Thoracoscopic bullectomy and pleurodesis in the management of recurrent secondary spontaneous pneumothorax
A 53-year-old African American man with a known history of advanced pulmonary sarcoidosis, obstructive sleep apnea on CPAP and mild pulmonary hypertension, was initially evaluated for possible lung transplant. He then presented with a first episode of spontaneous left pneumothorax requiring thoracostomy tube placement. The patient had evidence of prolonged air leak lasting more than four weeks, despite bedside pleurodesis with doxycycline and placement of an endobronchial valve in the left upper lobe (B1/B2 segments, IBV Spiration®). He was eventually discharged with a Heimlich valve before the thoracostomy tube was removed. However, he presented two days later with recurrent left pneumothorax requiring another chest tube placement. A thoracic surgery consultation was requested.
The patient otherwise had a remote history of smoking, had not been on oral steroids for 2 years, and used O2 mostly with activity.
- Left ventricle: Systolic function was normal by visual assessment. Ejection fraction was estimated in the range of 60–65%.
- Right ventricle: The ventricle was mildly dilated. Systolic function was normal.
Outpatient pulmonary function tests 1 year prior to the pneumothorax:
- FVC = 2.65 L (61%)
- FEV1 = 2.17 L (63%)
- DCLO = 27%
- FEV1/FVC = 82%
CT-SCAN of the chest as shown above.
Clinical Course and Outcomes
Despite his potential future candidacy for a lung transplant, a multidisciplinary discussion determined that a surgical bullectomy/blebectomy and pleurodesis was the only remaining option for the management of the patient’s recurrent pneumothorax and prolonged air leak.
The patient underwent a left video-assisted thoracoscopic (VATS) exploration with lysis of adhesions, bullectomy, mechanical pleurodesis with subtotal pleurectomy, and chemical pleurodesis with doxycycline. His hospital course was overall uneventful, except for a prolonged air leak. The first thoracostomy tube was removed on day 12; he was discharged on day 15 with the second tube connected to a Heimlich valve. The latter was removed in clinic on day 20.
The patient had no recurrence on the left side after a follow-up of 1.5 years. He remained overall functional despite the O2 requirements of 2-4 L/min, and opted to defer completion of the lung transplantation evaluation.
A spontaneous pneumothorax secondary to underlying interstitial lung disease can be associated with prolonged air leak and a high risk of recurrence. Although conservative management is advocated, more aggressive measures may become necessary for definitive treatment. Potential candidacy for lung transplantation should not be an absolute contraindication for surgical pleurodesis, although the risk of bleeding can be higher with future surgery.
- In the case of potential future lung transplantation, all conservative measures should be exhausted before surgical pleurodesis is considered.
- Thoracoscopic bullectomy and pleurectomy/pleurodesis is safe and successful in the treatment of complicated spontaneous pneumothorax secondary to interstitial lung disease.
Charles Bakhos, MD, MS, FACS
Associate Professor, Thoracic Medicine and Surgery
Lewis Katz School of Medicine at Temple University