S and secondary spontaneous pneumothorax. Primary

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1 Secondary Spontaneous Pneumothorax Fumihiro Tanaka, MD, Masatoshi Itoh, MD, Hiroshi Esaki, MD, Jun Isobe, MD, Youichiro Ueno, MD, and Ritsuko Inoue, MD Department of Thoracic and Cardiovascular Surgery, National Gifu Hospital, Gifu, Japan To assess the clinical manifestations and therapy of secondary spontaneous pneumothorax (SSP), 123 episodes of SSP in 67 patients were retrospectively reviewed and were compared with 254 episodes of primary spontaneous pneumothorax in 130 patients. The major underlying lung diseases associated with SSP were emphysema (22 patients) and tuberculosis (21 patients). The average age of patients with SSP was 66.8 years, and the most common symptom was dyspnea. The average arterial oxygen tension at onset of SSP was 61.1 f 12.1 mm Hg (mean f standard deviation), which was lower than that of patients with primary spontaneous pneumothorax (p < 0.01). The recurrence rate of open thoracotomy with pleural abrasion was 12.5% (3 of 24 episodes), which was not lower than that of thoracostomy tube drainage with chemical pleurodesis using tetracycline (recurrence rate, 18.8%) (p > 0.5). We concluded that considering the high age of the patients, the presence of underlying lung diseases, and the increased operative risk, thoracostomy tube drainage rather than open thoracotomy was preferred as the first choice of therapy for SSP. (Ann Thorac Surg 1993;55:372-6) pontaneous pneumothorax is classified into primary S and secondary spontaneous pneumothorax. Primary spontaneous pneumothorax (PSP) occurs in healthy individuals without a coexisting lung disease, usually as a result of rupture of a pulmonary bleb. Secondary spontaneous pneumothorax (SSP) is a pneumothorax that is related to the presence of an underlying lung disease such as chronic obstructive lung disease or pulmonary tuberculosis [l]. The clinical manifestations and treatment of PSP are well-documented and established, and there is minimal morbidity and no mortality when properly treated. However, in SSP, which often occurs in older individuals, the morbidity and mortality rates may be substantial, regardless of adequate therapy [Z]. The purpose of this report is to describe the clinical manifestation of SSP and also to assess the management, especially by open thoracotomy, of SSP. Material and Methods A total of 197 patients with 377 separate episodes of spontaneous pneumothorax treated at National Gifu Hospital from January 1, 1984, to December 31, 1988, were reviewed for this study. Pneumothoraces secondary to trauma or iatrogenic causes were excluded. Among these episodes of spontaneous pneumothorax, 123 episodes (32.5%) in 67 patients (34.0%) were related to the presence of obvious coexisting lung diseases and were categorized as SSP. All medical records of patients with spontaneous pneumothorax were reviewed, and those of patients with SSP were compared with those of patients with PSI'. Follow-up was accomplished by review of outpatient records Accepted for publication May 12, 1992 Address reprint requests to Dr Tanaka, Department of Respiratory Surgery, Matsue Red-cross Hospital, 200 Horo, Matsue, Shitnane, 690, Japan. or by telephone interview, and the minimum length of follow-up was 2 years. The average length of follow-up in SSP was 4.1 years, and that in PSP was 4.3 years. Counts were compared with the use of 2 analysis. Continuous data were compared by Student's t test if they were approximately normally distributed, or by a Mann- Whitney U test if not. Results Underlying Diseases The most common underlying disease was pulmonary emphysema, and 45 episodes (36.6%) in 22 patients (32.8%) occurred with this disease (Table 1). Twenty-eight episodes (22.8%) in 21 patients (31.3%) occurred with pulmonary tuberculosis. Pneumoconiosis was a cause of 26 episodes (21.1%) of spontaneous pneumothorax in 9 patients (13.4%). Less commonly, pneumothoraces occurred secondary to pulmonary fibrosis (9 episodes in 5 patients), primary lung cancer (4 episodes in 4 patients), sarcoidosis (2 episodes in 2 patients), or bronchial asthma (4 episodes in 2 patients)., diffuse panbronchiolitis, and eosinophilic granuloma were a cause of pneumothorax in 1 patient each. Sex and Age Sixty-one patients with SSP were male, and 6 were female (Table 2). The average age at the diagnosis of SSP was 66.8 years (range, 12 to 85 years), and was significantly greater than that of patients with PSI' (p < 0.01). Clinical Manifestations The most common symptom of SSP was dyspnea, which occurred in 79 episodes (64.2%), whereas patients complained of dyspnea in only 26 episodes of PSP (10.2%)(p < 0.01) (see Table 2). Chest pain, the most common by The Society of Thoracic Surgeons /93/$6.00

