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Thoracoscopic Appearance of Bilateral Spontaneous Pneumothorax^*

^* From the Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan.

Correspondence to: Masaya Tamura, MD, Department of Thoracic Surgery, Ishikawa Prefectural Central Hospital, Kuratsuki-Higashi 2-1, Kanazawa, Ishikawa, 920-8530, Japan; e-mail: m-tamura{at}sf.m.kanzawa-u.ac.jp

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Study objectives: We investigated the macroscopic features of bilateral pneumothorax (BLP) and compared them with those of unilateral pneumothorax (ULP).

Methods: Surgical cases of spontaneous pneumothorax (236 cases) were divided into two groups based on unilateral occurrence (206 cases) or bilateral occurrence (30 cases). The patients were divided into three groups by the macroscopic findings of lung disease. The first group consisted of those patients with solitary and small bullae (type I pneumothorax), the second group consisted of those with multiple and large bullae (type II pneumothorax), and the third group consisted of those with an aggregation of diffuse and tiny bullae (type III pneumothorax).

Results: In metachronous BLP cases, 18 patients (66.7%) revealed type III pneumothorax in the first occurrence site, and 13 of 18 patients (72.2%) revealed type III pneumothorax in the contralateral site. Type III pneumothoraces were more frequently found in patients with BLP (18 of 27 patients; 66.7%) compared with ULP (73 of 206 patients; 35.4%; p = 0.0086 [² test]). During a follow-up ranging from 12 to 129 months (median, 69 months), 7 patients (23.3%) in the BLP group developed recurrences. This rate was higher than that of the ULP group (5.3%; p = 0.0009 [² test]). Contralateral CT scan findings of their first occurrence were retrospectively reviewed. In 3 patients (15.8%) in the BLP group and 17 patients (12.3%) in the ULP group, apical lung bullae and blebs (ruptured or intact) could be detected on the contralateral lung (p = 0.703 [² test]).

Conclusions: The patients with an aggregation of diffuse and tiny bullae in their thoracoscopic findings had a high risk of contralateral recurrence. Macroscopic lung appearance in the contralateral site in such patients tended to reveal the same type as that in the primary site. CT scanning was not useful for predicting the risk of contralateral occurrence.

Key Words: bilateral spontaneous pneumothorax • blebs • bullae

	Introduction

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One of the key aims in the management of pneumothorax is the prevention of recurrence. Conservative treatment and tube thoracostomy are associated with an ipsilateral recurrence rate of 20 to 52%. Furthermore, physicians should always keep in mind that contralateral recurrence occurs in approximately 15% of patients.^{1 2 3} Many patients with macroscopic abnormalities never experience recurrence of their pneumothorax, however, on the other hand, the number of such recurrences of pneumothorax are greater for patients without abnormalities in their lungs. No studies have dealt with the correlation between the type of bullae and the risk of contralateral pneumothorax. In this study, we aimed to investigate retrospectively the macroscopic features of bilateral pneumothorax (BLP) compared with those of unilateral pneumothorax (ULP).

	Materials and Methods

TOP Abstract Introduction Materials and Methods Results Discussion References

 
The subjects were 236 patients (202 men and 34 women; age range, 14 to 39 years; mean [± SD] age, 26.2 ± 11.8 years) who had undergone surgery at the Thoracic Surgery Department of Ishikawa Prefectural Central Hospital between January 1992 and December 2001. This study included only cases of spontaneous pneumothorax (SP), and excluded the cases that revealed emphysematous change and no apparent bullae or blebs intraoperatively. Patients with catamenial or traumatic pneumothorax were excluded from the study. Data were collected retrospectively for all patients, including a detailed medical history, treatment modalities, history of asthma and smoking behavior, and nature of the lung disease (ie, blebs or bullae) with size, site of occurrence, and numbers. The patients were divided into three groups by the macroscopic findings of lung disease. The first group consisted of those patients with solitary and small bullae (type I pneumothorax), the second group consisted of those with multiple and large bullae (type II pneumothorax), and the third group consisted of those with aggregated diffuse and tiny bullae (type III pneumothorax) [Fig 1 ]. All the patients in this study were followed up for > 12 months and were checked for whether recurrence had occurred or not. All 236 patients were divided into two groups based on unilateral or bilateral occurrence. A CT scan of the thorax was performed in 19 cases of BLP (63.3%) and in 146 cases of ULP (70.9%). A high-resolution CT scan of the thorax was performed on each patient, with a slice thickness of 1 mm and a section spacing of 10 mm. Particular attention was focused on the detection of lung blebs or bullae in the lung affected by pneumothorax and in the contralateral lung.

View larger version (6K): [in this window] [in a new window] [Download PPT slide]   Figure 1.. Classification of the types of macroscopic lung findings.

	Results

TOP Abstract Introduction Materials and Methods Results Discussion References

 
The ULP group comprised 206 patients (176 men and 30 women), and the BLP group comprised 30 patients (26 men and 4 women). The BLP group consisted of 27 metachronous patients (23 men and 4 women) and 3 synchronous patients (3 men).

