Burden between Undersupply and Overtreatment in the Care of Primary Spontaneous Pneumothorax

Abstract

Background The optimal treatment of primary spontaneous pneumothorax (PSP) is still controversial. The purpose of this study was to analyze the incidence of recurrence, the recurrence-free time, and to identify risk factors for recurrence after PSP.

Methods We performed a retrospective analysis of 135 patients with PSP who were treated either conservatively with a chest tube (n = 87) or surgically with video-assisted thoracoscopic surgery (VATS; n = 48) from January 2008 through December 2012.

Results In this study, 101 (74.8%) male and 34 (25.2%) female patients were included with a mean age of 35.7 years. The indications for surgery included blebs/bullae in the radiological images (n = 20), persistent air leaks (n = 15), or the occupations/wishes of the patients (n = 13). A first ipsilateral recurrent pneumothorax (true recurrence) was observed in 31.1% of all patients (VATS: 6.25%, conservative: 44.8%). Including contralateral recurrence, the overall first recurrence rate was 41.3% (VATS: 14.6%, conservative: 57.5%). The recurrence-free time did not differ significantly between the treatment groups (p = 0.51), and most recurrences were observed within the first 6 months after PSP. Independent risk factors identified for the first recurrence were conservative therapy (p = 0.0001), the size of the PSP (conservative; p = 0.016), and a body mass index <17 (VATS; 0.022). The risk for second and third recurrences of PSP was 17.5 and 70%, respectively, for both treatment groups, but it was 100% after conservative therapy.

Conclusion Surgery for PSP should be selected based on the risk factors and the patient's wishes to prevent first recurrences but also to avoid overtreatment. The treatment of first and subsequent PSP recurrences should be with surgery since conservative treatment is associated with a 100% recurrence rate.

Keywords

pneumothorax - primary spontaneous pneumothorax - recurrence - recurrence-free time - risk factors

• References

• 1 Noppen M, De Keukeleire T. Pneumothorax. Respiration 2008; 76 (02) 121-127
• 2 Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus chest tube drainage in first episodes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir Crit Care Med 2002; 165 (09) 1240-1244
• 3 Schnell J, Stoelben E. Epidemiology of spontaneous pneumothorax in Germany between 2011 and 2013. Chirurg 2016; •••: 209
• 4 Tschopp JM, Bintcliffe O, Astoul P. , et al. ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. Eur Respir J 2015; 46 (02) 321-335
• 5 MacDuff A, Arnold A, Harvey J. ; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 (Suppl. 02) ii18-ii31
• 6 Baumann MH, Strange C, Heffner JE. , et al; AACP Pneumothorax Consensus Group. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119 (02) 590-602
• 7 De Leyn P, Lismonde M, Ninane V. , et al. Guidelines Belgian Society of Pneumology. Guidelines on the management of spontaneous pneumothorax. Acta Chir Belg 2005; 105 (03) 265-267
• 8 Yoon J, Sivakumar P, O'Kane K, Ahmed L. A need to reconsider guidelines on management of primary spontaneous pneumothorax?. Int J Emerg Med 2017; 10 (01) 9
• 9 Olesen WH, Lindahl-Jacobsen R, Katballe N. , et al. Recurrent primary spontaneous pneumothorax is common following chest tube and conservative treatment. World J Surg 2016; 40 (09) 2163-2170
• 10 Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342 (12) 868-874
• 11 Lippert HL, Lund O, Blegvad S, Larsen HV. Independent risk factors for cumulative recurrence rate after first spontaneous pneumothorax. Eur Respir J 1991; 4 (03) 324-331
• 12 Haraguchi S, Koizumi K, Hioki M. , et al. Postoperative recurrences of pneumothorax in video-assisted thoracoscopic surgery for primary spontaneous pneumothorax in young patients. J Nippon Med Sch 2008; 75 (02) 91-95
• 13 Chiu CY, Chen TP, Wang CJ, Tsai MH, Wong KS. Factors associated with proceeding to surgical intervention and recurrence of primary spontaneous pneumothorax in adolescent patients. Eur J Pediatr 2014; 173 (11) 1483-1490
• 14 Ryu KM, Seo PW, Park S, Ryu JW. Complete atelectasis of the lung in patients with primary spontaneous pneumothorax. Ann Thorac Surg 2009; 87 (03) 875-879
• 15 Tan J, Yang Y, Zhong J. , et al. Association between BMI and recurrence of primary spontaneous pneumothorax. World J Surg 2017; 41 (05) 1274-1280
• 16 Huang TW, Lee SC, Cheng YL. , et al. Contralateral recurrence of primary spontaneous pneumothorax. Chest 2007; 132 (04) 1146-1150
• 17 Bar-El Y, Ross A, Kablawi A, Egenburg S. Potentially dangerous negative intrapleural pressures generated by ordinary pleural drainage systems. Chest 2001; 119 (02) 511-514
• 18 Noppen M, Baumann MH. Pathogenesis and treatment of primary spontaneous pneumothorax: an overview. Respiration 2003; 70 (04) 431-438
• 19 Yu L, Li H, Hou S. , et al. Abnormal bone mineral density and bone turnover marker expression profiles in patients with primary spontaneous pneumothorax. J Thorac Dis 2016; 8 (06) 1188-1196
• 20 Kepka S, Dalphin JC, Parmentier AL. , et al. Primary spontaneous pneumothorax admitted in emergency unit: does first episode differ from recurrence? A cross-sectional study. Can Respir J 2017; 2017: 2729548
• 21 Morimoto T, Fukui T, Koyama H, Noguchi Y, Shimbo T. Optimal strategy for the first episode of primary spontaneous pneumothorax in young men. A decision analysis. J Gen Intern Med 2002; 17 (03) 193-202
• 22 Tomczyk G, Pawełczyk K, Marciniak M, Rzechonek A, Kołodziej J. Treatment of recurrent primary spontaneous pneumothorax - own experience. Pol Przegl Chir 2013; 85 (01) 12-19