Educational Material

ERS Annual Congress Amsterdam 26–30 September 2015

EDUCATIONAL MATERIAL

Challenging Clinical Cases 7 Pneumothorax: causes and treatment

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Challenging clinical cases 7 Pneumothorax: causes and treatment

AIMS: To discuss with the audience the various reasons and treatment options for a pneumothorax.

TARGET AUDIENCE: Radiologists, pathologists, pulmonologists, thoracic surgeons, respiratory therapists, respiratory physicians, clinical researchers, radiologists, fellows, and residents.

CHAIRS: A. Olland (Strasbourg, France)

PROGRAMME PAGE

07:10 The surgeons view 5 G. Massard (Strasbourg, France) 07:35 The pulmonologists view 47 J. Yserbyt (Leuven, Belgium)

Additional resources 80

Faculty disclosures 81

Faculty contact information 82

Answers to evaluation questions 83

EUROPEAN LUNG FOUNDATION

Bringing together patients and the public with respiratory professionals

To help you provide advice to your Recent factsheets: patients, ELF produces factsheets on lung health and disease. • Exercise and air quality: 10 top tips These are informed by patient • Vaccination and lung disease and professional interviews and • Chronic cough written in language that is easy to understand. • Smoking when you have a lung condition You can download an electronic • Primary spontaneous pneumothorax version of all the factsheets from • E-cigarettes the ELF website. There are over 30 • Work-related lung conditions titles, covering a range of topics, in more than 8 different languages. • Severe and difficult-to-treat asthma

www.europeanlung.org Pneumothorax: causes and treatment The surgeons view

Prof. Gilbert Massard Department of Thoracic Surgery Civil Hospital 1 place de l'Hôpital BP 426 CEDEX 67091 Strasbourg FRANCE [email protected]

5 Pneumothorax in difficult situations

Gilbert Massard Service de Chirurgie Thoracique

Hôpitaux Universitaires de Strasbourg6 Conflict of interest :

NONE !

7 Case # 1

Recurrent pneumothorax in

a young lady without

medical history

8 Case presentation

• Female patient, 29 year old

• Right pleurodesis (pleurectomy + apical stapling) by VATS 2011.

• Presents with right apical 15% pneumothorax in November 2013

• Reports at least 7 episodes of presumed partial pneumothorax (typical pain, mild transient dyspnea) during the past 18 months

9 10 Which statement reflects best your opinion ?

1. No chance, recurrence rate after VATS pleurodesis is low, around 3-5 % 2. Not unusual, recurrence rate of VATS is around 15 % 3. This is a typical preclinical LAM

4. Any other hypothesis ?

11 Which statement reflects best your opinion ?

1. No chance, recurrence rate after VATS pleurodesis is low, around 3-5 % 2. Not unusual, recurrence rate of VATS is around 15 % 3. This is a typical preclinical LAM

4. Any other hypothesis ?

Massard et al, Ann Thorac Surg 1999 12 Which statement reflects best your opinion ?

1. No chance, recurrence rate after VATS pleurodesis is low, around 3-5 % 2. Not unusual, recurrence rate of VATS is around 15 % 3. This is a typical preclinical LAM

4. Any other hypothesis ?

13 Further discussion with the patient reveals :

• Painful menstruation + premenstrual syndrome

14 Further discussion with the patient reveals :

• Painful menstruation + premenstrual syndrome • All episodes of pneumothorax, i.e. « pleural pain » during menstruation

15 Pathogenesis of catamenial PTX

congenital

• « Porous diaphragm »

acquired

• Endometriosis

visceral pleural tear

• Release of PG-F2

16 17 Diagnosis of catamenial PTX

• Frequently recurrent partial PTX • Failure of VATS pleurodesis suggestive

• Relation with menses not always obvious • Elevated marker Ca 125

Bagan et al, Eur Respir J 2008;31:140-2 18 Thoracoscopic findings :

• Diaphragmatic perforations – tendinous part – closure mandatory : suture / stapling / mesh • Endometriosis – brownish subpleural nodules – biopsy mandatory

19 Porous diaphragm

20 Endometriosis of visceral pleura

21 22 How to treat catamenial PTX??

