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Treatment of Complicated Spontaneous Pneumothorax by Simple Talc Pleurodesis 331

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Treatment of Complicated Spontaneous Pneumothorax by Simple Talc Pleurodesis 331 Thorax 1997;52:329±332 329 Treatment of complicated spontaneous Thorax: first published as 10.1136/thx.52.4.329 on 1 April 1997. Downloaded from pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia J M Tschopp, M Brutsche, J G Frey Abstract Spontaneous pneumothorax is a signi®cant Background ± Complicated (recurring or problem1 with an estimated recurrence rate of persistent) spontaneous pneumothorax 23±50% after the ®rst episode and higher after requires treatment either by talc pleuro- the ®rst recurrence.2 desis with bullae electrocoagulation or, There is little consensus about the treatment more aggressively, by thoracotomy or of spontaneous pneumothorax, with some video-assisted thoracoscopic surgery. authors3 recommending treatment by thora- However, the relative merits of bull- coscopy whereas others4 only recommend ectomy, pleurectomy, and pleurodesis thoracoscopy for recurrent or complicated have not yet been established in the treat- cases. Thoracotomy with pleurectomy and ment of spontaneous pneumothorax. bullectomy is the de®nitive treatment for Methods ± The complications, duration spontaneous pneumothorax and is associated of drainage, length of hospital stay, and with a very low recurrence rate but signi®cant immediate and long term success rate of morbidity and mortality.5 There is also debate treating complicated spontaneous pneumo- about whether the presence of bullae should thorax with talc pleurodesis under local alter the initial management. In patients with anaesthesia supplemented with nitrous bullae of >2 cm in diameter many authors re- oxide were studied. commend bullectomy either by thoracotomy6 Results ± Talc pleurodesis was performed or, more recently, by video-assisted tho- in 93 patients without serious complication racoscopic surgery and pleurectomy.78 How- (two benign arrhythmias, two sub- ever, both techniques require general cutaneous emphysema, two pneumonia, anaesthesia and intubation with a double lumen http://thorax.bmj.com/ one bronchospasm). The procedure was tube. To avoid such invasive procedures it is immediately successful in 90 patients generally accepted that, in the absence of bullae (97%) with a median duration of drainage of >2 cm diameter, chemical pleurodesis with of ®ve days (range 2±40) and a median talc by ªmedicalº thoracoscopy ± that is, with length of hospital stay of 5.2 days (range local anaesthesia ± could be performed ac- 3±40). After a mean follow up duration of companied, if necessary, by electrocoagulation 5.1 (range 1±9.4) years in 84 cases the long of bullous lesions. As others have observed,910 term success rate was 95%, although six however, we are not aware of any controlled cases developed a small localised re- study showing that procedures such as pleur- on September 25, 2021 by guest. Protected copyright. currence of spontaneous pneumothorax ectomy, bullectomy, or leak sealing signi®cantly which did not require further surgery. decrease the incidence of recurrent spon- Macroscopic staging at thoracoscopy was taneous pneumothorax beyond the reduction only carried out in the last 59 cases of that would result from performing pleurodesis whom 10 (17%) had bullae with a diameter by minimally invasive medical thoracoscopy. of >2 cm. In this group of patients the risk In our hospital ªmedicalº thoracoscopy has of de®nitive failure requiring surgery was been carried out only for recurrent or persistent signi®cantly higher than in those patients spontaneous pneumothorax, or for rare cases without such bullae (odds ratio 7; con- of a ®rst episode of secondary spontaneous ®dence interval 3.7 to 13.3; p=0.03), al- pneumothorax in patients with severe under- though eight of these patients did not lying lung disease, irrespective of the presence require thoracotomy. Total lung capacity or absence of bullae. We now report the results was reduced immediately after talc pleuro- of a study of the eYcacy, complications, dur- desis (mean (SD) 75 (23)% predicted at ation of drainage, and late recurrence rates of 10 days) but had improved to 95 (14)% spontaneous pneumothorax treated only by talc Centre Valaisan de Pneumologie, 3962 predicted at 12 months. pleurodesis under thoracoscopy and local an- Montana, Switzerland Conclusions ± This study shows that aesthesia. We have also investigated whether J M Tschopp simple thoracoscopic talc pleurodesis the presence of bullae with a diameter of >2 cm M Brutsche J G Frey under local anaesthesia is a safe and is a risk factor for recurrence after talc pleuro- eVective treatment for complicated spon- desis by medical thoracoscopy. Correspondence to: taneous pneumothorax. However, patients Dr J M Tschopp. with bullae of >2 cm in diameter have a Received 4 January 1996 Returned to authors greater risk of treatment failure. Methods 26 April 1996 (Thorax 1997;52:329±332) Revised version received thoracoscopy and talc pleurodesis 25 July 1996 Accepted for publication Keywords: complicated pneumothorax, video-assisted Patients were premedicated with atropine 26 September 1996 thoracoscopy, talc pleurodesis. 