2 Ann Thorac Surg 1993;55:3724 TANAKA ET AL 373 Table 1. Underlying Diseases Associated With Secondary Spontaneous Pneumothorax Disease Emphysema Pneumoconiosis Pulmonary fibrosis Primary lung cancer Sarcoidosis Asthma Diffuse panbronchiolitis Eosinophilic granuloma No. of Patients (female) No. of Episodes Total 123 symptom in PSP, was complained of in only 49 episodes of SSP (39.8%). Four patients with SSP were asymptomatic, with diagnosis made on a routine roentgenogram, whereas only 1 patient with PSP was asymptomatic, but the difference was not statistically significant (0.05 < p < 0.1). Arterial oxygen tension at the onset of SSP was 61.1? 12.2 mm Hg (mean? standard deviation), which was significantly less than the arterial oxygen tension at onset of PSP (p < 0.01). Arterial oxygen tension after resolution of SSP was 76.5 * 13.0 mm Hg, which was also less than the arterial oxygen tension after resolution of PSP (p < 0.01). Nonoperative Therapy Ninety-nine of 123 episodes of SSP (80.5%) were treated with nonoperative procedures, whereas 154 of 254 episodes of PSP (60.6%) were treated with nonoperative procedures (Table 3). This difference is statistically significant (p < 0.01). Nonoperative procedures included bed- Table 2. Clinical Findings in Patients With Spontaneous Pneurnothorax" Variable SSP PSP p Value No. of Patients Sex (WF) 61/ NS Age (Y) <0.01 No. of episodes Chief complaints at onset Dyspnea Chest pain Cough Asymptomatic PaO, (mm Hg) < < NS 4 1 NS At onset 61.1 * * 11.5 <0.01 After resolution (0.01 Values are shown as the mean? the standard deviation where indicated. NS = not significant; PaO, = oxygen tension; PSP = primary spontaneous pneumothorax; SSP = secondary spontaneous pneumothorax. Table 3. Treatment of Spontaneous Pneumothorax Variable SSP PSP p Value Nonoperative therapy 99 (80.5%) 154 (60.6%) <0.01 Observation 10 (8.1%) 59 (23.2%) <0.01 Needle aspiration 11 (8.9%) 12 (4.7%) NS Tube drainage 78 (63.4%) 83 (32.7%) <0.01 Without pleurodesis With pleurodesis" 32 2 Open thoracotomy 24 (19.5%) 100 (39.4%) <0.01 Indications for open thoracotomy Recurrent episodes 4 58 <0.01 Persistent air leak CO.01 Large blebs or bullae 6 18 NS Bilateral pneumothorax 1 2 NS a Pleurodesis was performed using tetracycline. NS = not significant; PSP = primary spontaneous pneumothorax; SSP = secondary spontaneous pneumothorax. rest and observation in 10 episodes, needle aspiration in 11 episodes, and thoracostomy tube drainage in 78 episodes. In 32 of 78 episodes treated with tube drainage, chemical pleurodesis using tetracycline was performed. Operation and Indications Only 24 episodes of SSP (19.5%) were treated with open thoracotomy, whereas 100 episodes of PSP (39.5%) were treated with open thoracotomy (p < 0.01) (see Table 3). The most common indication for open thoracotomy of SSP was a persistent air leak, which accounted for 15 of 24 episodes of SSP (62.5%), whereas only 22 of 100 episodes of PSP (22.0%) were treated with open thoracotomy due to a persistent air leak (p < 0.01). The other indications in SSP were recurrent episodes (4 episodes), large blebs or bullae (4 episodes), and bilateral pneumothorax (1 episode). On the other hand, the most common indication of open thoracotomy for PSP was recurrent episodes (58 of 100 episodes). A transaxillary approach was used in open thoracotomy for both SSP and PSP. Total excision of blebs and bullae and oversewing of the area were performed in 22 patients with SSP and in all 100 patients with PSP. Right pneumonectomy of the destroyed lung was performed in 1 patient and right upper lobectomy was performed in the other patient with SSP. Pleural abrasion with a dry gauze was also performed in all but 1 patient with SSP. Parietal pleurectomy was not performed in any of the patients with SSP. Pleural abrasion was performed in all patients with PSP. Recurrence Recurrence occurred in 38 of 123 episodes of SSP (30.9%) (Table 4). The recurrence rate with open thoracotomy was 12.5%, which was less than that with nonoperative therapy (35.4%) (0.02 < p < 0.05). The recurrence rate with thoracotomy tube drainage with chemical pleurodesis was only 18.8%, which was comparable with that with open thoracotomy (p > 0.5).

