Pneumothorax

General information:

• Air within the pleural space.
  
• Spontaneous pneumothorax especially common in teenagers caused for example by a rupture of a small lung bubble without common lung disease.
  
• Risk of recurrence is 16% after the first and 80% after the third episode.
  
• Pneumothorax may be caused a trauma (lung injured by broken ribs), a penetrating chest wall injury (sucking chest wound), an injury of the tracheobronchial tree, a severe asthmatic attack, pulmonary infections with development of an air fistula, artificial ventilation, resuscitation, or by a congenital cystic lung disease.
  
• Induced by a vale – like mechanism, tension pneumothorax is caused by an increasing accumulation of air within the pleural cavity leading to a mediastinal shift (dangerous situation).

Symptoms:

• In cases of mild spontaneous pneumothorax mild or no symptoms.
  
• Chest pain and shortness of breath, varying degrees of respiratory distress.
  
• Reduced or missing breath sounds on the side of the pneumothorax.
  
• In patients suffering from tension pneumothorax (beside the respiratory insufficiency) hemodynamic deterioration (neck vein distension in normovolemic patients) occurs.

Diagnostic workout:

• Thoracic X-ray (do not confuse up the medial margin of the scapula with the lung surface), eventually CT scan.

Treatment/Operation:

• Observation in cases of minimally closed stable pneumothorax. Supplemental oxygen may be necessary.
  
• If significant symptoms occur insert a chest tube (2nd or 3rd intercostal space in the medioclavicular line (classic technique) or in the medioaxillary line at the level of the breast nipples) to provide a water – seal drainage (Bülau drainage).
  - Perform a small skin incision after local (general) anaesthesia.
  - With the tip of a clamp slowly perforate the intercostal space via the upper edge of the rib.
  - Remove the clamp and insert the chest tube (reinforced by a trocar) through the prepared canal.
  - Remove the trocar and fix the tube with sutures (size: 3-0 to 1). A second suture is placed to close the skin after the chest tube removal.
  - Connect the chest tube to the water – sealed drainage system (Bülau system).
  - Induced by breathing movements, air bubbles should pass the water sealed drainage system.
  
• Surgical therapy should be considered if the air leak is persistent over a period of one week of water – sealed drainage, if the CT scan shows an underlying lung disease, if we have to deal with the second episode and if full lung expansion is not possible.
  - Surgical methods: closure of the air leak (suture or stapling with bleb resection) and/or parietal pleurectomy (apical and anteriolateral areas) via thoracotomy or thoracoscopic surgery. By using only the thoracoscopic approach pulmonary blebs may be overlooked.
  
• In cases of multiple recurrences, intrapleural instillation of tetracycline (Vibravenoes® and for pain control: e.g. 2% lidocaine administration into the chest tube 30 minutes before instillation) to obliterate the pleural cavity (pleurodesis) may be indicated.

Postoperative management:

• Chest tubes may be removed if the lung is fully expanded and drainage volumes decrease below 20 to 50cc during a 24 hours period.
  
• Start respiratory exercises beginning as soon as possible.

Prognosis:

• Some element of lung function may be permanently lost if the lung is not completely reexpanded.
  
• Children younger than 9 years of age are unlikely to develop a recurrence.
  
• After simple drainage therapy older children have a mean recurrence rate of about 50% (16% after the first, 80% after the third episode).
  
• Thoracotomy, resection of the blebs and sometimes pleurectomy is the most suitable surgical method to avoid recurrence.