior pleural proceduresAlmoosa, et al:

Of patients with LAM who had lung transplantation, 56% had prior pleurodesis18% had postoperative bleeding93% of the patients who had bleeding had prior pleurodesis

Suggestions

Involve practitioners familiar with LAMProcedures performed by specialists in pulmonary medicine/surgery and minimally-invasive techniquesKnow the management preferences of the local transplant centerIf lung transplantation a future possibility, consider less aggressive interventionIf lung transplantation less likely, consider more aggressive pleural therapyEven if pleurodesis has been performed, lung transplantation is feasible

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One Month after VATS Pleurodesis