• Anti-gonadotrophine treatment : – obvious when biopsy-proven endometriosis – logic when history is suggestive • Repeated operation – yes if the diaphragm is not described in the protocol – otherwise debatable

23 Epilogue

• Pleural endometriosis was confirmed by thoracoscopy

• Peritoneal endometriosis was confirmed by mini- laparoscopy

• Anti-gonadotrophin treatment initiated November 2013, stopped November 2014

• No further relapse so far

24 Case # 2

A 24-year-old patient with CF and recurrent spontaneous pneumothorax

25 Case presentation

• 24 year old male patient • CF diagnosed in the neonatal period • Regular follow-up at CF clinic • No patent diabetes mellitus • Colonisation with Staph aureus and Ps. aeruginosa • FEV-1 45 % • 2nd episode of partial right pneumothorax with pain and mild dyspnea

26 How do you rate the following statements ?

1. Pneumothorax is not related to the severity of the disease

2. Pneumothorax leads to a 4-fold increase of mortality

3. FEV-1 < 30% is a risk factor for pneumothorax

4. Incidence increases with age

27 PTX in CF : epidemiology

• Mean age at 1st PTX 21 years • Incidence increases with – Age – Severity of disease • Risk factors – Colonization with Pseudomonas sp or Aspergillus sp – FEV-1 < 30% – Requirement for enteral feeding – Hemoptysis

Amin et al, Cochrane Database Syst Rev 2009. CD007481 Flume et al, Chest 2005;128:720-8 28 How would you manage this case which would be an indication for pleudodesis in non-CF patients !!

1. Simple observation, does not need any invasive treatment

2. Simple observation, pleurodesis is prohibited in CF patients because it jeopardizes the perspective of lung transplantation

3. Chest tube insertion, because it is recurrent pneumothorax

4. VATS pleurodesis, because there is an increased risk of recurrence, and no increased risk for lung transplantation

29 PTX in CF : guide-lines for treatment

• Asymptomatic + < 20 % : observation

• All other : tube thoracostomy

• Recurrence mandates pleurodesis

Schidlow et al, Pediatr Pneumonol 1993;15:187-98 30 PTX in CF : comments on pleurodesis

• Does not jeopardize lung TX !! • Requirements: – respect extrapleural space – respect diaphragmatic nerves • Means : – chemical pleurodesis – VATS abrasion /pleurectomy – thoracotomy

Rolla M et al, Eur J Cardio-thorac Surg 2011;39: 716-25

Curtis et al, J Heart Lung Transplant 2005;24:865-9 31 Now : same question for 59-year-old patient with COPD !!

1. No reluctance for pleurodesis, a minority of these patients qualify for lung transplantation

2. Requirement of lung transplantation is unpredictable

3. Approach depends from comorbidity

4. Pneumothorax signifies that it is too late to leave smoking habits

32 Likelyhood of TX is low !!!

• Cardiovascular comorbidity • Potential contraindications in medical history • Addictions

• Prognosis of COPD may be estimated with BODE score

Celli BR et al, N Engl J Med 2004; 350 : 1005-12 33 Celli BR et al, N Engl J Med 2004; 350 : 1005-12 34 Celli BR et al, N Engl J Med 2004; 350 : 1005-12 35 Celli BR et al, N Engl J Med 2004; 350 : 1005-12

36 PTX in potential candidates for lung TX

• Emphysema

– BODE score !!

– Minority eligible for TX

• CF

– Most ultimately eligible

– PTX common

37 Case # 3

Spontaneous pneumothorax in a patient having undergone right pneumonectomy for cancer

38 Case presentation

• Male patient, 67 year old • Asbestos exposure • 57 pack/years • Myocardial infarction, 2x stented 2008 • Right pneumonectomy + adjuvant chemo for T3N1 in 2010

• Admitted with respiratory failure April 23rd, 2015 • Immediate chest tube insertion • Air leak stops on April 27th 39 Which statement reflects best your opinion ?

