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0 UHM 45-2 MAR-APR 2018.Indd UHM 2018, VOL. 45, NO. 2 – SPIROMETRY AND OXIDATIVE STRESS AFTER REBREATHER DIVING UHM 2018, VOL. 45, NO. 2 – DIVING AFTER PSP Review Article Can my patient dive after a first episode of primary spontaneous pneumothorax? A systematic review of the literature M. Alvarez Villela, MD 1,2, S. Dunworth, MD 1,4, N.P. Harlan, MD 1,5, RE Moon, MD 1,3 1 Center for Hyperbaric Medicine and Environmental Physiology, Duke University Medical Center, Durham, North Carolina, U.S. 2 Division of Cardiology, Montefiore Medical Center –Albert Einstein College of Medicine, Bronx, New York, U.S. 3 Department of Anesthesiology, Duke University, Durham, North Carolina, U.S. 4 Department of Anesthesiology, Stanford University, Palo Alto, California, U.S. 5 Division of Pulmonary Medicine University of Utah, Salt Lake City, Utah, U.S. CORRESPONDING AUTHOR: M. Alvarez Villela – [email protected] ___________________________________________________________________________________________________________________________________________________________________ ABSTRACT BacKground Introduction: Patients with prior primary spontaneous Spontaneous pneumothorax occurs in patients without pneumothorax (PSP) frequently seek clearance to dive. Despite antecedent trauma or iatrogenic event. When it occurs wide consensus in precluding compressed-air diving in this in patients who additionally have no apparent under- population, there is a paucity of data to support this decision. lying lung disease, this phenomenon is termed primary We reviewed the literature reporting the risk of PSP recurrence. spontaneous pneumothorax (PSP). Methods: A literature search was performed in PubMed and The incidence of PSP is age-related, and is estimated Web of Science using predefined terms. Studies published in to be 7.4/100,000/year in men and 1.2/100,000/year English reporting the recurrence rate after a first PSP were in women, peaking between the ages of 15-34 [1,2]. included. Diving physicians frequently encounter patients with Results: Forty studies (n=3,904) were included. Risk of PSP a history of PSP who wish to dive. Traditionally, the recurrence ranged 0-67% (22±15.5%; mean ± SD). Mean follow- up was 36 months, and 63±39% of recurrences occurred during consensus in the hyperbaric medicine field has been to the first year of follow-up. advise against any compressed-air diving since a recur- Elevated height/weight ratio and emphysema-like changes rence under water could lead to serious complications (ELCs) are associated with PSP recurrence. ELCs are present or death. As a result, case series examining this issue in 59%-89% (vs. 0-15%) of patients with recurrence and can are non-existent, and evidence to clearly support or be detected effectively with high-resolution CT scan (sensitivity reject this recommendation is lacking in the current of 84-88%). Surgical pleurodesis reduces the risk of recurrence literature. substantially (4.0±4% vs. 22±15.5%). The need for further evidence to help guide clinical Conclusions: Risk of PSP recurrence seems to decline practice is illustrated in the American College of Chest over time and is associated to certain radiological and clinical Physicians Delphi consensus statement on the manage- risk factors. This could be incremented by the stresses of com- pressed-air diving. A basis for informed patient-physician dis- ment of spontaneous pneumothorax [3]. Fifteen (15) cussions regarding future diving is provided in this review. percent of panel members said they would offer surgery to prevent recurrence to individuals with a history of ___________________________________________________________________________ PSP who are at high risk in case of recurrence – such KEYWORDS: pneumothorax, primary, spontaneous, diving, as divers or pilots-, rather than disqualifying them clearance to dive from their activities. Copyright © 2017 Undersea & Hyperbaric Medical Society, Inc. 199 UHM 2018, VOL. 45, NO. 2 – DIVING AFTER PSP One way to approach this issue is to examine the deviations. Where not reported, ranges were calculated rate of PSP recurrence in the general population to from the original study data. approximate the general risk in divers, and then con- Studies that performed survival analysis, or reported template the effect that physiological and mechanical the incidence of recurrence after chest computed to- stresses of compressed-air diving may have in increasing mography (CT) scan examination, or reported recur- that risk. rences after surgical treatment of a first PSP are given For this purpose, we conducted a systematic review special mention. of the literature on PSP recurrence, seeking to answer pertinent questions including: Results 1. What is the rate of PSP recurrence in the general In total, 491 studies were reviewed; 40 met criteria for population? inclusion. Results are summarized in Table 1 and in- 2. Can the presence of pulmonary abnormalities cluded studies are listed in Table 2. In total, 17 pro- such as blebs or bullae predict recurrence? spective observational studies, 18 retrospective studies, 3. Can blebs or bullae be reliably detected by four controlled trials and one cross-sectional study CT scan imaging? are included. 