The recurrence rate for pneumothorax is high; this is especially true in SSP, which has a rate of approximately 45% (compared with 30% in PSP). For this reason, the American College of Chest Physicians (ACCP) consensus statement on pneumothorax recommends chest tubes for all patients and pleurodesis with the first episode of a secondary spontaneous pneumothorax to prevent recurrences. The ACCP recommends medical thoracoscopy or video-assisted thorascopic surgery (VATS) as the primary procedure, and a limited axillary thoracotomy with pleural abrasion as a secondary approach.[4]
Chemical pleurodesis with talc or doxycycline may be performed via tube thoracostomy or thoracoscopy. VATS with bullae resection, stapling, and mechanical pleurodesis is a highly effective modality for preventing recurrence, but because the procedure requires induced collapse of 1 lung, patients with very poor lung reserve are not candidates for this procedure. In addition, general anesthetic risks must also be considered when electing for VATS. Success rates with chemical pleurodesis are 78%-91%, but they are 95%-100% with surgical interventions; therefore, the latter technique is preferred in patients with relatively good lung reserve.[6]
A retrospective of review of 569 patients treated from 1992 to 2008 with VATS for PSP and SSP showed that freedom from further surgery was seen in 98.1% of PSP patients at 5 years and 97.8% at 10 years after VATS, and in 96.1% of SSP patients at both 5 years and 10 years after VATS.[9] In both groups, no significant differences in results at 10 years were seen based on the pleurodesis technique used (ie, abrasion, chemical, or pleurectomy).
The patient in this case did not show any decline in respiratory function (pain rather than dyspnea was his presenting complaint); therefore, a tube thoracostomy was not performed. The procedure was also deferred because the patient was placed on heparin for his new pulmonary thrombus and he was also taking warfarin for his previous pulmonary embolus; both medications increase the risk for excessive bleeding with tube thoracostomy. He was observed in the intensive care unit with serial x-rays and had progressive spontaneous resolution over the next week, without need for an acute intervention. He was treated with unfractionated heparin for his pulmonary thrombus and an inferior vena cava filter was placed. After discharge, he was maintained on low-molecular-weight heparin because he had failed warfarin therapy. He was scheduled to undergo VATS to prevent recurrent pneumothorax.
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