1. We are lucky that the airleak stopped !

2. Pleurodesis is mandatory, because this patient could die with recurrent pneumothorax

3. Palliative care; pneumothorax after pneumonectomy for cancer is most often a symptom of recurrent disease

4. Surgical pleurodesis would be best, but ischemic heart diseae is a contraindication.

5. Surgery on a single lung is impossible

40 Which statement reflects best your opinion ?

1. We are lucky that the airleak stopped !

2. Pleurodesis is mandatory, because this patient could die with recurrent pneumothorax

3. Palliative care; this patient had advanced stage cancer and pneumothorax is certainly related to recurrent disease

4. Surgical pleurodesis would be best, but ischemic heart disease is a contraindication.

5. Surgery on a single lung is impossible

41 Spontaneous PTX after pneumonectomy

• Pleurodesis recommended • Choice of technique critical – talc slurry – awake thoracoscopy – thoracoscopy under CPB / ECMO – muscle-sparing thoracotomy

Ariyatnam et al, Ann Thorac Surg 2011;92: 7-9 Noda et al, J Thorac Cardiovasc Surg 2011;141:1545-7 Birdas et al, Interat Cardiovasc Thorac Surg 2005;4:1545-7 42 Some adminitions after pneumonectomy

• Avoid pleural procedures without guidance by imaging – Thoracentesis – Chest tube insertion • Avoid transthoracic procedures on the parenchyma – TTNA biopsy – RFA • Avoid to place central veinous catheters on the side of the remaining lung

43 Why pneumothorax can be a difficult issue !

• Relentless relapses catamenial PTX

• Potential candidate for TX CF

• Technical difficulties previous pneumectomy

44 Many thanks to my team !!

45 46 Pneumothorax: causes and treatment The pulmonologists view

Dr Jonas Yserbyt University Hospitals Leuven Herestraat 49 3000 Leuven BELGIUM [email protected]

AIMS

 To manage a pneumothorax based upon a notion of pathophysiology  To decide which cases can be managed by a pulmonologist  To identify cases that need a surgical approach

SUMMARY

Pneumothorax is defined as the presence of air in the pleural space and can be the result of three different aetiological mechanisms. Either a communication between alveolar spaces and pleural space or a communication between atmosphere and pleural space, less frequently as a result of the presence of gas-producing organisms in the pleural space. Spontaneous pneumothorax can be either primary (PSP, absence of clinically apparent underlying lung disease) or secondary (SP) to COPD, CF, PF, TBC, lung cancer,… Non-spontaneous pneumothoraces are either traumatic or iatrogenic.

The age adjusted male incidence is 7.4 to 18 per 100,000, the female incidence is 1.2 to 6 cases per 100,000. Known risk factors are ectomorphic habitus, male sex, cigarette smoking or genetic predisposition. Precipitating factors has been described including atmospheric pressure, storms, abrupt temperature change [1] and loud music [2].

Pathophysiological processes accounting for the presence of a pneumothorax are rupture of a subpleural bleb or of a bulla, so called emphysema-like changes (ELC) [3, 4] and the concept of pleural porosity [5].

Talc pleurodesis performed during medical thoracoscopy is an effective treatment option both in PSP and SP. Graded sterile talc has been used in Europe for more than 70 years for pleurodesis in recurrent spontaneous pneumothorax and has proofed to be inexpensive, efficient [6] and safe [7, 8].

Catamenial pneumothorax (CP) is a specific entity that needs highlighting. It is defined as spontaneous recurrent pneumothorax occurring in women of reproductive age, in temporal relationship with menses. It is often associated with thoracic and pelvic endometriosis and can be part as the so called “Thoracic endometriosis syndrome”: CP, haemoptysis, haemothorax, lung nodules, catamenial chest pain and pneumomediastinum. CP accounts for 18% - 33% of pneumothoraces in premenopausal women (mean age 35). There are 3 aetiological theories of CP: the physiologic hypothesis, the lymphovascular micro- embolization hypothesis, the transgenital-transdiaphragmatic passage of air theory and the migration theory [9].

