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Ann Thorac Surg 1996;62:1011-1015
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Spontaneous Hemopneumothorax

Department of Thoracic and Cardiovascular Surgery, Niigata City General Hospital, Niigata City, Japan

Accepted for publication May 2, 1996.

	Abstract

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 
Background. Spontaneous hemopneumothorax is a rare disorder, occurring in 1% to 12% of patients with spontaneous pneumothorax. We studied our previously treated patients to determine the nature of optimal operative management.

Methods. This was a retrospective case study. From 1987 to 1994, of 428 cases of spontaneous pneumothorax that occurred in 234 patients treated at our institution, hemopneumothorax developed in 10 patients (2.3%). The clinical features of these patients were studied.

Results. The amount of bleeding ranged from 600 to 1,600 mL, and 3 patients exhibited symptoms of shock, such as sweating, nausea, and syncope. Six patients underwent operation within 7 days from the onset, and this involved resection of the bullae or pneumorrhaphy, or both. The source of bleeding was identified in 5 patients. Pathologic examination showed marked fibrosis with alcian blue–positive deposits of aberrant vessels. All 6 patients continue to be well postoperatively without recurrence or complications. Four patients did not undergo early thoracotomy. However, decortication was required in 3 of these patients because of a reactive fluid collection in the pleural space, which led to impaired lung expansion.

Conclusions. Early surgical repair should be considered once diagnosis of a spontaneous hemopneumothorax is confirmed, because this provides better long-term results. Video-assisted thoracoscopic surgery as well as minithoracotomy should be considered as surgical options because of the improved quality of life they confer.

	Introduction

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 
Spontaneous hemopneumothorax involves the accumulation of air and blood within the pleural space in the absence of trauma or other obvious causes. The clinical picture is dramatic: there is a rapid progression of symptoms such as chest pain or dyspnea that may lead to life-threatening complications if not appropriately managed. Whittaker [1] was the first to report a patient with spontaneous hemopneumothorax who was successfully treated by aspiration. Decortication was the first surgical treatment, and this was performed by Elrod and Murphy [2] in a patient 6 weeks after the onset of spontaneous hemopneumothorax. With the improvement in anesthesia techniques and perioperative management, the mortality and morbidity associated with spontaneous hemopneumothorax have decreased and the treatment options have improved. Some studies have shown that an operation in the early stage provides a good outcome. Because of the various issues surrounding the clinical management of spontaneous hemopneumothorax, we undertook an analysis of the clinical course of patients with the disorder treated at our hospital in an effort to determine the nature of optimal treatment.

	Clinical Material

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 
From 1987 to 1994, 234 patients with spontaneous pneumothorax were treated in the Department of Thoracic and Cardiovascular Surgery of Niigata City General Hospital. There were 204 male and 30 female patients, and 428 episodes of spontaneous pneumothorax (386 in the male patients and 42 in the female) occurred that were treated with either drainage or operation. According to the criteria described by Ohmori and associates [3], spontaneous hemopneumothorax was defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with a spontaneous pneumothorax. The 10 patients with spontaneous hemopneumothorax represented 4.3% of the episodes of spontaneous hemopneumothorax and 2.3% of its incidence.

	Results

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 
The clinical features of the spontaneous hemopneumothorax in the 10 patients are listed in Table 1. All 10 were male and ranged in age from 17 to 53 years (mean, 29.9 years). Hemopneumothorax developed in the left pleural space in 6 patients and in the right pleural space in 4. It was the first occurrence of pneumothorax in 9 patients and represented recurrent disease in 1. All 10 patients experienced severe chest pain at onset; dyspnea also occurred in 4 patients. A chest roentgenogram revealed the presence of a pneumothorax associated with a fluid collection in the pleural cavity (Fig 1). The diagnosis of hemopneumothorax was confirmed by the aspiration of air and blood from a thoracostomy tube. The amount of aspirated blood ranged from 600 to 1,600 mL (mean, 1,242 mL). Two patients received a homologous blood transfusion. Symptoms of sweating, nausea, and syncope resulting from hypovolemic shock, which required vigorous fluid resuscitation, developed in 3 patients. Nine patients (patients 1 through 9) were treated initially with thoracic drainage by physicians and then transferred to our department within 3 days of the onset of symptoms. Neither a hemorrhagic diathesis nor a clotting disturbance was found in any of the 10 patients.

