(Chest. 1999;116:899-902.)
© 1999
American College of Chest Physicians
Physical Development of Surgically Treated Patients With Primary Spontaneous Pneumothorax*
Shozo Fujino, MD;
Shuhei Inoue, MD;
Noriaki Tezuka, MD;
Jun Hanaoka, MD;
Satoru Sawai, MD;
Masutaro Ichinose, MD and
Keiichi Kontani, MD
*
From the Second Department of Surgery, Shiga University of Medical Science, Otsu, Japan.
Correspondence to: Shozo Fujino, MD, The Second Department of Surgery, Shiga University of Medical Science, Otsu, Shiga 520-2192, Japan
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Abstract
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Study objectives: There have been many studies on the
physical characteristics at the time of contraction of a primary
spontaneous pneumothorax (PSP), but it has not been shown when and how
such physical characteristics develop. These issues were
investigated.
Patients and design: Physical
development of 27 male patients with PSP were examined. Their physical
records were collected with the patients' permission, and standard
curves, estimated from the Japanese nationwide records in the year
corresponding to the ages of the patients, were plotted as control
values.
Results: The height of patients was already
greater at 6 years of age. It showed a marked increase from 11 to 14
years. The body weight was more than the standard until 9 years, but it
became less after age 11, and this difference increased after age 15.
Rohrer's index was significantly lower than the standard at all ages,
and the difference was particularly large from 11 to 15 years. In the
standard group, there was a balance between the annual height and
weight gain. In the patient group, annual weight gain was similar to
that in the standard group whereas height began to increase 2 years
earlier, and as a result, ectomorphy, which was also observed before
this age, became marked at this age.
Conclusions: The
rapid increase in the vertical dimension of the thorax compared with
the horizontal dimension during the period of rapid physical
development is considered to affect intrathoracic pressure at the apex
of lung, which would have some influence on enhancing cyst
formation.
Key Words: height • physical development • primary spontaneous pneumothorax • Rohrer's index • weight
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Introduction
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A
correlation between primary spontaneous pneumothorax (PSP) and
ectomorphy has been noted.1
2
3
Ectomorphy, which describes
a tall figure with a flat thorax, is typically observed in Marfan
syndrome. Inasmuch as some patients with PSP are not ectomorphic,
physique is not the only cause of PSP, but there is no doubt regarding
its involvement. There have been a number of studies on the physical
characteristics at the time of contraction of the pneumothorax, but it
has not been shown when and how such physical characteristics
develop.4
In this study, we investigated these issues.
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Materials and Methods
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Of 95 patients with PSP who were treated surgically during a
study period of 7 years in our hospital, 27 male patients whose
physical development could be examined participated in the present
study. Four female patients whose physical development could be
examined were not included in this study.
The backgrounds of the 95 patients were as follows. The right side was
surgically treated in 48 patients, the left in 43 patients, and both in
4 patients. The patients consisted of 78 men and 17 women. The overall
mean age at operation was 27.5 years (range, 11 to 46 years), 26.8
years (range, 11 to 42 years) in the male patients, and 30.7 years
(range, 15 to 46 years) in the female patients. The age distribution of
the patients was such that patients in their 20s were most frequent,
followed by the teens and then the 30s.
At the time of surgery, the mean height of the male patients was 170.8
cm, their mean body weight was 54.7 kg, and Rohrer's index (RI), which
is defined as body
weight / height3 x 107,
was 109.8. Those values in female patients were 159.2 cm, 47.8 kg, and
118.5, respectively, indicating that the male patients showed a higher
degree of ectomorphy.
To investigate the characteristics of physical development in these
patients, their physical records were collected from their primary and
junior and senior high schools with the patients' permission. Records
kept by the patients themselves were used in some cases. Standard
curves estimated from the Japanese nationwide records of mean height
and body weight5
in the year corresponding to the ages of
the patients were plotted as control values.
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Results
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Because schools in Japan are allowed to discard physical records
of the students 5 years after their graduation, complete records from
primary to senior high school could be examined in only 31 young
patients. Of these 31, 27 male patients were examined in this study.
Because some low- and middle-teenage patients were included in this
group, the overall number of patients examined was 27 in the age group
from 6 to 11 years, 26 from 12 to 13 years, 25 at 14 years, 24 at 15
years, 23 at 16 years, and 20 at 17 years.
The mean age of the 27 patients analyzed in this study was 21.5 years
(range, 11 to 32 years), which was much younger than that of the total
patient population for the reason cited above. The mean age at the
first occurrence was 20.7 years, mean height 172.9 cm, mean body weight
54.2 kg, and RI 104.8, showing a slightly higher degree of ectomorphy
than the total male patient population. This may have been because
older patients were excluded.
Development of Height and Body Weight
The height of patients was already greater than the standard at 6
years of age and increased with a time course similar to the standard
curve. It showed a marked increase from 11 to 14 years, but the
increase slowed down from age 15 years and on. The difference between
the patients and the standard was significant at all ages (p < 0.05;
Fig 1
). The body weight was more than the standard from 6 to 9 years. After
11 years of age, it became less than the standard, with a similar
course of increase up to age 14. After age 15 years, the rate of
increase became slower, and the difference between the patients and the
standard increased. The difference was significant at ages 15 and 16
(p < 0.05; Fig 1
). As a result, RI was lower than the standard at
all ages, with the difference between the patients and the standards
being particularly large from age 11 to 15 years. The
difference was significant at all ages (p < 0.05; Fig 2 ).
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Figure 1. Development of height and body weight. The
difference between the patients and the standard was significant at all
ages in height and at ages 15 and 16 in weight (p < 0.05).