47 REFERENCES

1. Alifano et al. Atmospheric pressure influences the risk of pneumothorax: beware of the storm!Chest 2007; 131: 1877– 82. 2. Noppen M et al. Music: a new cause of primary spontaneous pneumothorax. Thorax 2004; 59:722- 724. 3. Sihoe et al. Can CT scanning be used to select patients with unilateral primary spontaneous pneumothorax for bilateral surgery? Chest 2000 118(2):380-3. 4. Huang et al. Contralateral recurrence of primary spontaneous pneumothorax.Chest 2007; 132: 1146–50. 5. Noppen et al. Fluorescein-enhanced autofluorescence thoracoscopy in patients with primary spontaneous pneumothorax and normal subjects.Am J Respir Crit Care Med 2006; 174: 26– 30. 6. Cardillo J et al. Videothoracoscopic talc poudrage in primary spontaneous pneumothorax: a single- institution experience in 861 cases.Thoracic Cardiovasc Surg 2006; 131: 322–328. 7. Bridevaux et al. Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective European multicentre study. Eur Respir J 2011; 38: a. 770–773 8. Sahn et al. Talc should be used for pleurodesis. Am J Respir Crit Care Med 2000; 162: 2023– 2024. 9. Visouli et al. Catamenial pneumothorax J Thorac Dis 2014;6(S4):S448-S460

EVALUATION

1. Primary Spontaneous Pneumothorax is … a. Unexisting since every pneumothorax is the result of pleural abnormalities. b. A medical emergency in case of recurrence. c. The result of transpleural pressure gradient, pleural porosity and pleural abnormalities in subjects without clinically overt pulmonary disease. d. Multifactorial in its aetiology and therefore difficult to treat.

2. A secondary pneumothorax is treated with… a. Single manual aspiration b. Chest tube drainage and prevention of recurrence c. By a thoracic surgeon in every case d. Bullectomy and pleurectomy to achieve the lowest recurrence rates possible

3. Endometriosis-related pneumothorax is… a. Always catamenial b. Very rare among cases of spontaneous pneumothorax in young women c. Completely preventable if women are on oral contraceptives d. Always treated by a surgical procedure

4. The most important predictor of success after talc pleurodesis is … a. The complete re-expansion of the treated lung b. The presence of a primary spontaneous pneumothorax c. The grading of the talc that is used d. The fact that it is applied during a surgical VATS procedure

48 5. Which of the following is untrue? a. Patients should be cautioned against commercial flights at high altitude until full resolution of the pneumothorax has been confirmed by a chest x-ray. b. Many commercial airlines advise a 6-week interval between the pneumothorax event and air travel c. The 6th edition of the IATA medical manual states that a passenger with an active pneumothorax could not be accepted for air travel in a commercial aircraft. IATA allows passengers on a commercial flight 7 days after full inflation of the lung and 4 days after inflation for a traumatic pneumothorax. d. In the absence of a definitive procedure, patients with SSP may decide to minimise the risk by deferring air travel. e. After a pneumothorax, diving should be discouraged permanently unless a very secure definitive prevention strategy has been performed.

49 PNEUMOTHORAX: CAUSES AND TREATMENT

J.Yserbyt University Hospitals Leuven ERS Congress Amsterdam 2015

50 Conflict of interest disclosure  I have the following, real or perceived direct or indirect conflicts of interest that relate to this presentation:

Affiliation / financial interest Nature of conflict / commercial company name

Tobacco-industry and tobacco corporate affiliate related conflict of interest

Grants/research support (to myself, my institution or Klinisch Onderzoeksfonds KU Leuven department):

Honoraria or consultation fees: Boston Scientific

Participation in a company sponsored bureau:

Stock shareholder:

Spouse/partner:

Other support or other potential conflict of interest:

This event is accredited for CME credits by EBAP and speakers are required to disclose their potential conflict of interest going back 3 years prior to this presentation. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgment. It remains for audience members to determine whether the speaker’s interests or relationships may influence the presentation. Drug or device advertisement is strictly forbidden. 51 Introduction

AIMS

• To manage a pneumothorax based upon a notion of pathophysiology

• To decide which cases can be managed by a pulmonologist

• To identify cases that need a surgical approach

52 PNEUMOTHORAX

• Presence of air in the pleural space • Negative intrapleural pressure : no spontaneous migration of air into the pleural cavity (Ppl < -36 cmH2O) • 3 possible mechanisms: – 1) communication between alveolar spaces and pleural space – 2) communication between atmosphere and pleural space – 3) presence of gas-producing organisms in the pleural space • Spontaneous -Primary spontaneous pneumothorax (PSP) : absence of clinically apparent underlying lung disease. -Secondary pneumothorax (SP) : COPD, CF, PF, TBC, lung cancer,… • Non-spontaneous (traumatic / iatrogenic)

