Understanding Pneumothorax
What is Pneumothorax?
The lungs are like balloons full of air; sometimes, they get punctured or burst. There are different types of pneumothorax. A burst is commonly caused by a puncture or tear in the lung tissue, usually due to rib fractures (traumatic pneumothorax) leading to the accumulation of air into the pleural cavity. Some underlying lung conditions, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, or lung cancer or idiopathic pulmonary fibrosis, may also increase the risk of developing a secondary spontaneous pneumothorax. Other risk factors might include medical procedures, such as thoracentesis (an invasive procedure consisting in the needle aspiration of excess fluid from the chest cavity) or mechanical ventilation in intensive care.
Sometimes, finding a reason for a pneumothorax is impossible, especially in young, tall and thin patients. In those cases, we call it primary spontaneous pneumothorax.
Symptoms of a Pneumothorax
The symptoms most often reported to healthcare professionals are:
1) Sudden and severe chest pain on one side
2) Shortness of breath may become more severe if there is a persistent air leak.
3) Rapid heart rate and low blood pressure if the pneumothorax is large enough to compress the heart or major blood vessels, we call it tension pneumothorax.
If left untreated or if there is a larger pneumothorax, it can lead to significant breathing problems, chest pain, and even death. However, a small pneumothorax with a small amount of air leaked from the lung may not cause any symptoms and may even resolve independently.
An Overview of Pneumothorax Surgery
What is Pneumothorax Surgery?
Pneumothorax Surgery, also known as surgical treatment or thoracic surgery or lung surgery when referring to this condition, is usually considered when the initial treatments fail, if a patient has recurrent pneumothoraces, or in cases of severe lung collapse. The primary surgical procedures include:
1. Video-Assisted Thoracoscopic Surgery (VATS)
This is a minimally invasive technique where the surgeon makes small incisions in the chest and inserts a thoracoscope (a tube with a small camera and light) and surgical instruments.
2. Chemical Pleurodesis
This procedure involves injecting a chemical into the pleural space, causing inflammation and scarring, which helps the lung adhere to the parietal pleura which is the inner lining of the chest wall, preventing future collapses. Talc pleurodesis is the most commonly performed procedure. This can sometimes be done through a chest drain insertion without the need for surgery, but in other cases, it may be done surgically, often in conjunction with VATS.
3. Mechanical Pleurodesis
Done during VATS or open thoracotomy, this procedure physically removes the pleura, creating scar tissue to help the lung stick to the chest wall.
4. Thoracotomy
In more severe or complicated cases, the surgeon may opt for an open thoracotomy, which involves making a larger incision in the chest to repair the lung or pleura.
The choice of surgical technique depends on several factors, including the cause and extent of the pneumothorax, the patient’s overall health and lung function, and the presence of underlying lung diseases.
Benefits of Surgery
Some benefits of undergoing surgery for pneumothorax include:
1. Resolve Persistent or Recurrent Pneumothorax
Surgery is often considered when a pneumothorax does not resolve on its own or when there are recurrent episodes or increased risk (ie pilots) or underlying lung problems.
2. Prevent Recurrence
One of the main benefits of surgery is a significant reduction in the recurrence rate of a recurrent pneumothorax. This is crucial for patients who have experienced multiple episodes.
3. Rapid Recovery and Improvement
Surgical interventions, especially minimally invasive techniques such as VATS, offer a quicker recovery compared to traditional open surgeries.
4. Enhanced Diagnosis and Management
During surgical repair of a pneumothorax, doctors have the opportunity to visually inspect the lungs and surrounding tissues, potentially identifying and treating other underlying issues or vulnerabilities in the lung that could cause future complications.
5. Safety and Reliability
With advancements in surgical techniques and technology, surgery, especially when performed using VATS, has become increasingly safe and effective. It’s associated with low complication rates and high success rates.
6. Psychological Long-Term Peace of Mind
For patients who have experienced a spontaneous pneumothorax (occurrence without an apparent cause), knowing that a recurrence is much less likely can provide significant psychological relief and reduce anxiety related to the possibility of another lung collapse.
The Surgical Process
Pre-operative Preparation
When we meet in the outpatient setting for a consultation, we will discuss your medical history in detail, if needed I will perform a physical examination and all the available treatment options will be presented; this is particularly important as sometimes there are conditions that can predispose you to pneumothorax. For example, women with endometriosis might develop a pneumothorax just before the period; this is called catamenial pneumothorax. Also, some genetic conditions could increase the chances of developing a pneumothorax.
