Role of CT in the Management of Pneumothorax in Patients with Complex Cystic Lung Disease

doi:10.1378/chest.112.1.275

Chest

Volume 112, Issue 1, July 1997, Pages 275-278

https://doi.org/10.1378/chest.112.1.275 Get rights and content

The diagnosis and treatment of pneumothorax in patients with complex cystic lung disease may be difficult when relying on plain chest radiography alone. We report four cases in which management was greatly facilitated by the use of CT scanning of the chest.

Section snippets

Case 1

A 23-year-old woman with severe lung disease (FEV₁ 31% predicted; FVC, 33% predicted; diffusion of carbon monoxide, 25% predicted) due to Langerhans' cell histiocytosis presented with acute breathlessness. In the past she had had bilateral pleurectomies for recurrent pneumothorax. A plain chest radiograph demonstrated a right apical pneumothorax. Simple tube drainage failed, and the patient underwent thoracotomy and oversewing of the air leak. Postoperatively, the air leak recurred, infection

Discussion

Patients with cystic lung disease are particularly likely to have pneumothorax. However, the reticular pattern, bullous formation, and partial adherence of the lung to the chest wall that are so prevalent in such patients make identification of pneumothorax difficult. In addition, instances of pneumothorax in such patients are rarely simple so that while comparison with prior radiographs or the taking of a lateral radiograph¹ may be useful, plain chest radiographs may fail to identify the

References (10)

R.A. Morgan et al.
Detection of pneumothorax with lateral shoot through digital radiography
Clin Radiol
(1993)
O. Engdahl et al.
Chest radiography—a poor method for determining the size of a pneumothorax
Chest
(1993)
B.W. Warner et al.
Value of computed tomography of the lung in the management of primary spontaneous pneumothorax
Am J Surg
(1991)
J.J. Carr et al.
Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers
Radiology
(1992)
W. Mitlehner et al.
Value of computed tomography in the detection of bullae and blebs in patients with primary spontaneous pneumothorax
Respiration
(1992)

There are more references available in the full text version of this article.

Cited by (37)