View larger version (171K): [in this window] [in a new window]   Fig 1. . A representative chest x-ray film (patient 5). A pneumothorax was present, together with a fluid collection in the intrapleural space.

View larger version (135K): [in this window] [in a new window]   Fig 2. . Photomicrographs of (A) control vessels of normal lung found in the resected specimen and (B) aberrant vessel between bulla and parietal pleura, in which intimal and medial fibrosis was evident. Alcian blue revealed mucous deposits in the media. The amount of smooth muscle was normal compared with that in the control vessel. (Hematoxylin and eosin; x20 before 53% reduction.)

	Comment

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 
Spontaneous hemopneumothorax, although a well-documented disorder, is a condition rarely encountered in clinical practice. It is reported to occur in 1% to 12% of all cases of spontaneous pneumothorax [4–8]. The incidence in our series is comparable with that previously reported. In the review by Fry and colleagues [9], the incidence of spontaneous hemopneumothorax was found to be thirty times higher for male than for female patients, a difference in incidence between men and women much larger than that for spontaneous pneumothorax.

The two mechanisms of bleeding in hemopneumothorax are (1) bleeding as a result of a torn adhesion between the parietal and visceral pleura [9–11] and (2) rupture of vascularized bullae [8]. The principal cause is thought to be a torn adhesion. In our series, the source of bleeding in 4 patients was identified at operation to be a torn adhesion around the bulla. There were no ruptured or vascularized bullae in our patients. Aberrant vessels between the parietal pleura and bullae, which are thought to be one type of adhesion, have been reported. This was found in 2 patients in our series. These aberrant vessels have been reported to be unusually thin walled and without a muscle layer [12]. However, pathologic examination in our series revealed that the aberrant vessel had a muscle layer similar to that in control vessels. Alcian blue–positive deposits were found in the arterial wall, which indicates mucoid degeneration and sclerosis. Fibrosis in the intima and media also was observed. These findings indicate an inability of the vessel to retract after disruption. This abnormality combined with the negative intrapleural pressure led to persistent hemorrhage into the pleural space.

The clinical features of spontaneous hemopneumothorax are dramatic and depend on the amount of the air leakage and the volume of the blood loss. It may be life-threatening, and aggressive management is required. The goals of treatment include hemostasis and reexpansion of the lung. Initial treatment consists of resuscitation with adequate fluid replacement and drainage of the pleural space. Generally, it is well known that an early thoracotomy has certain advantages and that the clinical outcome in patients is better than that in patients treated with drainage alone. A thoracotomy provides the opportunity to (1) stop the bleeding and evacuate coagulated blood from the pleural cavity, (2) seal the site of the air leak on the lung surface by resection of the areas with emphysematous bullae, and (3) secure effective drainage by drain placement under direct vision [4]. At one time, early surgical intervention was not performed if hemostasis and lung expansion were achieved with medical therapy alone. However, it was noted that a restrictive lung developed in these patients during follow-up and decortication was subsequently required. In our series, 3 patients underwent decortication at a later stage because of the development of a reactive fluid collection, which led to impaired lung expansion. Although the patients recovered after decortication, a longer hospital stay was required and the patients reported a poorer quality of life. For this reason, we now opt for doing an early thoracotomy as soon as possible in all patients. However, the time that elapses between the onset of the disorder and operation must also be considered. In our patients it ranged from 12 hours to 7 days, even when an operation was performed within 2 days of transfer. This delay was due to the fact that most of the patients with spontaneous hemopneumothorax were initially treated by conservative measures. Now the attending physicians contact us immediately when spontaneous hemopneumothorax is confirmed. As a result, this period has become increasingly shorter.