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Annual Changes in Height and Weight Gains
Annual changes in height and weight gains were compared in each
group. In the standard group, there was a balance between the height
gain and weight gain (Fig 3
, left, A). In the patient group, changes in the weight gain
were similar to those in the standard group except for a lower gain
from age 14 to 15 years, whereas height began to increase 2 years
earlier than weight. As a result, ectomorphy, which was also observed
before this age, became marked at this age (Fig 3
, right,
B).
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Figure 3. Annual changes in height and weight gains.
Left, A: in the standard group, there was a balance
between the height gain and weight gain. Right, B: in
the patient group, changes in the weight gain were similar to those in
the standard group, whereas height began to increase 2 years earlier
than weight.
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Discussion
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Most cases of spontaneous pneumothorax were regarded as
being secondary to pulmonary tuberculosis, until 1932, when
Kjaergard6
described PSP as a separate entity occurring in
previously healthy adults. As noted in the article by Withers et
al,7
Devilliers was the first to suggest the
rupture of subpleural blebs as a cause for spontaneous
pneumothorax. Since then, there have been many studies on factors
related to the formation and rupture of subpleural cysts.
West8
showed that the size of alveoli in the apex of the
lung is larger than that in the base of lung, which was considered to
reflect a considerable difference in the intrathoracic pressure between
these regions. This difference in size of alveoli is considered to be
one of the causes of the higher incidence of cyst formation in the apex
of the lung. Withers et al7
argued that a long and narrow
lung is prone to ischemia because of rapid growth of the parenchyma,
which can cause formation of subpleural cysts in the visceral pleura,
especially in the apex region. Fukuda et al9
found
degeneration of elastic fibers caused by a focal imbalance between
elastase and 
1-antitrypsin. It is generally considered
that negative pressure in the apex of the lung causes formation of
cysts if the vertical dimension of the thorax is large.
Although the risk of PSP occurrence or recurrence is probably
multifactorial, including physical characteristics, smoking
habit,1
anatomic abnormality of the bronchial
tree,10
sex, and genetic factors,3
the causes
of PSP are often related to the physical characteristics of the
patients. Physical characteristics of patients with PSP have been
investigated in many studies, some of which compared patient data with
those of normal subjects by age group.1
However, few
studies have focused on the physical development of individual
subjects.11
It is difficult to clarify how the formation of subpleural cysts is
related to such characteristics of patients as being tall, thin, and
young. However, rupture of one isolated subpleural cyst may be related
to a narrow upper thorax. The results of the present survey clearly
showed that at least several patients with PSP were ectomorphic from
childhood. It is also clear that they showed even more rapid growth in
the vertical direction than in the lateral direction during the period
of rapid physical development. This differential growth would increase
the negative pressure at the apex of the lung as West8
pointed out, having some influence on enhancing cyst formation during
this period. Kasagi et al11
also suggested that sex
differences in the rate of height increase during the period of rapid
physical development may account for the sex difference in the
prevalence of PSP. In the present study, comparison between sexes could
not be studied because there were only a few female patients. In recent
years, the frequency of PSP is believed to be increasing, especially in
women. It is possible that there are some changes in physical
development in young women.
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Summary
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Physical development was investigated in patients with PSP, and
the following results were obtained: (1) Patients with PSP are
ectomorphic from childhood. This is primarily because of their greater
than average height, but their body weight is also greater than average
in early childhood. (2) This ectomorphy is further exaggerated in the
period of rapid physical development as a result of more rapid increase
in height than weight. (3) The rapid increase in the vertical dimension
of the thorax compared with the horizontal dimension during this period
is considered to affect intrathoracic pressure at the apex of the lung,
which would have some influence on enhancing cyst formation.
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Footnotes
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Abbreviations: PSP = primary spontaneous
pneumothorax; RI = Rohrer's index
Received for publication November 10, 1998.
Accepted for publication April 20, 1999.
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References
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Nakamura, H, Izuchi, R, Hagiwara, T, et al (1983) Physical constitution and smoking habits of patients with idiopathic spontaneous pneumothorax. Jpn J Med 22,2-8[Medline]
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Sadikot, RT, Greene, T, Meadows, K, et al (1997) Recurrence of primary spontaneous pneumothorax. Thorax 52,805-809[Abstract]
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Abolnik, IZ, Lossos, IS, Gillis, D, et al (1993) Primary spontaneous pneumothorax in men. Am J Med Sci 305,297-303[Medline]
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Fujino, S (1992) Physical development of patients with spontaneous pneumothorax. Clin Dig Ser 4,26-27
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Japanese Health and Welfare Statistics Association. Jpn Health Welfare Stat 1975–1995; 22–42
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Kjaergard, H (1932) Spontaneous pneumothorax in the apparently healthy. Acta Med Scand Suppl 43,1-159
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Withers, JN, Fishback, ME, Kiehl, PV, et al (1964) Spontaneous pneumothorax, suggested etiology and comparison of treatment methods. Am J Surg 108,772-776[CrossRef][Medline]
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West, JB (1971) Distribution of mechanical stress in the lung, a possible factor in localisation of pulmonary disease. Lancet 1,839-841[CrossRef][ISI][Medline]
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Fukuda, Y, Haraguchi, S, Tanaka, S, et al (1994) Pathogenesis of blebs and bullae of patients with spontaneous pneumothorax: ultrastructural and immunohistochemical studies [abstract]. Am J Respir Crit Care Med 149,A1022
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Kasagi, A, Masuda, T, Saito, N, et al (1971) Spontaneous pneumothorax: consideration in respect of etiology. Intern Med 28,733-737
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Abstract
Introduction
