7. Suction
• Not routinely used because may cause re expansion
pulmonary edema
• Indicated when persistent air leak with or without incomplete
re-expansion of the lung after 48 hrs
• High-volume low-pressure systems such as Vernon-Thompson
pumps or wall suction with low pressure adaptors
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8. Bronchopleural fistula
• Communication between the bronchial tree and pleural space.
• Persistent air leak or a failure to re-inflate the lung despite
chest tube drainage for 24 h.
• Chest drains inserted into the lung parenchyma
• Management:
- Large bore chest drains (multiple if necessary) and the use of
drainage system
- Refractory cases surgical repair of the air leak by
thoracoplasty, lung resection/stapling, pleural
abrasion/decortication
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9. Thoracic surgeon
Indications for surgical advice:
• Persistent air leak (despite 5 to 7 days of chest tube drainage)
or failure of lung re-expansion.
• Synchronous bilateral spontaneous pneumothorax.
• Professions at risk (eg, pilots, divers).
• Pregnancy.
• Second ipsilateral pneumothorax.
• First contralateral pneumothorax.
• Spontaneous haemothorax
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10. Advice & f/up
• Avoid air travel until 1 weeks post fully resolution
• Avoid diving unless has undergone bilateral surgical
pleurectomy and has normal lung function and chest CT scan
postoperatively
• Observation/ NA F/up in 2-4 weeks
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PSP & SSP
SSP associated with lung disease e.g. TB, COAD & symptoms more severe than PSP
Size of pneumothorax not determine the severity of symptoms
Tension pneumothorax cardiorespiratoy distress i.e. cyanosis, sweating, severe tachypnoea, tachycardia and hypotension
Pneumothorax – erect inspiratory PA cxr displacement of pleural line
CT scan for small pneumothorax
PSP
Male, young, tall & thin
PSP referral to chest physician in 24hr, ref to thoracic surgeon if persistent air leak in 5-7 days chest tube
SSP early referral, d/w thoracic surgeon if persistent air leak in 48 hrs
Surgical empysema?
The size of the pneumothorax determines the rate of
resolution and is a relative indication for active
intervention.
Best measured by Digital radiography (Picture-Archiving Communication Systems,
PACS)
Chemical plerodesis – sclerosing agent e.g. tetracycline open or VATS approach
AIM: resect any visible bullae or blebs on
the visceral pleura and also to obliterate emphysema-like
changes9 or pleural porosities under the surface of the visceral
pleura.8 The second objective is to create a symphysis between
the two opposing pleural surfaces as an additional means of
preventing recurrence
1. Open thoracotomy and pleurectomy remain the procedure
with the lowest recurrence rate (approximately
1%) for difficult or recurrent pneumothoraces. (A)
2. Video-assisted thoracoscopic surgery (VATS) with
pleurectomy and pleural abrasion is better tolerated but
has a higher recurrence rate of approximately 5%. (A)
3. Surgical chemical pleurodesis is best achieved by using
5 g sterile graded talc, with which the complications of
adult respiratory distress syndrome and empyema are
rare.
