Ann Thorac Surg 2009;87:875-879. doi:10.1016/j.athoracsur.2008.11.062
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Complete Atelectasis of the Lung in Patients With Primary Spontaneous Pneumothorax
Kyoung Min Ryu, MD*,
Pil Won Seo, MD,
Seongsik Park, MD,
Jae-Wook Ryu, MD
Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Korea
Accepted for publication November 24, 2008.
* Address correspondence to Dr Kyoung Min Ryu, Department of Thoracic and Cardiovascular surgery, Dankook University Hospital, 16-5 Anseo-Dong, Cheonan, Chungnam, 330-715, Korea (Email: cskmin{at}naver.com).
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Abstract
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Background: Complete atelectasis of primary spontaneous pneumothorax (PSP) requires immediate air reduction. Surgical intervention has been considered proper treatment for persistent air leakage or recurrence. We examined whether this is the proper treatment by evaluating the natural course and treatment outcomes of complete lung atelectasis.
Methods: We retrospectively analyzed the records of 286 patients with a first episode of PSP. We classified patients as partial atelectasis (n = 201, 71%) and complete atelectasis (n = 85, 29%) by initial radiography. Surgical intervention was done for persistent air leakage or recurrence, and all surgery was performed by video-assisted thoracoscopic surgery. We compared both groups for demographic and operative variables.
Results: In all, 29.4% of the complete atelectasis group and 10% of the partial atelectasis group showed persistent air leakage. The ipsilateral recurrence rate was 70% for the complete atelectasis group and 39.2% for the partial atelectasis group. Video-assisted thoracoscopic surgery was performed in 78.8% and 45.3% of the complete atelectasis and partial atelectasis groups, respectively. The postoperative course and recurrence rate were not different between the two groups during 40.2 months of follow-up.
Conclusions: The PSP patients with complete atelectasis showed a higher incidence of persistent air leakage and ipsilateral recurrence than did PSP patients with partial atelectasis. Operative outcomes were good. Complete atelectasis of the lung in PSP patients is an indication for surgical intervention at their first PSP episode.
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Introduction
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The goal of the initial treatment for patients with primary spontaneous pneumothorax (PSP) is to reduce the amount of air in the pleural space regardless of the amount of air, except for a small pneumothorax that is less than 10% to 20% of total capacity [1, 2]. Surgical intervention is not advised for these patients unless the pneumothorax recurs. The generally accepted indications for surgery are a persistent air leakage, recurrent pneumothorax, and if the pneumothorax poses an occupational hazard [1, 2]. These indications have previously been considered reasonable because the recurrence rate of PSP is approximately 20% to 50% [3–5], and operative procedures like thoracotomy and pleurodesis are highly invasive for such a benign disease. However, there is a great deal of evidence that video-assisted thoracoscopic surgery (VATS) is a viable alternative to thoracotomy for the treatment of PSP [6]. Thoracoscopic bullectomy and a pleural adhesive procedure are currently considered to the standard treatment for PSP. There have been some recent reports that VATS is more effective for treating patients with a first episode PSP, and VATS has shown less morbidity and lower total costs as compared with conservative therapy [7, 8]. Yet the universally performed method for the initial treatment of the first episode of PSP is currently air reduction.
Complete atelectasis of the lung is also called complete pneumothorax, or a totally collapsed lung. This condition can possibly progress to tension pneumothorax, and some of these patients already have a tension component at the time of their diagnosis. The treatment is immediate air reduction with or without thoracostomy. The cause of complete atelectasis has not yet been explained, but bursting of a large subpleural bleb or the presence of a one-way valve air leakage process as occurs for tension pneumothorax has been suggested, so a high recurrence rate for complete atelectasis is very possible, as compared with that of patients with partial atelectasis of the lung. There is no evidence for different recurrence rates according to the amount of pneumothorax [3], but there is a lack of reports concerned with the natural course and treatment outcome of complete atelectasis in patients with PSP.
This retrospective study was conducted to evaluate the natural course and treatment outcomes of complete atelectasis of the lung in patients with PSP, as compared with that of patients with partial atelectasis of the lung, and we discuss the best way to treat this malady.
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Patients and Methods
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This study was approved by the Ethics Committee of Dankook University Hospital as a retrospective chart analysis (approval number 0807-031). The Committee waived the need for patient consent.
Patient Population
Between May 2002 and April 2006, 329 patients with a first episode of PSP were treated at our hospital. Among them, we retrospectively analyzed the medical records of 286 patients, and we excluded the patients who had bilateral pneumothorax, a contralateral recurrence, or surgery for an occupational hazard. We classified the patients into two groups: the complete atelectasis of lung group and the partial atelectasis of lung group. Complete atelectasis of lung was defined as an airless lung that was separated from the diaphragm (n = 85, 29%; Fig 1), according to the British Thoracic Society guidelines [9], and the others were classified as partial atelectasis of the lung (n = 201, 71%).
