SPONTANEOUS PNEUMOTHORAX AND
INDICATIONS FOR PLEURODESIS
Rishabh Shah, MD
Seattle Children’s Hospital
October 31, 2013
OBJECTIVES

Case report-CW

Discuss classification, presentation, and
symptoms of spontaneous pneumothorax

Discuss operative management

Discuss factors complicating operative
intervention
CASE REPORT-CW
16 year old male presents to outside ED with
sudden onset of left sided chest pain, without
shortness of breath
 Transferred to SCH after chest xray
demonstrated left pneumothorax, treated with
ketorolac
 History of recurrent right sided pneumothorax
requiring with talc and mechanical pleurodesis

HISTORY
PMH-recurrent right-sided pneumothorax, FTT
requiring G-tube, eosinophilic esophagitis,
ADHD, insomnia
 PSH-VATS RUL wedge resection of bullae, talc
and mechanical pleurodesis, G-tube
placement, myringotomies with tube placement
 FH-bipolar disorder, emphysema(PGF), no
history of connective tissue disorders
 SH-denies cigarette use

EXAM
Vitals: T: 37˚, HR: 53, BP: 109/59,
RR: 16, O2: 100% on room air
 No increased work of breathing
 Reduced lung sounds in anterior and apex of
left lung field

CHEST XRAY
MANAGEMENT
Taken to OR for VATS bleb resections and talc
pleurodesis
 24 French chest tube placed intraoperatively
and maintained on 20 cmH2O suction for 48
hours
 Stable chest xray after being placed on water
seal
 Discharged post-operative day 3

SPONTANEOUS PNEUMOTHORAX
Primary-spontaneously occuring pneumothorax
in an individual without evidence of underlying
lung disease
 Occurs primarily in tall, thin males (male-tofemale ratio of 1.9-10:1)
 Average age range of 13.3-16.5
 In adults, smoking history important, but less
so in pediatric poplation

CONTINUED
Secondary –related to underlying disease, which
can cause weakening of the connective tissue of
the lung
 Causes range from primary lung disorders, such as
cystic fibrosis, asthma, etc. to systemic diseases
such as connective tissue disorders and
autoimmune processes to infectious and
malignant processes
 Less male dominance (1.4-4.3:1 male-to-female
ratio)

PRESENTATION
Presents most commonly with sudden onesided chest pain and dyspnea
 Less often, anxiety, cough, and fatigue
 Secondary pneumothoraces present with more
severe dyspnea due to underlying reduced lung
function

MANAGEMENT

Initially, placement of chest tube for first
occurrence of primary spontaneous
pneumothorax

If failure to resolve pneumothorax (persistent
air leak), proceed to pleurodesis
PLEURODESIS

Method to obliterate pleural space

Promotes scarring between parietal and
visceral pleura
INDICATIONS

American College of Chest Physicians Delphi
Consensus Statement, “Management of
Spontaneous Pneumothorax,” recommends
surgical intervention following:
 second
occurrence of a primary spontaneous
pneumothorax
 first occurrence of a secondary spontaneous
pneumothorax.
 persistent air leak for greater than 4 days.
RELATIVE INDICATIONS
high-risk occupations (i.e., airline pilots, divers)
 a contralateral pneumothorax,
 bilateral pneumothoraces,
 AIDS

MODALITIES

Chemical-can be introduced through nonoperative and
operative methods



Talc and tetracycline derivatives most common agents
utilized
Operative approach provides added benefit of resection of
affected lung tissue as well as ability to assess lung
expansion
Mechanical-create raw surfaces that further produce
inflammation

Scrubbing pleural surface with a rough gauze pad or
stripping of pleura can be done
CONTRAINDICATIONS

Patients with trapped lung and incomplete lung
expansion

Severe inflammatory disease in which further
inflammation would compromise pulmonary
function
WHEN TO QUESTION USE OF PLEURODESIS

If successful, pleurodesis causes strong
scarring of visceral to parietal pleura with
obliteration of pleural space

In patients who are eligible for lung transplant,
these strong adhesions cause great difficulties
for transplant surgeon
MINI CASE REPORTS

HC-23 year old female with tuberous sclerosis
with history of multiple left and right
pneumothoraces finally treated with
mechanical pleurodesis in 2012 and 2013
CONTINUED

KS-47 year old female with severe
bronchiectasis secondary to cystic fibrosis
leading to spontaneous right pneumothorax in
2008 treated with mechanical pleurodesis,
bilateral lung transplant in 2013 with multiple
morbidities in the postoperative phase
REFERENCES
Dotson, K., Johnson, L. Pediatric spontaneous
pneumothorax. Pediatr Emer Care. 2012;28: 715723.
 Cameron, J. Pneumothorax, Current Surgical
Therapy, 9th Ed. 2008:2428-2432.
 Light, R. Primary spontaneous pneumothorax.
Uptodate. April 2013.
 Langenburg, S., Lelli, J. Childhood Lung Disorders.
Seminars in Pediatric Surgery. 2008;17: 30-33.
 Baumann, M., et al. Management of Spontaneous
Pneumothorax. Chest. 2001;119(2): 590-602.

QUESTIONS?