Homologous blood transfusion may also be required in these patients. Most of the patients in our series did not receive any homologous blood. Because patients with spontaneous hemopneumothorax tend to be young, they are able to recover from the anemia in the postoperative period. Early thoracotomy is therefore also necessary to obtain hemostasis shortly after the onset of symptoms.

In our series, most patients underwent operation with a minithoracotomy. In addition, 1 patient was treated with video-assisted thoracoscopic surgery, which has become widely accepted by thoracic surgeons. Although the bleeding in our patient was not massive or continuous, the bleeding point was visualized clearly with video-assisted thoracoscopy. No difficulties with hemostasis, evacuation of clot, and resection of bullae were encountered during operation. The patient did not experience any complications. Several experiences with the use of video-assisted thoracoscopic surgery for the treatment of spontaneous hemopneumothorax have been reported [13]. As a minimally invasive method, video-assisted thoracoscopic surgery should be considered an initial treatment option in patients in stable condition after initial resuscitation.

In conclusion, spontaneous hemopneumothorax is a rare clinical entity that can lead to potentially life-threatening complications. Once diagnosis is confirmed, early thoracotomy should be considered. It is not too much to say that an emergent operation is required for spontaneous hemopneumothorax. Such prompt operation not only leads to a shorter hospitalization but also confers better long-term results.

	Footnotes

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 
Address reprint requests to Dr Kanazawa, Department of Thoracic and Cardiovascular Surgery, Niigata City General Hospital, 2-6-1 Shichikuyama, Niigata City, 950, Japan.

	References

Top Footnotes Abstract Introduction Clinical Material Results Comment References

 

1. Whittaker JT. Case of hemopneumothorax, relieved by aspiration. Clinic Cincinnati 1876;10:793–8.
2. Elrod PD, Murphy JD. Spontaneous hemopneumothorax treated by decortication; a case report. J Thorac Surg 1948;17:401–7.[Medline]
3. Ohmori K, Ohata M, Narata M, et al. Twenty-eight cases of spontaneous hemopneumothorax. J Jpn Assoc Thorac Surg 1988;36:1059–64.
4. Åbyholm FE, Støren G. Spontaneous haemopneumothorax. Thorax 1973;28:376–8.[Abstract/Free Full Text]
5. Humbert P, Ohresser P, Arnaud A, Chauvin G, Leonardelli M. L'hémopneumothorax spontané idiopathique; étude clinique et thérapeutique (A propos de 7 observations). Ann Chir 1971;25:538–42.[Medline]
6. Hyde L, Hyde B. Benign spontaneous hemopneumothorax. Am Rev Tuberc 1951;63:417–26.[Medline]
7. O'Neill S. Spontaneous pneumothorax; aetiology, management and complications. Ir Med J 1987;80:306–11.[Medline]
8. Rowell NR. Spontaneous haemopneumothorax. Br J Tuberc 1956;50:214–20.
9. Fry W, Rogers WL, Crenshaw GL, Barton HC. The surgical treatment of spontaneous idiopathic hemopneumothorax; a review of the published experience with a report of thirteen additional cases. Am Rev Tuberc 1955;71:30–48.[Medline]
10. Eastridge CE. Spontaneous hemopneumothorax requiring thoracotomy. South Med J 1985;78:1392–3.[Medline]
11. Ross CA. Spontaneous hemopneumothorax. J Thorac Surg 1952;23:582–92.
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13. Tatebe S, Yoshiya K, Yamaguchi A. Video-assisted thoracoscopic surgery for spontaneous hemopneumothorax. Surg Laparosc Endosc (in press).

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tatebe, S. Articles by Sakurai, Y. Search for Related Content PubMed PubMed Citation Articles by Tatebe, S. Articles by Sakurai, Y.