Spontaneous pneumothorax constitutes a significant challenge with an estimated recurrence rate of 23% to 50%1 after the first episode, and this rate increases after the first recurrence.2 Pneumothorax is responsible for about 1.2% of medical admissions in a study in Nigeria.3
There are various guidelines for treatment of spontaneous pneumothorax from the British Thoracic Society, the Belgian Society for Pneumology, and American College of Chest Physicians.4–6 Treatments most of the time are adapted to suit the practice location and whether the pneumothorax is associated with complications or not. Complicated pneumothorax is defined as persisting air leakage for >48 hours after chest tube drainage or as recurrence. Traditionally, surgical interventions such as video-assisted thoracoscopic surgery (VATS) or limited thoracotomy with pleurectomy or pleural abrasion and bleb/bullectomy have long been considered the definitive treatment.7 This is a very effective option with very low failure or recurrence rate, but it is associated with significant morbidity and even some mortality and is considered by many to be a form of overtreatment.8
Medical thoracoscopy has also been recommended for such complicated cases, but the effectiveness of such intervention in both primary spontaneous (PSP) and secondary spontaneous pneumothorax (SSP) in a short-term/medium-term cohort has not been fully studied.8,9
Thoracoscopic talc pleurodesis (TTP) using talc powder has been shown to be safe in patients with recurrent PSP.10 However, data on the effectiveness were not provided.
This study aims at evaluating the effectiveness of TTP for management of complicated PSP and SSP.
A retrospective cohort analysis was performed of all patients with spontaneous pneumothorax who underwent TTP for complicated pneumothorax either due to persistent air leak or recurrence using thoracoscopy at the Interventional Clinic, University Hospital Brussels, Belgium over a 2-year period. Medical history and other data retrieved from the hospital register included episodes of pneumothorax, recurrence of pneumothorax after TTP, smoking habit, and immediate and long-term postoperative complications. Contacts were attempted with some patients on phone. Pulmonologists at the hospital had been performing thoracoscopy for many years for many indications including sympathecolysis. All these had been approved by the institution IRB. In such circumstances, CME at our institution allows retrospective data analysis.
Thoracoscopy was performed under simple single-lumen intubation general anesthesia in a lateral decubitus position as previously described.10,11 One entry port was used to insert the videothoracoscope and the pneumatic atomizer. Three to 4 g of graded talc (Steritalc1; Novatech, La Ciotat, France) was gently insufflated under visual control over the entire pleural surface.10 Graded talc is characterized by the particle size, which has to be 10 mm and should contain only a small percentage of smaller particles. No bleb or bulla intervention was undertaken. At the end of the procedure a standard chest tube (20 to 24 Fr) was inserted for drainage of air and fluid. Antiemetics and analgesics were administered according to the patient’s needs.
Simple descriptive statistics were used. Data are presented as frequency and mean. Association between failure of the procedure and type of pneumothorax was determined using a χ2 test and when value was <5 the Fisher test was used.
Characteristics of the Cases
Forty patients had undergone 41 TTPs for pneumothorax during the study period. Their ages ranged from 19 to 72 years, with a mean of 34.1±12.4 years. Patients in the age group of 25 to 34 years were the majority [14 (34.2%)]. There were 39 men and 2 women. Twenty-four (58.5%) cases occurred in those who are current smokers. This is presented in Table 1. Bullae/blebs were noticed in 4 of the patients.
Classification of the Pneumothorax
Twenty-five (61%) of the pneumothorax cases were classified as PSP at diagnosis, whereas 16 (39%) were classified as SSP (Table 2).
Seventeen (41.5%) PSPs were first episode, whereas it was a recurrence in 8. Seven (44%) SSPs were first episode, whereas it was a recurrence in 9 (56%). This is presented in Table 2. However, during follow-up, 4 of those previously classified as PSP were noted to have severe bullous disease, rheumatoid nodule (1), and lung cyst (1), thus resulting in 21 cases of PSP and 20 cases of SSP.
Patients underwent usual review and management, which included aspiration and chest tube drainage.
The decision to intervene was either because of persistent air leaks or because of recurrence. Twenty-four (58.5%) cases had persistent air leakage, whereas 17 (41.5%) were recurrences. Persistent air leak was defined as continuous drainage of air for >48 hours after chest tube drainage.
Frequencies of Recurrences After TTP in Each Type of Pneumothorax Over a 24-month Period
Data about the 41 TPP procedures were extracted and analyzed for adverse outcomes, especially recurrence from the immediate postoperative procedure until 24 months after (Table 3).