4. Can pneumothorax recur in patients with ____________________________________________________________________________ radiographically normal lungs? TABLE 1. Included studies 5. Can surgical treatment of a first episode prevent study design number of studies PSP recurrence? controlled trials 4 We then discuss what is known about PSP and diving, prospective observational 17 specifically what the plausible mechanisms of increased retrospective 18 cross-sectional 1 risk during compressed-air diving are. Total 40 ____________________________________________________________________________ Methods In February 2015 a search was conducted using PubMed General Characteristics of PSP Recurrence and Web of Science, combining the terms “spontaneous Within the selected studies, 3,904 patients with a first AND pneumothorax AND recurrence.” The search was episode of PSP were included (Table 3). limited to studies in adults (19+ years), humans, and The mean probability of PSP recurrence ranged work published in the English language. from 0-67% with an average of 22±15.5% (mean ± SD). Included studies [1] were original research and [2] Follow-up time ranged from one to 120 months studies that specifically reported the rate of recurrence with a mean of 36 months. after a first episode of primary spontaneous pneumo- Sixty-three percent (63±39%) of recurrences, ac- thorax (PSP) with a follow-up period of at least one cording to 21 studies, occurred during the first year of month after receiving any treatment modality. follow-up. Time to first recurrence, reported by 22 Studies were excluded if they reported the recur- studies, ranged from 2.8 to 107 months, with a mean rence rate after more than one PSP episode or after of 20 months. a secondary pneumothorax occurrence – whether The mean age was 28 years (range 16-43), and the spontaneous, iatrogenic or traumatic. prevalence of smokers was 64%. Additionally, a hand search of the references cited in the selected articles was conducted to ensure that Predictive value of chest CT scan in PSP recurrence all relevant studies were included. The prevalence of surgically detected blebs or bullae, The study selection process was conducted indepen- also termed emphysema-like changes (ELCs), in patients dently by two authors (Dunworth S and Alvarez Villela with PSP ranged from 77%-90% [4-6] and was as M), and discrepancies were resolved by discussion high as 100% when histology analysis is included [7]. between them. High-resolution CT scan (HRCT) has a sensitivity Demographic and clinical data for the included of 84%-88% and a specificity of 100% compared with patients are presented as simple means and standard surgery for detecting these ELCs [4,8]. The sensitivity 200 Alvarez Villela M, Dunworth S, Harlan NP, Moon RE UHM 2018, VOL. 45, NO. 2 – DIVING AFTER PSP UHM 2018, VOL. 45, NO. 2 – DIVING AFTER PSP _________________________________________________________________________________________________________________________________________________________ TABLE 2. List of included studies Year First Author Study Design Intervention N Mean Follow-up Overall Mean Publ. Comparison Time (months) Recurrence Rate 1993 Abolnik (23) Retrospective None 286 107.2 mo 41% 2006 Ayed (48) RCT SA vs. CTD 137 24 mo 31% vs. 25% 2013 Casali (17) Retrospective None 176 58 mo 57% (Monocenter) 2005 Chan (49) Retrospective None 91 12 mo 15.70% (Monocenter) 2008 Chen (29) Retrospective SA vs. SA+minocycline 64 13 mo 33.3% vs. 12.9% instillation 2013 Chen (50) RCT SA vs. SA+minocycline 214 18 mo 49.1% vs. 29.2% instillation 2008 Chen (26) Retrospective CTD vs. VATS 52 19.3 mo 22.7% vs. 3.3% 2003 Chou (5) Prospective None 51 38 mo 0.0% 1957 Cliff (51) Retrospective None 149 not specified 12% 1946 Cohen (52) Cross-sectional None 30 not specified 10% 1967 Cran (53) Retrospective None 836 not specified 18.8% 1953 DuBose (54) Prospective None 65 not specified 20% 1993 Ferraro (25) Retrospective None 239 1 mo 34.2% 2010 Ganesalingam (20) Retrospective None 100 57 mo 54% 2000 Hatz (6) Prospective None 53 53.2 mo.† 7.5% 2007 Huang (16) Retrospective None 231 92 mo 14.30% 1962 Hyde (55) Retrospective None 200 not specified 17.5% 2013 Kawaguchi (4) Prospective None 93 not specified 8% observational 1998 Kim (10) Prospective after None 61 6 mo. 17.75% VATS based on CT 1993 Krasnik (12) Prospective Thoracotomy vs. 393 not specified 8% VATS+Tetracycline Inst. 2006 Kuzucu (27) Retrospective Observation vs. CTD 58 25.6 mo 66.8% vs. 21.8% (Monocenter) vs. VATS vs. 0% 2011 Laituri (9) Retrospective None 34 not specified 13.85% 1991 Lippert (21) Prospective None 122 62.4 mo 17% 2003 Margolis (7) Prospective None 156 62 mo.† 0.0% 2006 Marquette (56) Prospective None 41 10.7 mo 24% 2007 Martinez-Ramos (18) Prospective None 55 30.7 mo 24% 2014 Massongo (24) Prospective None 60 24 mo 16.70% 1992 Mitlehner (11) Prospective None 35 9.6 and 31.7 mo 25% 1948 Myerson (57) Prospective None 36 not specified 14.7% 2002 Noppen (58) RCT SA vs.
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