Treatment Method
The initial management for all the cases of PSP was performed in the same manner for both groups. The patients with a small pneumothorax that was less than 10% of the total chest capacity were discharged, and the other patients were treated by closed thoracostomy with using a 20F chest tube. The chest tube was placed in the underwater-seal drainage apparatus, and negative low-pressure suction was then applied. The chest tube was removed soon after confirming that there was no air leakage and that the lungs were able to expand on their own. Chest radiographs were taken immediately after removing the tube, and the patients were discharged shortly after removal of the chest tube. The surgical indications were an ipsilateral recurrence (a second episode) or persistent air leakage for more than 5 days during the first episode.
Operation Techniques and Postoperative Care
All the patients who were surgical candidates were operated on using video-assisted thoracoscopy (VATS) under general anesthesia with single-lung ventilation. Three ports were placed on the seventh intercostal space at the mid axillary line, the fourth intercostal space at the anterior axillary line, and the fifth intercostal space at the posterior axillary line. After a thorough examination of the entire visceral pleural surface, the blebs were resected with using an endoscopic stapling device (Autosuture GIA Universal; Tyco Healthcare, Norwalk, CT; or Endopath ETS45; Ethicon EndoSurgery, Cincinnati, OH) according to the surgeon's preference. Special care was taken to place the staple line on normal lung tissue so as not to include the blebs. Saline solution was then instilled to identify the air leak. If no air leakage was found, then parietal pleural abrasion was performed by using gauze. One chest tube was placed through the camera port site so that adequate lung reexpansion could be verified. The postoperative care for the patients who underwent thoracostomy was the same as described above.
Follow-Up
After being discharged from the hospital, the patients received follow-up care at 1 week and at 1, 6, 12, and 24 months either by telephone interviews or by clinic visits, and chest radiographs were taken during the clinic visits.
Data Collection
The clinical data included the duration of the air leakage period, recurrence after nonoperative management, the operation rate, the operative findings, the duration of postoperative chest tube drainage, the length of the hospital stay, and postoperative recurrence. These data were compared between the groups. The continuous variables are expressed as mean ± SD, and the categorical variables are presented as frequencies (%).
Statistical Analysis
All analyses were carried out using statistical software (SPSS version 14.0 for Windows; SPSS, Chicago, IL). Univariate analysis for comparing the continuous variables between groups was performed using independent t tests, and comparing the categorical variables was performed with 
2 tests. Differences were considered statistically significant for p values less than 0.05.
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Results
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The mean age of the patients in the partial atelectasis group was 21.2 ± 5.7 years, and the mean age of the patients in the complete atelectasis group was 22.1 ± 5.0 years. Ninety-two percent of the 201 patients in the partial atelectasis group and 89% of the 85 patients in the complete atelectasis group were male. The mean body mass index of the patients in the partial atelectasis group was 19.6 ± 2.0 and that in the complete atelectasis group was 19.2 ± 1.8. Eighty-one percent of the partial atelectasis patients and 76% of the complete atelectasis patients were smokers at the time of diagnosis. All of these variables were not statistically different between the groups (Table 1).
In the partial atelectasis group, the initial management with using nonoperative methods was successful for 90% of the 201 patients. Ten percent of the patients failed because of persistent air leakage during the first episode, and these patients were then treated by VATS. The ipsilateral recurrence rate after successful management was 39.2% of the 181 patients, and these patients were treated by VATS. The overall number of VATS-treated patients was 91 (45.3%) of 201 patients. Closed thoracostomy was performed for all the cases in the complete atelectasis group. The rate of initial management failure, which was caused by persistent air leakage, was 29.4% of 85 patients, and these patients were treated by VATS. The ipsilateral recurrence rate after successful management was 70% of 60 patients, and VATS was performed for these patients. The overall number of VATS-treated patients was 67 (78.8%) of 85 patients. There were statistically significant differences between the groups for persistent air leakage during the first episode, ipsilateral recurrence, and the total number of patients treated with VATS (Table 2).
For the patients who underwent operation, the operation time was 39.2 ± 11.8 minutes for the partial atelectasis group and 40.4 ± 10.2 minutes for the complete atelectasis group, and there was no statistically significant difference between the groups. No bleb or a slightly dystrophic zone of the apex was found in 26% of the patients in the partial atelectasis group. These findings were observed in 27% of the patients in the complete atelectasis group, and there was no statistically significant difference between the groups. The duration of postoperative chest tube drainage and the length of the postoperative hospital stay between the groups were also not statistically different. The mean follow-up period was 40.2 ± 17.1 months. The postoperative recurrence rate for this period was 8.8% for the partial atelectasis group and 6.0% for the complete atelectasis group; there was no statistically significant difference between the groups (Table 3).
The hospital stay for the patients who do not undergo an operation, the hospital stay before the operation at their first episode, and the postoperative hospital stay between the groups were not statistically different (Table 4).