3 374 TANAKAETAL Ann Thorac Surg 1993;55:3724 Table 4. Recurrence Rates of Various Treatments in Patients With Secondary and Primary Spontaneous Pneumothorax Treatment SSP PSP p Value Nonoperative therapy 35.4% (35199)" 44.8% (691154) NS Observation 20.0% (2/10) 52.5% (31159) <0.05 Needle aspiration 45.5% (5/11)" 58.3% (7112) NS Tube drainage 35.9% (28178)" 37.3% (31183) NS Without pleurodesis 47.8% (W%)" 38.2% (31181) NS With pleurodesis 18.8% (6132)' 0.0% (012) NS Open thoracotomy 12.5% (3124) 3.0% (31100) <0.01 Total 30.9% (381123) 28.3% (72254) NS a Significance: p < 0.05, nonoperative therapy versus open thoracotomy in secondary spontaneous pneumothorax. drainage with pleurodesis versus without pleurodesis in secondary spontaneous pneumothorax. NS = not sigruficant; PSI' = primary spontaneous pneumothorax; SSP = secondary spontaneous pneumothorax. Significance: p < 0.05, tube The overall recurrence rate in patients with PSP was 28.3% (72 of 254 episodes), which was comparable with that in patients with SSP (30.9%). Only 3 of 100 patients with PSP (3.0%) treated with open thoracotomy had a recurrence, whereas 3 of 24 patients with SSP (12.5%) treated with open thoracotomy had a recurrence (0.02 < p < 0.05). Eleven of 38 recurrences in SSP (28.9%) occurred within 1 month or less, 16 recurrences (42.1%) in 1 to 6 months, one recurrence (2.6%) in 6 to 12 months, and four recurrences in 1 to 2 years (Fig 1). Thus, 32 recurrences in SSP (84.2%) occurred within 2 years of the previous episode. The average time to recurrence in SSP was days (2 standard error), which was similar to that in PSP ( days). Complications There were no complications related to nonoperative therapy for both SSP and PSP. No intraoperative complications occurred. There were 9 postoperative complications in SSP: 7 air leaks that persisted more than 5 days, 1 lmonthrr Primary Spontaneous Pneumothorax q w - Secondary Spontaneous Pnemothorax (n = 72) (n-38) pneumonia, and 1 heart failure (Table 5). The average postoperative chest tube placement interval in SSP was days (2 standard error), which was significantly longer than that in PSP (p < 0.01). Mortality Twelve patients with SSP died (Table 6), whereas no patients with PSP died. One patient (patient 7) who had open thoracotomy and in whom an air leak persisted postoperatively died of pneumonia 10 days after operation. Six patients (patients 1, 2, 3, 4, 5, and 6) died before the pneumothorax had resolved. All of these 6 patients died within 1 month after the onset of the pneumothorax. Five patients (patients 8, 9, 10, 11, and 12) died after pneumothorax had resolved; 4 of these patients died within 2 months after the pneumothorax had resolved. Patient 12 with pulmonary tuberculosis died 9 months after the pneumothorax had resolved, due to development of lung cancer. Comment Spontaneous pneumothorax commonly occurs in young male patients without any apparent lung disease; it occurs less commonly in patients with underlying lung disease, which is categorized as secondary [l, 31. The most common underlying lung disease in our series was, as has Table 5. Postoperative Complications Complications SSP PSP pvalue Prolonged air leak (more 7 3 (0.01 than 5 days) Days that air leak persisted after operation" 4.3? CO NS Heart failure 1 0 NS Hemothorax 0 1 NS Respiratory failure 1 0 NS number of patients "Yrnbt), of p.tl."t* Fig I. lnterual between resolution of pneumothorax and recurrence. Mean 5 the standard deviation. NS = not significant; PSP = primary spontaneous pneumothorax; SSP = secondary spontaneous pneumothorax.