Seven patients in the BLP group and 52 patients in the ULP group underwent video-assisted thoracic surgery (23.3% vs 25.2%, respectively; p = 0.67 [² test]). The estimate of the macroscopic appearance of BLP was shown in Table 1 . In metachronous cases, 18 patients (66.7%) revealed type III bullae in the primary pneumothorax site. Thirteen of 18 patients (72.2%) had type III bullae in the secondary pneumothorax site. The mean time interval between primary and secondary occurrence was 20.6 months (range, 1 to 72 months). Twenty patients (74.1%) experienced contralateral pneumothorax within 24 months from the occurrence of the primary pneumothorax. A comparison of macroscopic findings of patients with BLP and ULP is summarized in Table 2 . There were no differences concerning the history of asthma and smoking behavior between the two groups. Type III bullae were more frequently found in patients with BLPs (18 of 27 patients; 66.7%) compared with those with ULPs (73 of 206 patients; 35.4%), and statistical significance could be found (p = 0.0086; [² test]). During a follow-up period ranging from 12 to 129 months (median duration, 69 months), 7 patients (23.3%) in the BLP group developed recurrences. This rate was higher than that of the ULP group (5.3%; p = 0.0009 [² test]). Contralateral CT scan findings at the first occurrence were retrospectively reviewed. In 3 patients (15.8%) in the BLP group and 18 patients (12.3%) in the ULP group, apical lung bullae and blebs (ruptured or intact) could be detected on the contralateral lung.

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion References

Janssen et al⁶ compared the videothoracoscopic appearance of first and recurrent pneumothoraces, and assessed the relationship between endoscopic appearance and recurrence rate. We could not find a report investigating the relationship between macroscopic findings of the lung and the rate of contralateral recurrence. In our study, type III pneumothorax showed contralateral recurrence more frequently than type I and II (type III, 19.8%; types I and II, 6.3% [excluded occurrence of synchronous BLP]). Thirteen of 18 type III cases (72.2%) showed the same macroscopic findings in the contralateral site as those in the primary site. The postoperative recurrence rate was higher in the BLP group than in the ULP group, and statistically significant differences could be seen.

The cause of SP is unknown. However, blebs and bullae seem to play a role in the pathogenesis, since they are frequently found during thoracoscopy, thoracotomy, and sternotomy. Thoracoscopic and thoracotomic studies⁷ have shown the presence of blebs and bullae in 48 to 100% of patients with unilateral primary spontaneous pneumothoraces. In our study, 213 of 236 patients (90.4%) revealed bullae or blebs. In addition, a number of patients with thoracoscopically normal findings (26%) have experienced pneumothoraces.⁶ Naunheim et al⁸ observed that the incidence of postoperative ipsilateral pneumothorax was higher in a group in which no blebs were detected intraoperatively than in a group in which blebs were detected. Certainly, there seems to be no proof that bullae are the cause of primary or recurrent SP in the majority of cases. Schramel et al⁷ reported that the inflammatory changes in the distal airways of smokers suggests that endobronchial obstruction is part of the pathogenesis of primary SP. Smoking is related to a ninefold increase in the relative risk of contracting pneumothorax among women, and a 22-fold increase in relative risk in men.⁹ Numerous studies^{10 11} have demonstrated increased numbers of inflammatory cells in the small airways of smokers. Endobronchial obstruction due to the accumulation of inflammatory cells between the pulmonary parenchyma and the bronchial tree can induce overpressure in alveolar tissue, resulting in the rupture of the pulmonary parenchyma. This is a reasonable theory, but it is merely the trigger for an occurrence of pneumothorax. Although we could prove the communication between the pleural cavity and the bulla or bleb in some of our patients, it remains unclear whether bullae or blebs are the sites of rupture, so the patients who showed no visible bullae were excluded from this study.

Giant bullae are considered to be hard to rupture, because the rise in the internal pressure in the bulla spreads in a horizontal direction. The change of pressure inside a bulla would be greater in a smaller bulla than in a larger one. Janssen et al⁶ reported that a high incidence of adhesions could be found in patients with their first SP and suggested that an inflammatory reaction preceded the event of SP. In our study, discoloration or thickening of the visceral pleura was more highly recognized in type III bullae than in other types of bullae. This may be one of the reasons why type III bullae have a high potential for rupture. Type III bullae tend to present a diffuse and skipping pattern, and to extend other lobes. Such patients are considered to have the same kind of pleural disease in their contralateral lung.

Sihoe et al¹² insisted that the detection of lung bullae by CT scanning in the contralateral lung following unilateral SP is associated with a higher rate of subsequent occurrences of pneumothorax in that lung. On the contrary, Mitlehner et al¹³ analyzed 35 patients with primary SP who had undergone thoracic CT scans and concluded that the presence of blebs and/or bullae had no predictive value for recurrence during follow-up. A number of reports were unfavorable regarding the predictive value of CT scanning for the development of recurrences.^{14 15 16} In our study, 15.8% of BLP patients (3 of 19 patients) revealed contralateral bullae on preoperative CT scan findings, which was a slightly higher percentage than that of the ULP group (12.3%; 18 of 146 patients), but there were no statistically significant differences (p = 0.723 [² test]). This may be because thin-slice CT scanning was not used in our study, so tiny bullae like those found in type III pneumothoraces could not be detected preoperatively.

In conclusion, patients with an aggregation of diffuse and tiny bullae easily relapse in their contralateral lung. Contralateral macroscopic findings of the lung tend to be the same as those of the primary site. CT scanning cannot be used to predict the risk of contralateral occurrence.

	Footnotes

 
Abbreviations: BLP = bilateral pneumothorax; SP = spontaneous pneumothorax; ULP = unilateral pneumothorax

Received for publication November 19, 2002. Accepted for publication April 23, 2003.

	References

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