You might also have sought medical attention for the same condition, and things might not be improving, in which case I am happy to provide a second opinion to ensure nothing was missed. Equally, you might want to switch your care from the NHS to the private sector so that you can return to your normal life much sooner without waiting for scans and treatment.
I will order a chest CT scan. You might have already had a chest x-ray at your local hospital. Still, a CT is a much more accurate test that will allow me to thoroughly appreciate the texture of the lung and see if there is any pocket of air or blebs (air blisters) in the visceral pleura that need to be removed to reduce the chances of recurrence. A CT scan will be without contrast; that is, there is no need to put a needle in your arm; it is very quick, and painless, and, with modern CT, the radiation exposure is minimal.
During Surgery
The surgery is carried out under general anesthesia, this is usually very light and doesn’t give the usual problems that patients might have previously experienced or heard of.
The procedure can last up to one hour, but usually, it is much faster around 25 to 30 min. It also depends on the individual conditions and technique chosen (keyhole vs open or pleurectomy vs chemical pleurodesis).
At the end of the surgery, patients wake up with one chest tube, that is usually removed the following day or when the air leak, if present post-surgery, is completely gone and the lung is fully expanded.
Post-operative
Patients are woken up immediately after surgery, they are conscious and able to talk. They spent usually around one hour in the recovery room to make sure all is well and then they go back to their room. Most of my patients are discharged 24 to 48 hours later.
Recovery After Pneumothorax Surgery
Post-Operative Care
The first few hours after surgery, you’ll be monitored closely for any complications. Pain management will be provided to keep you comfortable.
Chest Tube
You may have a chest tube in place to remove excess air or fluid. This tube will typically remain for a few days until your lung has re-expanded properly.
Pain Management
While minimally invasive surgery causes less post-surgical pain than traditional open surgery, you may still experience some discomfort. Pain medications will be prescribed to manage any pain you may have.
Hospital Stay
Most patients stay in the hospital for 1 to 3 days after pneumothorax surgery, depending on the severity of the condition and the surgical method used.
Breathing Exercises
You’ll be encouraged to perform breathing exercises to help your lung fully expand and prevent complications like pneumonia.
Gradual Recovery
You’ll be encouraged to begin light walking soon after surgery to improve circulation and prevent blood clots, but you should avoid any heavy lifting or strenuous activities until your doctor gives the green light.
Conditions that involves sudden variation in air pressure such flying should be avoided for 4 to 6 weeks if possible, if necessary it is possible to fly even after a week with some precautions. Scuba diving should be avoided.
Risks and Complications
While complications are rare, it’s important to stay vigilant during your recovery. Watch for the following signs and report them to your doctor immediately:
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Increased shortness of breath
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Sudden chest pain or discomfort
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Fever or chills
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Redness, swelling, or discharge at the affected side
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There is always a risk of recurrence to be mindful of
Cases of Pneumothorax
Case 1: James is very fit; he regularly exercises in the gym, lifts weights, and trains for marathons. He previously complained of sudden chest pain after lifting weights and noticed his running wasn’t as good. He attributed these symptoms to a pulled muscle. One day, feeling particularly unwell and short of breath, he went to A&E and was diagnosed with a large pneumothorax. After a chest tube insertion, he was admitted for observation. Six days later, with the drain still bubbling, he was referred for surgery and went home the following day. In two weeks, he returned to work and resumed training for the marathon, never again feeling short of breath.
Case 2: Robert is a busy manager who went skiing with his family in Switzerland. He fell on a particularly challenging slope and hit his chest against a pillar. He felt short of breath and in excruciating pain. He was taken by air ambulance to the nearest hospital, where he was diagnosed with several broken ribs and a pneumothorax. He was treated locally and repatriated to the UK by his medical insurance with a chest drain. Once back in the UK, he doesn’t know what to do about the drain and the broken rib. Thankfully, he has private medical insurance that referred him to me. He had a quick surgery and is back at work after two weeks.
Case 3: Richard smoked quite heavily for about 30 years, suddenly he experienced severe shortness of breath and went to the local A&E, where he was diagnosed with lung emphysema and a pneumothorax. He was admitted to hospital, and after 7 days, he still had a significant amount of air leaking through the drain. He enquired about private treatment, and 2 days later, he went home back to his family.