53 CASE 1: MALE 18 YEARS OLD; NON SMOKER

54 EPIDEMIOLOGY PSP

• Age adjusted male incidence of 7.4 to 18 per 100,000 • Age adjusted female incidence 1.2 to 6 cases per 100,000 • Risk factors : – Ectomorphic habitus – Male sex – Smoking (cannabis) -> Rb-ILD – Genetic/embryogenic • Precipitating factors : – atmospheric pressure (Diff 10 mBAR; clustering of PSP) – storms, abrupt temperature change (Alifano et al. Chest 2007; 131: 1877– 82) – loud music • Not known as a risk factor: – Physical exercise (PSP typically occurs at rest) – Valsalva

55 POPULAR MISUNDERSTANDINGS

• No need for routinely expiratory chest radiography

• Contralateral shift of the trachea and mediastinum is a completely normal phenomenon in SP and not at suggestive for tension pneumothorax (extremely rare in PSP).

• Discriminatie PSP from SP ! - PSP : calm down and think about the best/minimally invasive solution - SP : in case of known/suspected lung disease : act !

56 SAME PATIENT… 2 MONTHS LATER….

57 PATHOGENESIS : LACK OF DIRECT EVIDENCE

• 3 possible mechanisms: – 1) communication between alveolar spaces and pleural space – 2) communication between atmosphere and pleural space – 3) presence of gas-producing organisms in the pleural space

• Rupture of a subpleural bleb, or of a bulla • Minority of blebs are actually ruptured at the time of thoracoscopy • Emphysema-like changes (ELC) • In patients without clinical evidence for emphysema • Seen in > 80% of PSP pts subjected to CT scan (even in non-smokers) • CT scanning in PSP as a possible recurrence prediction tool (Sihoe et al. Chest 2001; 119: 1294 – Huang et al. Chest 2007; 132: 1146–50) • ‘‘Pleural porosity’’

58 PATHOGENESIS : PLEURAL POROSITY

“Areas of disrupted mesothelial cells at the visceral pleura, replaced by an inflammatory elastofibrotic layer with increased porosity, allowing air leakage into the pleural space” - in PSP : Masshof ey al .Dtsch Med Wochenschr 1973; 98: 801–805 - in SP : Ohata et al. Chest 1980; 77: 771–776

Evidence for this concept : - blebs and bullae occur in 15% of normal subjects - high recurrence rates of up to 20% of bullectomy alone - EM : mesothelial cells and pore-like structures cover ELC - fluo-enhanced autofluorescence or infrared thoracoscopy

59 Noppen et al. Am J Respir Crit Care Med 2006; 174: 26–30

60 ETIOLOGY

61 Knowledge about pathogenesis of pneumothorax

Appropiate treatment modalities:

1) At presentation Avoid misunderstandings

2) Prevention of recurrence

62 APPROPIATE TREATMENT OPTIONS

• There’s a lot a pulmonolgist can do : both in PSP and SP !

• At presentation : Try to avoid chest tube drainage in PSP

• Beware of young girls and old guys ! -> don’t make it messy when using graded talc

63 Acta Chir Belg. 2005 May-Jun;105(3):265-7 64 PREVENTION OF RECURRENCE

65 GRADED TALC

• Inexpensive (15 EUR - vial 4g)

• Efficient (Cardillo J Thoracic Cardiovasc Surg 2006; 131: 322–328) • Safe : Bridevaux et al Eur Respir J 2011; 38: 770–773: Multicentric prospective trial (n=418 – 9 centers); no cases of ARDS, no admission on ICU, no mortality • ARDS : 1/659 cases (Sahn et al Am J Respir Crit Care Med 2000; 162: 2023–2024) – no cases in treatment PSP • Used in Europe for > 70 yrs for pleurodesis in recurrent spontaneous pneumothorax • Recurrence rates (non-randomized) 6.5% in PSP and 8.7% SP

66 6 MONTHS LATER … ON INTERNAL MEDICINE …

67 Acta Chir Belg. 2005 May-Jun;105(3):265-7

68 ABOUT YOUNG GIRLS

- 43 year old female patient, non smoker

- 2001 : bilateral pneumothorax treated with bilateral pleurectomy

- 3/2007 : Chronic dyspnea

69 70 Histopathology : Focal gland structures (IHC ER+) lined by endometrial epithelium. Presence of hemosiderin in macrophages.