As shown, there was no acute respiratory distress syndrome event across both categories. There was no recurrence in the PSP group at the immediate post-TTP period, whereas there were 2 (10%) and 1 (5%) recurrences in the immediate and 3 months post-TTP period, respectively, in those with SSP. Between 6 to 12 months and 12 to 24 months, there was 1 case of recurrence each in PSP and SSP. During a 24-month follow-up period, there were 2 recurrences in patients with PSP and 5 recurrences in patients with SSP, giving a prevalence of 9.5% and 25%, respectively. Statistical significance was set at P=0.001.
Patients were discharged within 1 to 15 days after talcage with a mean duration of 3±3.2 days.
For those with failed talcage, bullectomy was performed in 2 cases, decortication in 1, and pleurectomy and abrasion in 1 case. Others had a successful repeat talcage.
Successful management of pneumothorax should regard cause and extent of the air leak and must be directed toward rapid and full expansion of the lung, minimal risk of recurrence, low or no morbidity and mortality, low cost, and short hospital stay.12 In this study, TTP met this criteria especially in patients with PSP.
All the patients in this series presented with indications for pneumothorax recurrence procedures like second episode of pneumothorax or with persistent air leaks after chest tube drainage.5
There was no case of acute respiratory distress syndrome or death in the immediate postthoracoscopy period. There was no documentation of any severe pain in any patient, although a pain scoring was not done. However, the fact that they were discharged within 3 days could be indicative of a mild pain.
The success rate after TTP ranged from 95% to 95.3% for all types of complicated spontaneous pneumothorax. Overall, in this cohort of patients, the success rate for TTP was 83%.
The success rate after TTP in complicated PSP was 100%, 100%, 95.3%, and 95.3% at immediate, 3 months, 6 to 12 months, and 12 to 24 months postthoracoscopy period, respectively, and the overall 2-year recurrence rate was 9.57%.
For SSP, the success rate was 90% at immediate postoperative period and 95% each for other time points, and the 2-year recurrence rate was 25%. Taken together, it appears that the success rate was higher for PSP than for SSP all through the time points, especially at the immediate postoperative period and at 3 months posttalcage. None of the patients complained of any severe pain at follow-up.
Our study shows that TTP is both safe and effective as a first-line approach in managing complicated spontaneous pneumothorax.
The success rate appears to be generally better for PSP cases than for SSP and this was statistically significant; however, more large-scale studies will be needed to establish this. The observed difference may also indicate the ability to achieve adequate lung reexpansion or presence of minimal or no bullae in PSP; hence, talc powder was able to get to most of the pleural surface thereby achieving pleurodesis.
The success rate and recurrence rates obtained for PSP in this study were similar to earlier reports.13
Even for patients with SSP a success rate of 75% at 24 months is encouraging. Regarding efficacy of VATS as a therapeutic modality for spontaneous pneumothorax, Qureshi et al14 reported a recurrence rate of 5.25%, which is quite similar to our results. Therefore, proper selection of SSP patients for TTP is key for its success. Adequate attention on preprocedure evaluation and immediate postprocedure complications are essential for the prevention of recurrence. In our opinion, nonsmokers and patients with smaller bullae are at lower risk of recurrence. Patients with large bullae should undergo bullectomy. TTP is an effective treatment modality for complicated spontaneous pneumothorax; however, larger studies are needed for its widespread application.
For the intervention to be effective and to enhance success, smoking cessation should be rigorously pursued as well. This was shown in a series that reported pneumothorax recurrence after TTP in 3 patients, all of whom were smokers.12 More than half of the patients were actively smoking, whereas some were ex-smokers; this may be responsible for the failure rate in this study. This observation is confirmed in another study in which 56 smokers and 59 nonsmokers had PSP treated with VATS and followed up for 67 months. The smokers had a significantly higher recurrence rate after VATS (57%) compared with 22% in the nonsmoker.15 In addition, smoking is associated with mild restrictive lung function after TTP.16 The association between failure of TTP and smoking should be examined in large-scale prospective studies.
TTP and other forms of thoracoscopy, for example, medical thoracoscopy, has opened opportunities for management of pneumothorax and other pleural diseases in resource-limited countries where patients may not be able to afford the cost of invasive surgical techniques, which may not even be readily available. Thoracoscopy could be performed in an endoscopy suite as a day case procedure both for diagnostic and therapeutic purposes. This will reduce utilization of an already low health care budget and also improve the quality of care in such resource-limited settings.
In summary, our study confirms the short-term and medium-term effectiveness of talc pleurodesis in the treatment of patients with complicated pneumothorax, either recurrent spontaneous pneumothorax or pneumothorax with persistent air leakage, and may be recommended also as a viable alternative to invasive surgical techniques in resource-limited settings.
The author thank European Respiratory Society for providing Dr O.O. Adewole with a Short-term Training Fellowship STTF 1200 during which the study was conducted. We also thank the staff of Interventional Department, Respiratory Division, University Hospital, Brussels.
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