Pneumothorax surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]

Overview

Surgery is the mainstay of treatment for the management of pneumothorax. The type of surgical modality opted depends on various conditions such as the size of the pneumothorax, underlying disease/procedure causing it and the type (open/closed vs simple/tension). Initially, airway, breathing and circulation should be maintained along with high concentration oxygen therapy. Tube thoracotomy used to be the preferred surgical procedure. Nowadays, video assisted thoracoscopic surgery (VATS) has widely replaced the open surgical procedure.

Indications

Surgical intervention is recommended for the management of pneumothorax.[1][2][3][4]

The choice of intervention depends on the following factors:

  • Size of the pneumothorax
  • Underlying disease/procedure causing pneumothorax
  • Associated comorbid condition
  • Type of pneumothorax (open/closed vs simple/tension)

Initial management

First aid

In all patients with chest trauma along with respiratory difficulty, following measures ahould be taken as the first line management:

  • Maintaining the airway patency
  • Assessment of breathing
  • Prevention of circulatory collapse
  • Oxygen therapy
  • Patient should be positioned upright, unless there is a contraindication to it, such as spinal injury.

Oxygen therapy

  • Immediate administration of 100% oxygen results in accelerated resorption of pleural air.[5][6]
  • Patients who have contraindications to simple aspiration or tube thoracotmy can be given high concentration supplemental oxygen.

Surgical techniques

Following surgical techniques are used to treat pneumothorax:[7][8][9]

  • Simple aspiration
  • Open thoracotomy
  • Video-assisted thoracoscopic surgery (VATS)

Surgery

  • Simple aspiration
  • Open thoracotomy used to be the most commonly used surgical procedure along with wedge resection of the leaking part of the lung.
  • Nowadays, video-assisted thoracoscopic (VATS) surgery has widely replaced the open surgical procedure for spontaneous pneumothorax.

Simple aspiration

Indications:

  • Mostly done in small spontaneous pneumothorax.[10]

Procedure:

Advantages:

Disadvantages:

  • Not recommended for larger size pneumothorax.

Tube thoracostomy

  • Recommended if thoracoscopy is not readily available and simple aspiration fails.[19]

Complications of the procedure

Video assisted thoracoscopic surgery

  • Morbidity associated with thoracotomy can be avoided by using VATS for persistent primary spontaneous pneumothorax..[20][21]
  • VATS has lower morbidity, low invasiveness, and lower cosmetic issues compared to open thoracotomy.
  • VATS is used in recurrent pneumothorax.

References

  1. Gudbjartsson T, Tómasdóttir GF, Björnsson J, Torfason B (2007). "[Spontaneous pneumothorax: a review article]". Laeknabladid. 93 (5): 415–24. PMID 17502684.
  2. Haynes D, Baumann MH (2010). "Management of pneumothorax". Semin Respir Crit Care Med. 31 (6): 769–80. doi:10.1055/s-0030-1269837. PMID 21213209.
  3. Galbois A, Zorzi L, Meurisse S, Kernéis S, Margetis D, Alves M; et al. (2012). "Outcome of spontaneous and iatrogenic pneumothoraces managed with small-bore chest tubes". Acta Anaesthesiol Scand. 56 (4): 507–12. doi:10.1111/j.1399-6576.2011.02602.x. PMID 22191997.
  4. Tsai WK, Chen W, Lee JC, Cheng WE, Chen CH, Hsu WH; et al. (2006). "Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adults". Am J Emerg Med. 24 (7): 795–800. doi:10.1016/j.ajem.2006.04.006. PMID 17098099.
  5. Chadha TS, Cohn MA (1983). "Noninvasive treatment of pneumothorax with oxygen inhalation". Respiration. 44 (2): 147–52. PMID 6836190.
  6. Delius RE, Obeid FN, Horst HM, Sorensen VJ, Fath JJ, Bivins BA (1989). "Catheter aspiration for simple pneumothorax. Experience with 114 patients". Arch Surg. 124 (7): 833–6. PMID 2742485.
  7. Hilton P (2004). "Evaluating the treatment options for spontaneous pneumothorax". Nurs Times. 100 (28): 32–3. PMID 15311535.
  8. Chan SS (2000). "Current opinions and practices in the treatment of spontaneous pneumothorax". J Accid Emerg Med. 17 (3): 165–9. PMC 1725386. PMID 10819376.
  9. Vallee P, Sullivan M, Richardson H, Bivins B, Tomlanovich M (1988). "Sequential treatment of a simple pneumothorax". Ann Emerg Med. 17 (9): 936–42. PMID 3137850.
  10. Swierzy M, Helmig M, Ismail M, Rückert J, Walles T, Neudecker J (2014). "[Pneumothorax]". Zentralbl Chir. 139 Suppl 1: S69–86, quiz S87. doi:10.1055/s-0034-1383029. PMID 25264729.
  11. Mendis D, El-Shanawany T, Mathur A, Redington AE (2002). "Management of spontaneous pneumothorax: are British Thoracic Society guidelines being followed?". Postgrad Med J. 78 (916): 80–4. PMC 1742255. PMID 11807188.
  12. Ireland AJ, Dorward AJ (1993). "Management of pneumothorax. Consider ATLS guidelines". BMJ. 307 (6901): 444. PMC 1678430. PMID 8374466.
  13. Pallin M, Open M, Moloney E, Lane SJ (2010). "Spontaneous pneumothorax management". Ir Med J. 103 (9): 272–5. PMID 21186751.
  14. Miller AC, Harvey J (2001). "Pneumothorax: what's wrong with simple aspiration?". Chest. 120 (3): 1041–2. PMID 11555554.
  15. Devanand A, Koh MS, Ong TH, Low SY, Phua GC, Tan KL; et al. (2004). "Simple aspiration versus chest-tube insertion in the management of primary spontaneous pneumothorax: a systematic review". Respir Med. 98 (7): 579–90. PMID 15250222.
  16. Chan SS (2008). "The role of simple aspiration in the management of primary spontaneous pneumothorax". J Emerg Med. 34 (2): 131–8. doi:10.1016/j.jemermed.2007.05.040. PMID 17961959.
  17. Chan, Stewart Siu-Wa (2008). "The Role of Simple Aspiration in the Management of Primary Spontaneous Pneumothorax". The Journal of Emergency Medicine. 34 (2): 131–138. doi:10.1016/j.jemermed.2007.05.040. ISSN 0736-4679.
  18. Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A (2002). "Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study". Am J Respir Crit Care Med. 165 (9): 1240–4. doi:10.1164/rccm.200111-078OC. PMID 11991872.
  19. Makris D, Marquette CH (2007). "[Management of pneumothorax]". Rev Prat. 57 (5): 503–11. PMID 17583135.
  20. Ayed AK, Al-Din HJ (2000). "The results of thoracoscopic surgery for primary spontaneous pneumothorax". Chest. 118 (1): 235–8. PMID 10893385.
  21. Sawada S, Watanabe Y, Moriyama S (2005). "Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: evaluation of indications and long-term outcome compared with conservative treatment and open thoracotomy". Chest. 127 (6): 2226–30. doi:10.1378/chest.127.6.2226. PMID 15947341.



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