doi • 10.5578/tt.66527 Tuberk Toraks 2018;66(1):76-77 Geliş Tarihi/Received:03.02.2018 • Kabul Ediliş Tarihi/Accepted: 19.02.2018

Difficulty in management of pneumothorax in an octogenarian with pulmonary fibrosis

1 Shinichiro Okauchi 1 1 Division of Respiratory Medicine, Mito Medical Center, Tsukuba University, Hajime Osawa Mito, Japan 1 Hiroaki SATOH 1 Tsukuba Üniversitesi Mito Tıp Merkezi, Solunum Bölümü, Mito, Japonya EDİTÖRE MEKTUP EDİTÖRE LETTER TO THE LETTER TO EDITOR

Dear Editor, 23rd day (Figure 1-C). Two months after the removal of the chest tube, the respiratory condition of the patient Treatment of pneumothorax in patients with idiopathic does not deteriorate. pulmonary fibrosis (IPF) is often problematic. Especially in elderly patients with IPF, treatment of pneumothorax Pneumothorax is a common complication in IPF may often be unsuccessful due to unexpected compli- patients, who can present increased morbidity caused cations. We would like to share our experience in by exacerbation of the respiratory manifestations of the pneumothorax treatment in a very elderly patient with disease, which can lead to respiratory failure and death IPF. (1). Pneumothorax in patients with IPF, air leaks from complicatedly modified lungs are sustained, and pul- An 84-year-old man was referred to our hospital with monary re-expansion is difficult to achieve due to an exacerbation of dyspnea. Ten years prior to this contraction tendency. If the lungs are re-expanded, presentation, the patient was diagnosed with idiopath- fortunately, pleurodesis is a conceivable effective treat- ic pulmonary fibrosis (IPF) (Figure 1-A). In addition to ment, but this is also problematic. Many of the drugs bilateral diffuse ground-glass opacities, traction bron- used for this treatment are accompanied by fever and chiectasis and honeycombing, right pneumothorax pain, but it is presumed that many elderly patients was found in the chest radiograph (Figure 1-B). Arterial cannot tolerate these complications. By performing blood gas on room air revealed PaO 38.3 mmHg, 2 pleurodesis in patients with IPF, dyspnea apparently PaCO 45.3 mmHg and pH 7.47 (O : 5L/min). A tho- 2 2 develops due to decreasing respiratory function (2). racic tube was inserted and deaeration was attempted. Although surgical therapy may be selected as a treat- Reactive pleural effusion was discharged in large quan- tities, but air leak continued. Taking poor respiratory state and general condition of the patient into consid- Yazışma Adresi (Address for Correspondence) eration, pleurodesis was not carried out. The pleurode- Dr. Hiroaki SATOH sis by autologous blood was also considered, but the Division of Respiratory Medicine, air leak disappeared on the 21st after inserting the Mito Medical Center, Tsukuba University, MITO - JAPAN thoracic tube and the tube could be removed on the e-mail: [email protected]

76 Okauchi S, Osawa H, Satoh H.

Figure 1. Chest radiograph taken half a year before this hospitalization showing bilateral diffuse ground-glass opacities (A). Right pneumothorax was found in the chest radiograph which was taken at the time of hospitalization (B). Chest radiograph taken two months after removal of the chest tube showing no recurrence of pneumothorax (C). ment for pneumothorax of patients with pulmonary RE­FE­REN­CES fibrosis, there are also problems in surgical treatment. 1. Panos RJ, Mortenson RL, Niccoli SA, King TE Jr. Clinical There are patients who do not have re-expansion of the deterioration in patients with idiopathic pulmonary fibrosis: lung due to contraction tendency in fibrosing lung. In causes and assessment. Am J Med 1990;88:396-404. addition, some patients lead to fatal acute exacerba- 2. Lange P, Mortensen J, Groth S. Lung function 22-35 years tion of IPF triggered by pleurodesis or surgical treat- after treatment of idiopathic spontaneous pneumothorax ment (3-5). with talc poudrage or simple drainage. Thorax 1988;43:559- 61. In our patient, some favorable factors existed: 3. DiBardino DJ, Vanatta JM, Fagan SP, Awad SS. Acute No deterioration of nutritional condition during the respiratory failure after pleurodesis with doxycycline. Ann treatment period, absence of delirium, no infectious Thorac Surg 2002;74:257-8. complication, no deterioration in activities of daily 4. Rehse DH, Aye RW, Florence MG. Respiratory failure living and cognitive function. In fact, albumin level following talc pleurodesis. Am J Surg 1999;177:437-40. before insertion of the thoracic tube was 2.5 g/dL, and 5. Elsayed HH, Hassaballa A, Ahmed T. Is video-assisted that at the day of removal of chest tube was 2.8 g/dL. thoracoscopic surgery talc pleurodesis superior to talc Long-term placement of the tube must be a great stress pleurodesis via tube thoracostomy in patients with for elderly patients, and long-term bed stay may also secondary spontaneous pneumothorax? Interact Cardiovasc cause deterioration in activities of daily living and cog- Thorac Surg 2016;23:459-61. nitive function. To our best knowledge, there has been no previous report on a pneumothorax that was suc- cessfully treated with conservative medical manage- ment in an octogenarian with IPF. Our experience might provide some clinical information on the treat- ment of pneumothorax in very elderly patients with IPF.

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