Value of computed tomography of the lung in the management of primary spontaneous pneumothorax

doi:10.1016/0002-9610(91)90199-N

The American Journal of Surgery

Volume 162, Issue 1, July 1991, Pages 39-42

https://doi.org/10.1016/0002-9610(91)90199-N Get rights and content

Abstract

The treatment of patients with primary spontaneous pneumothorax remains controversial, since recurrence and the ultimate need for thoracostomy cannot be predicted. In the current study, computed tomography (CT) of the lung was performed prospectively on 26 consecutive patients with primary spontaneous pneumothorax to determine whether the size and/or the number of apical blebs would correlate with recurrence and/or need for thoracostomy. Both the number of blebs and the bleb score (calculated by the number of blebs multiplied by a numeric value assigned a range of bleb sizes) of the affected lung was significantly greater in patients with a history of recurrent pneumothorax and/or ultimate need for thoracostomy as treatment. CT of the lung may be useful in predicting the natural history of pneumothorax.

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Cited by (69)

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Pneumothorax may be primary (without apparent pulmonary disease) or secondary (associated with pulmonary disease) and is either spontaneous or traumatic. The management of pneumothorax in the pediatric population is somewhat controversial, but imaging plays an important role in both detection and treatment. Plain chest radiography is an appropriate first-line imaging modality. Ultrasound has emerged as an imaging modality that is rapid and has the advantage of avoiding ionizing radiation exposure. Computed tomography is utilized as a secondary study when there is concern for underling pathology, such as pulmonary blebs or bullae or in cases of penetrating thoracic trauma.
Spontaneous pneumothorax: Time to rethink management?
2015, The Lancet Respiratory Medicine
Citation Excerpt :
Previous studies with different designs have investigated the presence of bullae on CT scans, with contradictory results. Early small studies had suggested that presence of bullae might be predictive of high recurrence rate and hence justify early surgical intervention.57,58 Sihoe and colleagues58 reported that contralateral recurrence was substantially more common in patients with blebs and bullae on the contralateral lung at the time of initial surgery for unilateral primary spontaneous pneumothorax than it was in patients without contralateral blebs and bullae.
There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.
Primary spontaneous pneumothorax: To pleurodese or not?
2013, The Lancet
Radiological Predictors of Recurrent Primary Spontaneous Pneumothorax Following Non-surgical Management
2010, Heart Lung and Circulation
Citation Excerpt :
Using imaging modalities, various radiological markers have been investigated for their ability to predict recurrence. More recently, the presence of dystrophic pulmonary lesions (visualised using computed tomography (CT)) has been studied in this way, however the outcomes of the studies have been inconsistent with some groups finding a definite predictive role [7,8] while others reported this predictive significance to be insufficient [9–11]. To our knowledge, CXRs have not been specifically investigated for the presence of predictive markers.
Studies to date have not identified any reliable predictors for recurrence of primary spontaneous pneumothorax (PSP) on plain chest radiograph (CXR). The aim of this study was to assess whether abnormalities on CXR at first presentation of PSP can be used to predict recurrence of PSP.
The study included all patients admitted to The Canberra Hospital between 1998 and 2004. CXRs taken at initial presentation were reviewed retrospectively by an independent radiologist. Radiological abnormalities on CXR included: pleural thickening: blebs/bullae; pleural irregularities and pleural adhesions.
One hundred patients were followed up for a mean duration of 57 months. The total rate of recurrence was 54%. Multivariate analysis found that the presence of an abnormality (irrespective of the type) increased the likelihood of recurrence and the risk of recurrence increased with each additional abnormality. Patients having one, two and three or more abnormalities were 3.0 (95% CI = 2.09, 3.91, p = 0.018), 5.3 (95% CI = 4.47, 6.13, p < 0.001) and 12.6 (95% CI = 11.57, 13.63, p < 0.001) times more likely to develop recurrence respectively.
In view of these results we now offer surgical treatment at first presentation PSP in patients in whom we identify two or more radiological abnormalities on CXR.
Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated?
2010, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
After 2 years of follow-up, the number of patients at risk is 24. It has been years since some centers used CT scans to determine the underlying etiology or detect apical blebs in cases of PSP.16-18 Since 2006, the CT scan has been implemented in our hospital as a routine examination for PSP.
More than 50% of patients with primary spontaneous pneumothorax have contralateral blebs/bullae, and about a quarter will develop a contralateral pneumothorax. The purpose of this prospective study was to determine the need for elective treatment of asymptomatic contralateral blebs/bullae in patients presenting with primary spontaneous pneumothorax.
From May 2006 through June 2008, results from 35 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs receiving unilateral video-assisted thoracic surgery, 35 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery, and 16 patients with ipsilateral primary spontaneous pneumothorax receiving bilateral video-assisted thoracic surgery for positive contralateral blebs were collected. Their demographic and operating data were also recorded.
There was no significant difference in age, gender, smoking percentage, body mass index (kg/m²), blood loss, and postoperative pain among groups. There was longer operative time and length of stay in group receiving bilateral surgery. Within the follow-up period of 16.68 ± 9.91 months (median, 17.50), no recurrence on either lung was found in the group operated on both sides, while contralateral occurrence was found in 17.14% of the group with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery within the period of 18.15 ± 8.07 months (median, 21).
The study showed that the preemptive video-assisted thoracic surgery for the contralateral blebs/bullae effectively prevented the contralateral occurrence.
Evidence-based management of paediatric primary spontaneous pneumothorax
2009, Paediatric Respiratory Reviews
Citation Excerpt :
Surgical referral is recommended in patients with ongoing evidence of airleak at 4 days.30 The presence of cystic lesions, such as blebs (≤ 2 cm) and bullae (> 2 cm), located in the immediate subpleural lung or within the pleura, have been postulated as an underlying aetiology and independent risk factor for recurrence.44 Whilst occasionally visible on plain CXRs (Fig. 3), computed tomography (CT) scanning is required for more accurate assessment.
The exact incidence of paediatric primary spontaneous pneumothorax (PSP) is unclear, although PSP incidence in the general population is between 6 and 18 per 100 000. PSP has been reported throughout the paediatric age range. A potential genetic predisposition for familial cases has been recently identified. Whilst there is universal consensus on the management of tension pneumothorax, lack of agreement and consistency exists across a wide range of management issues for other aspects of PSP management. Paediatric PSP may have a higher recurrence rate than adult PSP, and the presence of apical lung cysts or bullae is not predictive of recurrence. The decision for surgical intervention should be based on documented recurrence. There is a lack of paediatric evidence to guide management decisions, and extrapolation of predominantly adult data to younger age groups should not be encouraged. Given the relatively low apparent incidence, a multicentre approach to future research is required in order to generate the evidence required for informed management of PSP in children.

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Scientific paperValue of computed tomography of the lung in the management of primary spontaneous pneumothorax

Abstract

J Thorac Cardiovasc Surg

Clin Radiol

Am J Surg

Ann Thorac Surg

The management of spontaneous pneumothorax and bullous emphysema

Surg Clin North Am

Malignant interstitial emphysema of the lungs and mediastinum as an important occult complication in many respiratory diseases and other conditions: an interpretation of clinical literature in light of laboratory experiment

Medicine (Baltimore)

Scientific paper
Value of computed tomography of the lung in the management of primary spontaneous pneumothorax