Visouli et al. J Thorac Dis 2014;6(S4):S448-S460

71 72 CATAMENIAL PNEUMOTHORAX

• Spontaneous recurrent (>1) pneumothorax, occurring in women of reproductive age, in temporal relationship with menses

• Associated with thoracic and pelvic endometriosis – Thoracic endometriosis affects the right hemithorax in 85-90% of cases.

• “Thoracic endometriosis syndrome” : CP, haemoptysis, haemothorax, lung nodules, catamenial chest pain and pneumomediastinum

• “Temporal relationship” : inconsistent – “72 hours before or after the onset” or “within 5 to 7 days of menses”

• In ovulating women – pregnancy, menarche and ovulatory suppressants generally not considered. Nevertheless, there are rare case reports of “CP” in women on ovulatory suppression and during pregnancy

• Between 18% - 33% of PneuTx cases in premenopausal women ~ endometriosis ; mean age 35

73 CATAMENIAL PNEUMOTHORAX

• Aetiological theories:

- Physiologic hypothesis : PG F2 -> vaso- & bronchoconstriction (pre-existing defects of visceral pleura)

- Lymphovascular micro-embolization : spreading of endometriosis through blood & lymph vessels

-> subpleural : CP -> central : haemoptysis

- Transgenital-transdiaphragmatic passage of air theory: - Pre-existing diaphragmatic defects

- Migration theory: - Right-sided lesions - Acquired diaphragmatic defects

• Non-catamenial; endometriosis related pneumothorax (!)