Giant pulmonary bullae in children
2020, Journal of Pediatric Surgery Case Reports
Citation Excerpt :
Ventilation perfusion scanning can help in determining the regional function of a particular part of the lung but has largely been replaced by CT scan. CT scan can also provide important characteristics of the bulla, such as size (volume), position and most importantly the condition of the residual lung, and can also help differentiate bullae from simple pneumothorax which may result in unnecessary intervention [1,4,9,14–16]. Bullae may regress by itself, autobullectomized.
Bullous lung disease in pediatric patients is a rare entity, and reports of Giant Bullae (GB) in pediatric age group are very few in number. Due to scarcity of these reports, management depends on individual patient presentation.
We present two cases with giant pulmonary bullae. The first one is an 11-year-old male child with two weeks history of cough, right sided chest pain and CT scan showed multiple thin-walled air-filled cysts in the same side with mediastinal shift. Bullaectomy was done through a posterolateral thoracotomy. The patient had uneventful intraoperative and postoperative course and discharged improved. He remained stable on subsequent postoperative follow ups. The second patient was 12 years old female who presented with 2 years history of exertional dyspnea with left sided chest pain, cough, loss of appetite and significant weight loss. Chest CT scan revealed left side giant multiseptated bullae with significant mediastinal shift. Bullaectomy was done through a left posterolateral thoracotomy, however the lung remained collapsed despite increased positive pressure ventilation. Patient improved symptomatically, but the lung showed no improvement on subsequent chest x-rays. There was no air leak through the chest tube, which was removed on the seventh postoperative day and patient discharged. Despite marked clinical improvement, the lung remained collapsed on outpatient follow up.
These case series represent a rare event in the pediatric population and patients with GB present with compressive symptoms mimicking tension pneumothorax. This series can provide guidance on management of these cases for clinicians.
Pneumothorax in cystic fibrosis: beyond the guidelines
2016, Paediatric Respiratory Reviews
Citation Excerpt :
Therefore a low threshold is justified for the use of a chest CT scan to aid evaluation and management. They allow a more accurate assessment of size of a pneumothorax, identify a site for the chest drain insertion and help confirm resolution following treatment [7]. Aspiration is recommended in the BTS guidelines however there is little evidence to support this in CF patients.
Chemical pleurodesis for spontaneous pneumothorax
2013, Journal of the Formosan Medical Association
Citation Excerpt :
Although chest CT scans can reveal the underlying pathophysiologic lesions that cause spontaneous pneumothorax and can be regarded as the “gold standard” in the detection of small pneumothoraces and in size estimation,23,24 the American Collage of Chest Physicians (ACCP) does not recommend the routine use of this imaging technique for patients with first-time primary or secondary pneumothoraces.21 CT may, however, be useful for evaluating patients with recurrent secondary pneumothorax, to determine the best treatment for persistent air leakage, or to plan a surgical intervention.25 The British Thoracic Society (BTS) recommends using CT when required to differentiate between pneumothorax and bullous lung disease, when aberrant tube placement is suspected and when the plain chest radiograph is difficult to read owing to the presence of subcutaneous emphysema.4
Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is sub-divided into primary and secondary. The severity of pneumothorax could be varied from asymptomatic to hemodynamically compromised. Optimal management of this benign disease has been a matter of debate. In addition to evacuating air from the pleural space by simple aspiration or chest tube drainage, the management of spontaneous pneumothorax also focused on ceasing air leakage and preventing recurrences by surgical intervention or chemical pleurodesis. Chemical pleurodesis is a procedure to achieve symphysis between the two layers of pleura by sclerosing agents. In the current practice guidelines, chemical pleurodesis is reserved for patients unable or unwilling to receive surgery. Recent researches have found that chemical pleurodesis is also safe and effective in preventing pneumothorax recurrence in patients with the first episode of spontaneous pneumothorax or after thoracoscopic surgery and treating persistent air leakage after thoracoscopic surgery. In this article we aimed at exploring the role of chemical pleurodesis for spontaneous pneumothorax, including ceasing air leakage and preventing recurrence. The indications, choice of sclerosants, safety, effects, and possible side effects or complications of chemical pleurodesis are also reviewed here.
Pneumothorax in the critically ill patient
2012, Chest
Citation Excerpt :
The technology is particularly useful in patients with significant underlying lung disease, which may obscure chest radiographic findings. Specifically, CT scanning is an excellent tool to differentiate bullous lung disease from pneumothorax, which may help avoid unnecessary drainage attempts that may result in the creation of a parenchymal-pleural fistula.35 Pneumothorax size can best be calculated with CT imaging.
Pneumothorax in critically ill patients remains a common problem in the ICU, occurring in 4% to 15% of patients. Pneumothorax should be considered a medical emergency and requires a high index of suspicion, prompt recognition, and intervention. The diagnosis of pneumothorax in the critically ill patient can be made by physical examination findings or radiographic studies including chest radiographs, ultrasonography, or CT scanning. Ultrasonography is emerging as the diagnostic procedure of choice for the diagnosis and management guidance and management of pneumothoraces, if expertise is available. Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy. If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed. With widespread use of CT scanning, there have been more occult pneumothoraces diagnosed, and the most recent literature suggests that drainage is preferred. In patients with a persistent air leak or failure of the lung to expand, current guidelines suggest that an early thoracic surgical consultation be requested within 3 to 5 days.
Pneumothorax and Barotrauma
2008, Critical Care Medicine: Principles of Diagnosis and Management in the Adult
Chest Radiography
2007, Cardiothoracic Critical Care

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: revision accepted November 15.

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Chest

Special Reports: ArticlesRole of CT in the Management of Pneumothorax in Patients with Complex Cystic Lung Disease

Section snippets

Case 1

Discussion

Clin Radiol

Chest

Am J Surg

Plain and computed radiography for detecting experimentally induced pneumothorax in cadavers

Radiology

Value of computed tomography in the detection of bullae and blebs in patients with primary spontaneous pneumothorax

Respiration

Special Reports: Articles
Role of CT in the Management of Pneumothorax in Patients with Complex Cystic Lung Disease