European Pediatric Surgeons' Association Survey on the Management of Primary Spontaneous Pneumothorax in Children

Aim To evaluate the practice patterns of the European Pediatric Surgeons' Association (EUPSA) members regarding the management of primary spontaneous pneumothorax (PSP) in children. Methods An online survey was distributed to all members of EUPSA. Results In total, 131 members from 44 countries participated in the survey. Interventional approach (78%) is the most common choice of treatment in the first episode, and most commonly, chest tube insertion (71%) is performed. In the case of a respiratory stable patient, 60% of the responders insert chest tubes if the pneumothorax is more than 2 cm. While 49% of surgeons prefer surgical intervention in the second episode, 42% still prefer chest tube insertion. Main indications for surgical treatment were the presence of bullae more than 2 cm (77%), and recurrent pneumothorax (76%). Eighty-four percent of surgeons prefer thoracoscopy and perform excision of bullae with safe margins (91%). To prevent recurrences, 54% of surgeons perform surgical pleurodesis with pleural abrasion (55%) and partial pleurectomy (22%). The responders who perform thoracoscopy use more surgical pleurodesis and prefer shorter chest tube duration than the surgeons performing open surgery (p < 0.05). Conclusion Most of the responders prefer chest tube insertion in the management of first episode of PSP and perform surgical treatment in the second episode in case of underlying bullae more than 2 cm and recurrent pneumothorax. The surgeons performing thoracoscopy use more surgical pleurodesis and prefer shorter chest tube duration than the responders performing open surgery. The development of evidence-based guidelines may help standardize care and improve outcomes in children with PSP.

Functional Adhesion of Pectin Biopolymers to the Lung Visceral Pleura

Pleural injuries and the associated “air leak” are the most common complications after pulmonary surgery. Air leaks are the primary reason for prolonged chest tube use and increased hospital length of stay. Pectin, a plant-derived heteropolysaccharide, has been shown to be an air-tight sealant of pulmonary air leaks. Here, we investigate the morphologic and mechanical properties of pectin adhesion to the visceral pleural surface of the lung. After the application of high-methoxyl citrus pectin films to the murine lung, we used scanning electron microscopy to demonstrate intimate binding to the lung surface. To quantitatively assess pectin adhesion to the pleural surface, we used a custom adhesion test with force, distance, and time recordings. These assays demonstrated that pectin–glycocalyceal tensile adhesive strength was greater than nanocellulose fiber films or pressure-sensitive adhesives (p < 0.001). Simultaneous videomicroscopy recordings demonstrated that pectin–glycocalyceal adhesion was also stronger than the submesothelial connective tissue as avulsed surface remnants were visualized on the separated pectin films. Finally, pleural abrasion and hyaluronidase enzyme digestion confirmed that pectin binding was dependent on the pleural glycocalyx (p < 0.001). The results indicate that high methoxyl citrus pectin is a promising sealant for the treatment of pleural lung injuries.

COVID-19 pneumonia complicated by late presentation of bilateral spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema

Introduction. Over the last few months the coronavirus disease 2019 (COVID-19) pandemic has created overwhelming challenges for physicians across the world. While much has been described in the literature about lung infiltrates and respiratory failure associated with infection of coronavirus 2 (SARS-CoV-2), pneumothorax is reported as a rare (a rate of one percent) but life-threatening complication of COVID-19 pneumonia. Late bilateral spontaneous pneumothorax has been described in only few cases. The aim of the review is to consider pneumothorax as a possible complication of COVID-19 pneumonia, which is also one of the causes of respiratory deterioration and potentially fatal outcome in these patients. Case Outline. This article describes the clinical course of the patient who tested positive for SARS-CoV-2 on reverse-transcriptase polymerase chain reaction (RT-PCR) testing of nasopharyngeal and oropharyngeal swab specimens and who presented with COVID-19 pneumonia complicated by bilateral, spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema. He didn't have underlying lung disease or risk factors for pneumothorax, except administered NIV/CPAP during first hospitalization. The patient was successfully treated with surgical (chest drainage, thoracoscopy and pleural abrasion) and non-surgical methods (by application of drugs and other supportive therapies). Conclusion This review demonstrates that the possibility of a late pneumothorax should be kept in mind in patients with, or recovering from, COVID-19 disease with progressive dyspnea. The timely diagnosis and management of pneumothorax will reduce COVID-19 associated mortality.

