Anthony Arnold

Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010

The term ‘pneumothorax’ was first coined by Itard and then Laennec in 1803 and 1819 respectively,1 and refers to air in the pleural cavity (ie, interspersed between the lung and the chest wall). At that time, most cases of pneumothorax were secondary to tuberculosis, although some were recognised as occurring in otherwise healthy patients (‘pneumothorax simple’). This classification has endured subsequently, with the first modern description of pneumothorax occurring in healthy people (primary spontaneous pneumothorax, PSP) being that of Kjaergaard2 in 1932. It is a significant global health problem, with a reported incidence of 18–28/100 000 cases per annum for men and 1.2–6/100 000 for women.3 Secondary pneumothorax (SSP) is associated with underlying lung disease, in distinction to PSP, although tuberculosis is no longer the commonest underlying lung disease in the developed world. The consequences of a pneumothorax in patients with pre-existing lung disease are significantly greater, and the management is potentially more difficult. Combined hospital admission rates for PSP and SSP in the UK have been reported as 16.7/100 000 for men and 5.8/100 000 for women, with corresponding mortality rates of 1.26/million and 0.62/million per annum between 1991 and 1995.4 With regard to the aetiology of pneumothorax, anatomical abnormalities have been demonstrated, even in the absence of overt underlying lung disease. Subpleural blebs and bullae are found at the lung apices at thoracoscopy and on CT scanning in up to 90% of cases of PSP,5 6 and are thought to play a role. More recent autofluorescence studies7 have revealed pleural porosities in adjacent areas that were invisible with white light. Small airways obstruction, mediated by an influx of inflammatory cells, often characterises pneumothorax and may become manifest in the smaller airways at an earlier stage with ‘emphysema-like changes’ (ELCs).8 Smoking has been implicated in this …

Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection

BACKGROUND More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. METHODS We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. RESULTS The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. CONCLUSIONS Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).

Thoracic ultrasound: an important skill for respiratory physicians

We read with interest the article by Qureshi and colleagues describing thoracic ultrasound (TUS) characteristics for the detection of malignant pleural effusions.1 This relatively simple bedside technique has been routinely performed by the respiratory physicians in our department in a busy general hospital for the last 4 years, resulting in a gradual reduction in the number of radiology departmental procedures from 63 to 17 per annum. A recent audit of our activity showed that over a period of 18 …

Spontaneous Pneumothorax After Traumatic Pneumonectomy: A Role for Talc Pleurodesis in Secondary Prevention?

We report a case of spontaneous contralateral pneumothorax 2 months after a pneumonectomy, with the initial placement of an intercostal chest drain on the side of the pneumothorax. Due to the high risk of a subsequent life-threatening pneumothorax, pleurodesis became an important consideration. Surgical pleurodesis can be complicated by the risks of single lung ventilation; therefore, talc pleurodesis was performed by using the intercostal drain once the lung had fully expanded. The patient remains free of recurrence 14 months after the pneumonectomy. Our case suggests that talc may be an effective alternative method of secondary prevention of a pneumothorax after a pneumonectomy.

Simulation-Based Bronchoscopy Training

We read with great interest an article by Kennedy and colleagues 1 in a recent issue of CHEST (July 2013) in which a systematic review and meta-analysis of stud ies revealed signifi cant improvements in skills and behaviors when comparing simulation-based bronchoscopy with no intervention. However, the article also identifi ed gaps in evidence, such as the lack of clear understanding of optimal design or choice of modalities in relation to simulationbased bronchoscopy train ing. Based on our experience of setting up a regional simulation bronchoscopy program, we are able to address these issues. We established fi ve clinical skills laboratories that deliver simulation bronchoscopy training. We also set up a group of regional experienced bronchoscopists responsible for the development of simulation bronchoscopy training. We have run 15 courses and trained . 60 candidates. Although initially we used different formats for the courses, the trainees’ overall experience of simulationbased bronchoscopy was extremely positive. Based on our initial experience, we established that the optimal design for delivering simulation-based bronchoscopy courses should incorporate a blend of short lectures, e-learning, and hands-on experience using simulation. To be successful, simulation-based bronchoscopy requires a high trainer-to-trainee ratio (ideally 1:2), and, therefore, we established a faculty of experienced bronchoscopists with a special inter est in procedural training. Our results confi rmed signifi cant improvement, for both novices and more experienced trainees, in the technical ability of handling bronchoscopes, their understanding of anatomy and identifi cation of bronchial segments, and their knowledge of the procedure; the improvements were in the range of 20% and 30% when using high fi delity alone and in combination with low-fi delity bronchoscopy simulation, respectively. 2