Management of Spontaneous Pneumothorax

Initial Mild Spontaneous Pneumothorax (assumed primary spontaneous pneumothorax)

–  Medical observation Additional Episodes Spontaneous Pneumothorax Evacuation of air in pleural space via chest tube

Consider further evaluation of secondary causes of

pneumothorax Additional clinical evaluation – CT scan looking for blebs If blebs are present, counsel patient on risk of recurrent

pneumothorax

Management of Spontaneous Pneumothorax: A Case Study Suzanne Kujawa RNC, MSN, CPNP-PC

Ann & Robert H. Lurie Children’s Hospital of Chicago

Training Program Components

23rd Annual Scientific Conference – APSNA 2014

Objectives Describe the signs and symptoms of spontaneous pneumothorax Discuss the management options for secondary spontaneous pneumothorax Discuss associated diagnoses with spontaneous pneumothorax

Background Primary spontaneous pneumothorax (PSP) in the adult population is 6-18 per 100,000 Data regarding spontaneous pneumothorax in the pediatric population is limited There are no established guidelines for management of pediatric patients.

Guidelines are extrapolated from adult data Conditions Associated with Spontaneous Pneumothorax §  Male Gender (65-81% are male) §  Tall and thin body habitus §  Marfan’s Disease §  Smoke inhalation/exposure (cannabis or tobacco)

§  Remodeling of airways and increased risk of cystic lesions

Practice Pearls A significant pneumothorax will require evacuation Surgical intervention is usually indicated if the pneumothorax is found to be secondary

A first episode of secondary spontaneous pneumothorax may not require surgical intervention if the family is opposed The higher number of blebs, the higher the risk of rupture Families and patients may choose clinical observation, unilateral surgical intervention or bilateral intervention based on preference after receiving counseling

References Cheng, Y. L., Huang, T.W., Lin, C. K., Lee, S. C., Tzao, C.g, Chen, J. C., & Change, H. (2009). The impact of smoking in primary spontaneous pneumothorax. The Journal of Thoracic and Cardiovascular Surgery, 192-195. Chou, S. H., Li, H. P., Lee, J. Y., Chang, S. J., Lee, Y. L, Chang, Y. T., Kao, E. L., Dai, Z. K., & Huang, M. F. (2010). Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated? General Thoracic Surgery, 139, 5, 1241-1245. Kelly, A. M. (2009). Treatment of spontaneous pneumothorax. Current Opinion in Pulmonary Medicine, 15, 4, 376-379. Nathan, N., Guilbert, J., Larroquet, M., Lenoir, M., Clement, A., & Epaud, R. (2010). Efficacy of blebs detection for preventive surgery in children’s idiopathic spontaneous pneumothorax. World Journal of Surgery, 34, 185-189. Robinson, P., Cooper, P., & Ranganathan, S. (2009). Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatric Respiratory Reviews, 10, 110-117. Shaikhrezai, K., Thompson, A., Parkin, C., Stamenkovic, S., & Walker, W. (2011). Video-assisted thoracoscopic surgery management of spontaneous pneumothorax – long-term results. European Journal of Cardio-thoracic Surgery, 40, 120-123. Shih, C. H., Yu, H. W., Tseng, Y. C., Chang, Y. T., Liu, C. M., and Hsu, J. W. (2011). Clinical manifestations of primary spontaneous pneumothorax in pediatric patients: An analysis of 78 patients. Pediatrics and Neonatology, 52, 150-154.

Signs and Symptoms of Spontaneous Pneumothorax May occur at rest or with increase of intrathoracic pressure via valsalva Chest pain, Shortness of breath, Oxygen desaturation Increased work of breathing

Right pneumothorax identified by two arrows, chest tube in place

Case Study: AN, 15 year old male History: Previously healthy 15 year old male, occasional marijuana use, no reported cigarette use Symptoms: 3 day history of non-productive cough followed by pleuritic chest pain

Presented to an OSH for increased chest pain. OSH course: CXR demonstrated a large left sided pneumothorax. 28 French chest tube placed at OSH and transferred to Lurie Children’s. Management at Lurie Children’s- Family counseled on possibility of blebs and offered chest CT as inpatient or outpatient Family counseled that apical bleb resection may be indicated for ipsilateral pneumothorax or second, contralateral episode Inpatient Chest CT – “Several apical blebs (none with a diameter greater than 2 cm) are identified bilateral, at least 7 on the right and at least 6 on the left. In addition to the blebs, a few prominent apical lines are identified in the right lung apex” per CT report Taken to the OR on 5/16/2014 - bilateral thoracoscopy, VATS, bilateral apical bleb resection and pleurodesis Post-operatively: Had an air leak treated with chest tube to suction. Right chest tube removed POD #2, left removed POD #3. CXR post-pull 5/20/2013: tiny left apical pneumothorax Presented to the ED on 6/27/2013 for evaluation of sharp chest pain. CXR stable from discharge film Presented to the ED on 11/19/2013 for evaluation of left sided chest pain and pleuritic pain. CXR negative for pneumothorax

Clinical Guidance Family and patient counseling

Blebs found on CT – pneumothorax is secondary Increased risk of recurrence in the future Management options-

clinical observation and serial chest X-Rays Surgical management – unilateral versus bilateral

VATS – Video-Assisted Thoracoscopic Surgery Blebectomy - resection of lung with blebs Pleurodesis – chemical or mechanical

irritation of the pleura •  For secondary spontaneous pneumothorax with bleb

rupture, resection of the bleb on the affected side is recommended. Families may choose unilateral versus bilateral procedures.

Resection of Apical Bleb CT results demonstrating apical bleb

and pneumothorax