Analysis of pneumothorax recurrence risk factors in 843 patients who underwent videothoracoscopy for primary spontaneous pneumothorax: results of a multicentric study

OBJECTIVES Risk factors for pneumothorax recurrence after videothoracoscopy for primary spontaneous pneumothorax are still being debated. The goal of this study was to assess whether the pleurodesis technique and other variables are possibly associated with the postoperative ipsilateral recurrence of pneumothorax. METHODS We retrospectively collected data of 1178 consecutive ≤40-year-old patients who underwent videothoracoscopy for primary spontaneous pneumothorax in 9 centres between 2007 and 2017. We excluded patients with hybrid pleurodesis and/or incomplete follow-up, leaving for analysis 843 cases [80% men; median age (interquartile range) 22 (18–28) years]. Univariable and multivariable analyses were performed by logistic regression and tested by Cox regression model to assess factors related to ipsilateral pneumothorax recurrence including age, gender, body mass index, smoking habit, cannabis smoking, respiratory comorbidity, dystrophic severity score, surgical indication, videothoracoscopy port number and side, lung resection, pleurodesis technique and postoperative prolonged air leak (&gt;5 days). RESULTS Blebs/bullae resection was performed in 664 (79%) patients. Pleurodesis was achieved by partial pleurectomy in 228 (27%) cases; by pleural electrocauterization in 176 (21%); by pleural abrasion in 121 (14%); and by talc poudrage in 318 (38%). During a median follow-up period of 70.0 months (95% confidence interval 66.6–73.4), pneumothorax recurred in 79 patients (9.4%); among these, 29 underwent redo surgery; 34, chest drain/talc slurry; and 16, clinicoradiological observation. The only independent risk factor for recurrence was postoperative prolonged air leak (P &lt; 0.001) that was significantly related to blebs/bullae resection (P = 0.03). CONCLUSIONS In this multicentric series, postoperative ipsilateral pneumothorax recurrence was remarkable and independently related to prolonged postoperative air leak; besides the retrospective study setting, the pleurodesis method did not have an impact on recurrence. To prevent prolonged air leak, blebs/bullae treatment should be accurate and performed only if indicated.

Approach to pneumothorax surgery: a national survey of current UK practice

Background Pneumothorax is a common condition with various management options. We aimed to determine the current surgical practice in the United Kingdom. Method An online questionnaire regarding surgical strategy was sent to all consultants who were members of the Society for Cardiothoracic Surgery (80 thoracic). Results Fifty-six consultants, mainly thoracic, responded to the survey. Video-assisted thoracoscopic surgery was unanimously the preferred approach, the majority (59%) using 3 ports. Regarding the timing of surgery, 53 (95%) surgeons would intervene at first presentation with persistent air leak and/or lung collapse, 41 (73%) for a first bilateral pneumothorax, 22 (39%) only for recurrent pneumothorax, and 18 (32%) for the first computed tomography evidence of bullae. Apical bullectomy + pleurectomy was the preferred technique for 26 (46%) surgeons, and apical bullectomy + apical pleurectomy + pleural abrasion was the choice for 13 (23%). Some surgeons were concerned about talc and avoid it. The majority (70%) used a single apical drain with or without 24–48 h suction. Regarding chest radiography, the response was variable but 48% performed immediate postoperative and/or daily chest radiographs. Currently, most surgeons (59%) use digital drains and feel it monitors air leaks better. The perceived chronic pain (1%–3%) and recurrence rates (0%–3%) were stated by 59% and 86%, respectively. Conclusion There is variability in the surgical management of pneumothorax among surgeons across the UK, but they all use video-assisted thoracoscopic surgery as the intervention of choice for pneumothorax surgery, and there is a shift towards early surgical intervention.

Simultaneous bilateral spontaneous pneumothorax

Introduction. Simultaneous bilateral spontaneous pneumothorax (SBSP) is a potentially life-threatening state that may imitate many lung diseases. The aim of this report was to describe the presentation and highlights the potential difficulties in diagnosis and management of patients with SBSP. Case outline. A 23-year-old female was urgently assessed because of a progressive dyspnoea of 2-day's duration with associated bilateral chest pain. Lung auscultation revealed equally diminished breath sounds on both sides. During initial examination, there was the evidence of symptomatic deterioration with bilateral pleuritic chest pain, increased dyspnoea and agitation. She was found to have type II respiratory failure with the following biochemical parameters: pH=7.34, PaCO2=6.3 kPa and PaO2=7.9 kPa. The chest radiograph confirmed bilateral partial pneumothoraces of approximately 30%. Both left and right-sided thoracostomies with large-bore chest drain insertions were performed emergently, followed by partial resolutions of pneumothoraces. CT of the chest demonstrated residual pneumothoraces bilaterally with multiple apical bullae. In the further course, she subsequently underwent video-assisted thoracoscopic surgery with bilateral apicoectomies, bullectomies and pleural abrasion. Her chest drains were removed 3 days after surgery and a chest radiograph post-treatment demonstrated resolution of the pneumothoraces. She was discharged home without complications. Conclusion. Using clinical presentation, diagnostic algorithm and therapeutic management applied in the case of our patient, we emphasized a few mandatory steps in establishing the diagnosis of SBSP and further treatment.