Persistent air-leak in spontaneous pneumothorax — clinical course and outcome

Abstract

Persistent air-leak in patients with spontaneous pneumothorax (SP) is not uncommon and may present a management dilemma in those who are unfit or unwilling for surgery. Video-assisted thoracoscopic surgery (VATS) has been advocated in the management of patients with broncho-pleural fistulae (air-leak persisting beyond 7 days): however the optimum time for surgical intervention remains unclear. We reviewed the records of 130 episodes of SP in 115 patients over a 2-year period to determine clinical course and outcome, particularly with respect to duration of air-leak. There were 90 first episodes and 40 recurrent episodes. Eighty-one episodes (62%) occurred in patients with underlying lung disease (secondary pneumothorax). Initial management consisted of chest-tube drainage in 104 episodes (80%) occurring in 90 patients, percutaneous needle aspiration in five patients (4%) and observation in 21 episodes (16%) in 20 patients. In the group treated with chest-tube drainage, there was spontaneous resolution of air leak and lung re-expansion in 90 episodes (87%). The overall incidence of broncho-pleural fistula was 34.6%. In the primary SP group. 75% of air-leaks ceased by 7 days and 100% by 15 days. In the secondary SP group, 61% of air-leaks resolved by 7 days and 79% by 14 days, after which time resolution of air-leak proceeded at a much slower rate. Five patients underwent surgery while nine patients were discharged with residual pneumothoraces. There were no major complications or mortality. Based on our findings, we advocate surgery for patients with air-leak persisting beyond 14 days, while favouring a conservative approach before this time, as the majority of air-leaks (especially in patients with primary pneumothorax) would resolve by 14 days.

Size of Pneumothorax can be a New Indication for Surgical Treatment in Primary Spontaneous Pneumothorax: A Prospective Study

“…The prevalence of PAL (14.9%) and ipsilateral recurrence (14.4%) in our study was similar to those reported in the literature. 11,14) As the recurrence rates have been reported to be 54% within four years after the first attack, it can be thought that the recurrence rate in our study might be increased after long follow-up period. 15) Bulla/bleb resection and wide pleural abrasion was applied to our patients via AT or VATS.…”

“…3,12) This may suggest that simple tube drainage is an unsatisfactory treatment for even a first episode of PSP, particularly in the presence of a large pneumothorax, lifestyle or medical factors that would make recurrence especially dangerous. 13) Chee, et al 14) observed PAL in 25% of the cases with PSP. In our study, closed thoracic drainage was applied in all cases, and PAL was considered as air leak persisted longer than five days and cases with PAL or ipsilateral recurrence were operated.…”

Recurrent Spontaneous Pneumothorax during the Recovery Phase of ARDS Due to H1 N1 Infection

“…Among patients with pneumothorax, 30 to 38% of them have recurrence (12). Although primary spontaneous pneumothorax usually resolves in 2 to 4 days of drainage, pneumothoraces in patients with underlying lung disease often last substantially longer (13). In our case, post-ARDS recurrent pneumothorax needed drainage for three weeks.…”

Tube Thoracostomy: Is an Emergency Physician Adequate for the Job?

“…According to the literature, the recurrence rate is 16%-52%, based on the treatment method used for the first episode of spontaneous pneumothorax (29). Studies reporting higher recurrence rate in SSP than in PSP are available, although the reverse is also reported (30).…”