74 ABOUT OLD GUYS

75 76 POWDER ALERT…

77 POWDER ALERT…

78 Conclusion

PSP is no medical emergency : think before doing

There’s a lot a pulmonologist can do

Beware of young girls and old guys

79 Recommended reading list and E-learning resources

1. Matsuoka K, Ito A, Murata Y, Kuwata T, Takasaki C, Imanishi N, Matsuoka T, Nagai S, Ueda M, Miyamoto Y. Four cases of contralateral pneumothorax after pneumonectomy. Ann Thorac Surg. 2014 Oct; 98(4):1461-3. doi: 10.1016/j.athoracsur.2013.12.066. PubMed PMID: 25282215. 2. Gaunt A, Martin-Ucar AE, Beggs L, Beggs D, Black EA, Duffy JP. Residual apical space following surgery for pneumothorax increases the risk of recurrence. Eur J Cardiothorac Surg. 2008 Jul; 34(1):169-73. doi: 10.1016/j.ejcts.2008.03.049. Epub 2008 May 1. PubMed PMID: 18455414. 3. Dernevik L, Belboul A, Rådberg G. Initial experience with the world's first digital drainage system. The benefits of recording air leaks with graphic representation. Eur J Cardiothorac Surg. 2007 Feb; 31(2):209-13. Epub 2006 Dec 27. PubMed PMID: 17194600. 4. Oey IF, Peek GJ, Firmin RK, Waller DA. Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation. Eur J Cardiothorac Surg. 2001 Oct; 20(4):874-6. PubMed PMID: 11574247. 5. Ishiyama T, Iwashita H, Shibuya K, Terada Y, Masamune T, Nakadate Y, Matsukawa T. High- frequency jet ventilation during video-assisted thoracoscopic surgery in a patient with previous contralateral pneumonectomy. J Clin Anesth. 2013 Feb; 25(1):55-7. doi: 10.1016/j.jclinane.2012.05.008. Epub 2012 Dec 17. PubMed PMID: 23257249. 6. Ghigna MR, Mercier O, Mussot S, Fabre D, Fadel E, Dorfmuller P, de Montpreville VT. Thoracic endometriosis: clinicopathologic updates and issues about 18 cases from a tertiary referring center. Ann Diagn Pathol. 2015 Jul 8. pii: S1092-9134(15)00109-4. doi: 10.1016/j.anndiagpath.2015.07.001. [Epub ahead of print] PubMed PMID: 26243726. 7. Alifano M. Catamenial pneumothorax. Curr Opin Pulm Med. 2010 Jul; 16(4):381-6. doi: 10.1097/MCP.0b013e32833a9fc2. Review. PubMed PMID: 20473170. 8. Rolla M, D'Andrilli A, Rendina EA, Diso D, Venuta F. Cystic fibrosis and the thoracic surgeon. Eur J Cardiothorac Surg. 2011 May; 39(5):716-25. doi: 10.1016/j.ejcts.2010.07.024. Epub 2010 Sep 6. Review. PubMed PMID: 20822917. 9. Judson MA, Sahn SA. The pleural space and organ transplantation. Am J Respir Crit Care Med. 1996 Mar; 153(3):1153-65. Review. PubMed PMID: 8630560. 10. Amin R, Noone PG, Ratjen F. Chemical pleurodesis versus surgical intervention for persistent and recurrent pneumothoraces in cystic fibrosis. Cochrane Database Syst Rev. 2012 Dec 12; 12:CD007481. doi: 10.1002/14651858.CD007481.pub3. Review. PubMed PMID: 23235645. 11. Tobin MJ. Chronic obstructive pulmonary disease, pollution, pulmonary vascular disease, transplantation, pleural disease, and lung cancer in AJRCCM 2000. Am J Respir Crit Care Med. 2001 Nov 15; 164(10 Pt 1):1789-804. Review. PubMed PMID: 11734426. 12. Bintcliffe OJ, Hallifax RJ, Edey A, Feller-Kopman D, Lee YC, Marquette CH, Tschopp JM, West D, Rahman NM, Maskell NA. Spontaneous pneumothorax: time to rethink management? Lancet Respir Med. 2015 Jul; 3(7):578-88. doi: 10.1016/S2213-2600(15)00220-9. Review. PubMed PMID: 26170077. 13. Delpy JP, Pagès PB, Mordant P, Falcoz PE, Thomas P, Le Pimpec-Barthes F, Dahan M, Bernard A; EPITHOR project (French Society of Thoracic and Cardiovascular Surgery). Surgical management of spontaneous pneumothorax: are there any prognostic factors influencing postoperative complications? Eur J Cardiothorac Surg. 2015 Jun 12. pii: ezv195. [Epub ahead of print] PubMed PMID: 26071433. 14. Parlak M, Uil SM, van den Berg JW. A prospective, randomised trial of pneumothorax therapy: manual aspiration versus conventional chest tube drainage. Respir Med. 2012 Nov; 106(11):1600- 5. doi: 10.1016/j.rmed.2012.08.005. Epub 2012 Aug 24. PubMed PMID: 22925840.

80 Faculty disclosures

Dr Jonas Yserbyt has received consultation fees from Boston Scientific. His former congress registration was financed by Boehringer Ingelheim. His work benefited also from grants/research support from Clinical Research Fund KU Leuven.

81 Faculty contact information

Prof. Gilbert Massard Department of Thoracic Surgery Civil Hospital 1 place de l'Hôpital BP 426 CEDEX 67091 Strasbourg FRANCE [email protected]

Dr Anne Olland Department of Thoracic Surgery Civil Hospital 1 place de l'Hôpital BP 426 CEDEX 67091 Strasbourg FRANCE [email protected]

Dr Jonas Yserbyt University Hospitals Leuven Herestraat 49 3000 Leuven BELGIUM [email protected]

82 Answers to evaluation questions

Please find all correct answers in bold below

Pneumothorax: causes and treatment. The pulmonologists view - Dr Jonas Yserbyt

5. Which of the following is untrue? a. Patients should be cautioned against commercial flights at high altitude until full resolution of the pneumothorax has been confirmed by a chest x-ray. b. Many commercial airlines advise a 6-week interval between the pneumothorax event and air travel c. The 6th edition of the IATA medical manual states that a passenger with an active pneumothorax could not be accepted for air travel in a commercial aircraft. IATA allows passengers on a commercial flight 7 days after full inflation of the lung and 4 days after inflation for a traumatic pneumothorax. d. In the absence of a definitive procedure, patients with SSP may decide to minimise the risk by deferring air travel. e. After a pneumothorax, diving should be discouraged permanently unless a very secure definitive prevention strategy has been performed.