4 Ann Thorac Surg 1993:55:372-6 TANAKA ET AL 375 Table 6. Fatalities With Secondary Spontaneous Pneurnothorax Patient No. Age (Y) Patients who died before pneumothorax was resolved 1 62 Male 2 68 Male 3 83 Male 4 64 Male 5 84 Male 6 48 Male Pulmonary fibrosis 7 71 Male Emphysema Patients who died after pneumothorax was resolved 8 70 Male Emphysema 9 70 Female Male Male Emphysema Male lnterval Between Sex Underlying Disease Cause of Death Pneumothorax Onset and Death Radiation pneumonitis Respiratory failure Operation-related death 7 days 2 days 9 days 10 days 10 days 21 days 20 days 7 days 2 years 50 days 21 days 9 months already been reported [l, 21, pulmonary emphysema, accounting for 36.6% of cases of SSP. Pulmonary tuberculosis accounted for 22.8% in our series, whereas Getz and Beasley [4] reported that only 3 (10.7%) of 28 secondary pneumothoraces were related to pulmonary tuberculosis [4]. This may suggest that in our country, Japan, the prevalence of tuberculosis remains high. The most common symptom in patients with SSP was not chest pain, which was the most common symptom in patients with PSP, but was dyspnea; in patients with SSP, who are usually older than those with PSP and also have previously diminished lung function because of underlying lung diseases, even a small pneumothorax can produce severe respiratory distress [5]. Management and Recurrence Spontaneous pneumothorax may be treated with observation, needle aspiration, thoracostomy tube drainage with or without pleurodesis, or open thoracotomy. The choice of therapy must be based on the severity and duration of symptoms, the presence of an underlying pulmonary disease, a history of previous episodes, and the occupation of the patient. In management of our patients with SSP, tube drainage was performed in 78 episodes (63.4%), and observation and needle aspiration were performed in only 10 episodes (8.1%) and 11 episodes (8.9%), respectively. Shields and Oilschlager [2] reported that observation was carried out in only 7 episodes (11.7%), needle aspiration in only 4 episodes (6.7%), and thoracostomy tube drainage in 39 episodes (65.0%) in a series of 49 men 40 years of age and older with 60 episodes of spontaneous pneumothorax. Patients with SSP should be treated with tube drainage regardless of the size of pneumothorax for rapid reexpansion of functioning lung tissue, whereas bed-rest or needle aspiration has been reevaluated in selected healthy young patients with a small pneumothorax [l, 2, 51. In these patients, air leaks sometimes last more than 10 days, but because of a significantly increased operative risk, tube drainage should be continued for a longer period than in PSP. The risk of recurrent pneumothorax vanes widely in published reports because of the varying age and associated lung disease patterns of the patients. DeVries and Wolfe [6] estimated that there was a 32% recurrence rate among patients treated with nonoperative methods. Granke and co-workers [7] reported that 11 of 49 patients treated with tube drainage had a recurrence (22.4%), and there were no recurrences in the operative group of 78 patients. Seremetis [8] reported a 49% rate (21 of 44) of recurrence in patients treated with bed-rest, a 38% recurrence rate (31 of 81) in those treated with tube drainage, and no recurrence after open thoracotomy. Schoenenberger and co-workers [9] reported that recurrence rates were 30% after 10 * 10 months in both PSP and SSP. Thus, the recurrence rates observed in our series of 30.9% in SSP and 28.3% in PSP are comparable with figures seen in other series. To prevent recurrence, the diseased site should be resected and the pleural space obliterated. Pleural space obliteration is accomplished by chemical pleurodesis, mechanical pleural abrasion, or partial pleurectomy. Chemical pleurodesis is a blind procedure and can result in adhesions that are too dense and in scars over some pleural areas, with inadequate adhesions in other areas; this can result in serious pleural complications. In spite of these disadvantages, chemical pleurodesis finds occasional application in the prevention of recurrence in patients with serious respiratory impairment due to underlying lung disease in whom thoracotomy for pleurectomy or pleural abrasion would carry an unacceptable risk. Thoracostomy tube drainage with chemical pleurodesis using tetracycline was used in 32 of our episodes of SSP. The recurrence rate was 18.8%, which is significantly less than that of observation alone, needle aspiration, or tube thoracotomy without pleurodesis, and was comparable with that of open thoracotomy with pleural abrasion. Many surgeons continue to consider bleb resection