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Comment
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Primary spontaneous pneumothorax is a common disease, and it is very troublesome for teenagers, even though it is not a serious condition. Some of these patients complain of mental stress due to the fear of recurrence. The recurrence rate after the first episode is 20% to 50%, and this increases to 60% to 80% after the second episode [3–5, 10]. For many years, the universally accepted indications for surgery were a persistent air leakage, recurrent pneumothorax, and whether the PSP posed an occupational hazard such as diver or pilot. Video-assisted thoracoscopic surgery (VATS) has recently become more popular, and most thoracic surgeons are already familiar with this procedure. For the treatment of PSP, the initial enthusiasm for performing VATS has been tempered by the high rate of recurrence. That is because VATS causes less of an inflammatory response in the pleura, and there is a greater chance that blebs will not be detected [11–13]. According to a recent report, the overall recurrence rates between open thoracotomy and VATS were slightly higher in the VATS group, but there was no statistical difference between the two groups [6]. Therefore, considering the low morbidity, the decreased invasiveness, and the cosmetic issues of VATS, it is generally agreed that the standard treatment for PSP is thoracoscopic bullectomy [6].
The absolute indications for offering surgery at the first episode have been hemopneumothorax, tension pneumothorax, previous contralateral pneumothorax, and synchronous bilateral pneumothorax. According to the changes of surgical strategies, many reports have been published that have advocated aggressive treatment for PSP, such as surgery for the first episode [7, 8], surgery for the radiologic visible blebs [6, 14], and preventive surgery for contralateral blebs [15]. Surgery for the first episode of PSP is very reasonable to eliminate the patient's fear of recurrence, but a large number of the first episodes of PSP do not recur, which means that some of these patients undergo unnecessary surgery. The data from the studies concerned with surgery for treating visible blebs and on preventive surgery give the rationale for performing surgery and the patients have shown acceptable surgical outcomes, but all of these studies have not presented any data on the natural course of PSP, including the incidence of recurrence after conventional treatment.
The main purpose of this study was to evaluate the natural course of PSP, including the recurrence rate and the treatment outcomes after treating complete atelectasis of lung in patients with PSP, because there are scant data on this from the previous reports. In this current study, we did not find the general causes of complete atelectasis, including the patient's age, sex, height, weight, body mass index, and smoking history. The period of diagnosis from symptom onset was longer for the patients with partial atelectasis, as compared with that of the patients with complete atelectasis, but there was no statistical difference. These data were not included in the final results owing to the lack of accuracy because the symptoms were quite subjective and the findings were very nonspecific. The patients with complete atelectasis had a higher incidence of persistent air leakage of more than 5 days, as compared with that of the patients with partial atelectasis. All of the patients with complete atelectasis underwent VATS. The recurrence rate for the patients with complete atelectasis, excluding the VATS that was performed for persistent air leak, was 70%. This rate is about the same as the rate for a third episode of PSP, as reported by others. The recurrence rate of partial atelectasis was 39.2%, and the recurrence rate for the complete atelectasis cases was 45.2%. Our data for the recurrence rates were similar to other reported data [3–5].
The cause of complete atelectasis has not yet been explained, but it may be suggested that the bursting of a large subpleural bleb or the presence of a one-way valve air leakage process may be the cause, so it is very possible for the patients with complete atelectasis to have a high recurrence rate compared with the patients with partial atelectasis of lung. Our surgical findings showed that the patients with complete atelectasis did not have so many subpleural blebs or large blebs, as compared with the patients with partial atelectasis. These findings suggest that complete atelectasis develops by bursting a subpleural bleb, and there is a one-way valve air leak process, like the pathogenesis of tension pneumothorax [16]. These bursting subpleural bleb with complete atelectasis may have a "fish-mouth" appearance; this is hard to spontaneously heal, and it is the cause of the higher incidence of persistent air leakage and recurrence. We did not check for spontaneous healing for all of our surgical cases, but we performed an air leakage test before surgical bullectomy in 87 of all the surgical cases. In these cases, positive air leakage was found in 25 cases. Sixteen cases (64%) showed total atelectasis, and 9 cases (36%) showed partial atelectasis. Even though the number of cases was small, these findings may be evidence that explains the difficulty for complete atelectasis of the lung to spontaneously heal.
Even though we did not exactly explain the cause of the etiology and the high recurrence rate of complete atelectasis, complete atelectasis may well be a surgical condition. We finally treated this with VATS in 78.8% of the patients with complete atelectasis, which is statistically different from the treatment given for partial atelectasis. The surgical outcomes and postoperative recurrence rates were similar for both groups. According to the higher incidence and higher failure rate of initial air reduction for the cases of complete atelectasis, VATS is considered to be the standard treatment option for the first episode of complete atelectasis. Even though there were no statistically significant differences for the duration of the hospital stay between groups, that the hospital stay before the operation was longer than the one after it for the first episode shows it is cost effective to perform an immediate operation for a patient who has the proper surgical indications.
This study has limitations in that it was a retrospective study. Further prospective randomized trials are needed to evaluate the indications for surgical intervention. If the results of these future studies are similar to our data, then we recommend that the first episode of complete atelectasis of the lung in patients with PSP is an indication for surgical intervention.
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Abstract
Introduction