0.5 mg and during the procedure received 330 Tschopp, Brutsche, Frey titrated midazolam (3±10 mg) and pethidine Table 1 Thoracoscopic talc pleurodesis: complications and Thorax: first published as 10.1136/thx.52.4.329 on 1 April 1997. Downloaded from (25±100 mg) under careful supervision and immediate success rate (93 procedures in 89 individuals) continuous monitoring of blood pressure, Benign arrhythmia 1 ECG, oxygen saturation, and end tidal carbon Subcutaneous emphysema 2 Pneumonia 2 dioxide pressure (Ohmeda, Louisville, USA). Bronchospasm 1 Thoracoscopy was carried out in the lateral Pleurodesis in <7 days 81 Surgery in <7 days 1 decubitus position under local anaesthesia with Success with drainage >7 days 2 lignocaine 1%. A 7 mm diameter trocar (Wolf, Successful second procedure 7 Unsuccessful second procedure 2 Knittlingen, Germany) was inserted in the ®fth Immediate success rate 90 axillary intercostal space in the mid axillary Total surgical cases (de®nitive failure) 3 line. A 0° optical telescope (Panoview; Wolf) was inserted and connected to a video camera and monitor (Sony). The pleurae were in- Pneumocystis carinii pneumonia, sarcoidosis, spected and any ¯uid was removed. By ex- bronchiectasis, or bullous lung disease without amining the chest radiographs and under direct COPD). Seven had been refused general an- vision we then selected the best site for the aesthesia because of poor health. second point of entry. Two trocars and two In the last 59 cases who presented between chest tubes were used so that we could choose 1990 and 1994 spontaneous pneumothorax the best intercostal space to manipulate the was staged macroscopically according to Van- lung with blunt forceps and inspect the visceral derschuÈren11 during thoracoscopy and they pleura in the apical and interlobar regions, cut were followed up by lung function tests and any pleural adhesions by diathermy to expose chest radiography at six, 12, and 24 months. all the visceral pleura to talc spraying, optimise talc spraying at the apex where lung lesions were generally found, and so that at the end of data analysis thoracoscopy we could leave one tube at the Immediate success was de®ned as the pro- apex or adjacent to any bullae or pulmonary portion of cases with talc pleurodesis who had tears and one in the lower and posterior part a complete re-expansion of their lung during of the pleural space to drain any pleural ¯uid. the hospital stay, and long term success was No electrocoagulation, stapling or ligation of de®ned as the number of cases with talc pleuro- any parenchymal lesions was carried out, even desis who did not require any surgical treatment when a leak was visualised. At the end of the at any time (®rst thoracoscopy or follow up). procedure the patient inhaled a mixture of 50% Results are expressed as mean (SD) with me- oxygen/50% nitrous oxide and 3±5 ml of pure dians and ranges where relevant. talc was insuZated into the pleural space. The http://thorax.bmj.com/ two drains (16 French gauge) were connected to underwater seal suction with a negative pres- Results sure of 30 cm H2O for at least two days or until macroscopic lesions air leakage stopped. When an air leak persisted In the last 59 cases thoracoscopy showed a for more than seven days or a localised pneumo- normal visceral pleura in 20 cases (stage I, thorax occurred, 500±1000 mg tetracycline 34%) and some pleural adhesions in 11 cases chlorhydrate was instilled. If judged clinically (stage II, 19%). One patient was in severe necessary, a further thoracoscopic examination respiratory failure secondary to emphysema on September 25, 2021 by guest. Protected copyright. was performed with local application of talc if and talc was insuZated immediately without none was seen on the visualised pleura. Post- cutting any adhesions. Blebs or bullae with a operative analgesia was carried out using diameter of <2 cm were found in 18 cases 0.5±1 mg intravenous morphine every 5±7 min- (stage III, 30%) and in 10 cases bullae with a utes self-administered by the patient (Lifecare diameter of >2 cm (stage IV, 17%) were found. PCA 4200 pump, Abbott Cham, Switzerland) in combination with intravenous propacetamol 1±6 g daily. immediate success rate The median duration of drainage was ®ve days (range 2±40) and the median length of hospital patients stay was 5.2 days (range 3±40). There were no Eighty nine patients of median age 30.5 years serious complications such as empyema or re- (range 15±79) referred to our chest hospital for expansion oedema and no deaths (table 1). persistent or recurrent spontaneous pneumo- One man with primary recurrent spontaneous thorax from 1986 to 1994 were included in the pneumothorax required thoracotomy with ple- study. Persistent spontaneous pneumothorax urectomy after three days of drainage because was de®ned as a pneumothorax with persistent of a large persistent air leak. Nine cases required air leakage after seven days of chest tube drain- a second procedure (details in table 2) with age.
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