5 376 TANAKAETAL Ann Thorac Surg 1993; and dry gauze pleural abrasion, which was employed in our series, to be effective in preventing recurrence [lo]. Youmans and co-workers [ 111 reported their clinical experience with pleural abrasion (only one recurrence in 30 patients). But our result (recurrence rate with pleural abrasion, 12.5%) suggests that pleural abrasion is not adequate to prevent recurrence in SSP. Weeden and Smith [12] reported their results of pleurectomy and demonstrated only a 3.7% major complication rate (8/241). The recurrence rate was only 0.43% (one in 233 patients) [12], which may be lower than the recurrence rate (12.5%) in our series treated with pleural abrasion. Deslauriers and co-workers [13] reported that only 2 (0.6%) of 409 patients treated with pleurectomy had a recurrence. Moreover, Weeden and Smith [12] reported no significant change in the results of respiratory function tests performed before and 6 months or more after pleurectomy. Thus, they advocated the use of transaxilhry apical pleurectomy for the younger age group, and a full pleurectomy in the older age group, who often have chronic obstructive lung disease that is not confined to the apex of the upper lobe. Morbidity and Mortality Even though most patients with SSP can be managed successfully, death may result from respiratory failure caused by the pneumothorax, particularly in older patients with extensive underlying lung disease. Shields and Oilschlager [2] reported a 16.3% mortality rate (8 of 48 patients) in patients more than 40 years old. Six of these eight deaths were contributed to or were directly the result of the pneumothorax. Dines and co-workers [14] reported 10 of 57 patients with SSP associated with emphysema who died as a result of spontaneous pneumothorax, and concluded that although an uncommon complication, spontaneous pneumothorax is most serious and requires emergency thoracostomy tube drainage. References 1. Deslauriers J, Leblanc P, McClish A. Bullous and bleb diseases of the lung. In: Shields TW, ed. General thoracic surgery. 3rd ed. Philadelphia: Lea & Febiger, Shields TW, Oilschlager GA. Spontaneous pneumothorax in patients 40 years of age or older. Ann Thorac Surg 1966; Singh SV. Current status of parietal pleurectomy in recurrent pneumothorax. Scand J Thorac Cardiovasc Surg 1979;13: Getz SB, Beasley WE. Spontaneous pneumothorax. Am J Surg 1983;145:82%7. 5. George RB, Herbert SJ, Shames JM, Ellithorpe DB, Weil H, Ziskind MM. Pneumothorax complicating pulmonary emphysema. JAMA 1975;234: De Vries WC, Wolfe WG. The management of spontaneous pneumothorax and bullous emphysema. Surg Clin North Am 1980;60: Granke K, Fischer CR, Gago 0, Moms JD, Prager RL. The efficacy and timing of operative intervention for spontaneous pneumothorax. Ann Thorac Surg 1986;42: Seremetis MG. The management of spontaneous pneumothorax. Chest 1970;57: Schoenenberger RA, Haefeil WE, Weiss P, Ritz RF. Timing of invasive procedures in therapy for primary and secondary spontaneous pneumothorax. Arch Surg 1991;12676& Clagett OT. The management of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1968;55: Youmans CR, Williams RD, McMinn MR, Derrick JR. Surgical management of spontaneous pneumothorax by bleb ligation and pleural dry sponge abrasion. Am J Surg 1970; Weeden D, Smith GH. Surgical experience in the management of spontaneous pneumothorax, Thorax 1983; 38: Deslauriers J, Beaulieu M, Despres JP, Lemieux M, Leblanc J, Desmeules M. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 1980;30: Dines DE, Clagett OT, Payne WS. Spontaneous pneumothorax in emphysema. Mayo Clin Proc 1970;45:481-7.