Table-3: Complications in relation to
etiology of pneumothorax
|
Cause |
Complications/Surgical Treatment |
|
Pul –Tuberculosis (n=53) |
Infection of Tube site –1 Peritubular leak –2 Surgical Emphysema – 10 Tube Dislodged – 1 Decortications – 6 Plenrodesis – 1 Broncho Pleural fistula – 1 Died –6 |
|
PSP (n=29) |
Surgical
emphysema – 3 Decortications – 1 Pleurodesis – 3 Died – 1 Tube site infection – 2 Brancho Pleural fistula - 1 |
|
Infection (n=24) |
Decortications
– 5 Surgical emphysema – 5 Peritubular leak – 1 Died – tension pneumothorax
– 1 Brancho Pleural fistula - 1 |
|
COPD (n=12) |
Surgical
emphysema – 6 Died – 1 Necrosis of stitches &
Peritubular leak – 2 |
|
Iatrogenic
(n=12) |
Surgical
emphysema – 2 |
|
Trauma/
Bullet Injury (n=6) |
Surgical
emphysema – 1 |
|
ILD (n=3) |
Broncho
Pleural fistula – 1 Refer
for surgical treatment Died
– 1 |
|
Asthma
(n=4) |
Tube
site infection + leak –1 Peritubular
leak – 1 |
|
Bronchiectasis
(n=2) |
Surgical
emphysema – 1 |
|
Tuberous Sclerosis (n=1) |
Nil |
PSP – Primary spontaneous pneumothorax COPD- chronic
obstructive pulmonary disease ILD –
Interstitial lung disease
Fig-1: Percentage of smoker
in different disease entities
DISCUSSION
Pneumothorax
is classified into spontaneous occurring without a preceding event, traumatic
due to direct or indirect trauma and iatrogenic, categorized by some
investigators as a subdivision of traumatic pneumothorax.3
Spontaneous pneumothorax is further subdivided into primary spontaneous
pneumothorax and secondary pneumothorax.
Pneumothorax in apparently healthy individuals is a
relatively common disease, particularly in those in their second and third
decades of life.4 Spontaneous pneumothorax is primarily a disease of young people and is
predominant in males.5 Our study also showed that pneumothorax is
common in young people and particularly in second and third decade of life.
Primary spontaneous pneumothorax is usually caused by
the rupture of the subpleural bleb. They are usually multiple and mostly occur
at lung apices.6 According to this study Primary Spontaneous
pneumothorax (PSP) occured in 29 (1.86%) cases. So it can be concluded by this
study that PSP is not the commonest cause of pneumothorax in our country. It is
occurring more in males as we see in this study with tall and thin bodies.7-8
Secondary spontaneous pneumothorax is caused by an
underlying lung disease. The disease that is associated the most with secondary
spontaneous pneumothorax is chronic obstructive pulmonary disease (COPD).9
COPD patients tend to be middle aged or elderly while emphysema is the
commonest cause of pneumothorax above the age of 40.10 This study
shows that COPD is responsible for 8.22% of the total cases. All the patients
were above the age of 40, showing that they were middle age or elderly. Almost
all of them were smokers except one who was a female. It is well established
that smoking increases the risk of contracting first pneumothorax.11 In
this study 28% of our patients were smokers. Whereas 91% of COPD patients were
smokers.. Therefore, smoking could be implicated clearly in the development of
initial pneumothorax mainly in COPD patients. Secondary spontaneous pneumo-thorax
(SSP)is an important complication of pulmon-ary tuberculosis that demands
appropriate manage-ment. Tuberculous lung cavities or blebs rupturing in to
pleural space cause pneumothorax. However, most of the time mechanism of SSP in
pulmonary TB is unclear.12,13 Our study shows that Pulmonary Tuber-culosis
is the leading cause of pneumothorax in 36.30% cases. According to Ferraro and
associates14 PSP represents 80% and SSP represents only 20% of
spontaneous pneumothorax. The data of Light5 point to a nearly equal
frequency of PSP and SSP while our study shows that SSP is responsible for more
than 67.80% cases and the major cause of SSP is pulmonary TB. The treatment
options available for spontaneous pneumothorax are observation, supple-mentary
oxygen, simple aspira-tion, tube thoracos-tomy, tube thoracostomy with
instillation of sclero-sant, thoracoscopy, and open thoractomy.15 In
our setup intercostal tube drainage is the mainstay of treatment as majority of
patients present to us in advanced stages of disease. In PSP the resolution
time was within 3 weeks time in 60% of cases. In Pulmonary Tuberculosis (PTB)
some patients took longer time to respond even more than 5 weeks due to under
lying parenchymal lung disease. In some patients the lung does not expand fully
after the chest tube is inserted. The usual reason that the lung does not
expand is that there is a persistent air leak. In PTB patients about 7% were
subjected to surgical intervention i.e. decortications (thoracotomy) while in
PSP only 2 had thoracotomy. Six patients having SSP with infection had
thoracotomy. Six patients having PTB died. The recurrence rate could not be
analyzed because most of the patients did not turn up for follow up. This study
indicates that most of the patients had resolution of pneumothorax within 2-3
weeks of chest intubation. It can be concluded that if the pneumothorax does
not resolve within this period, then surgical intervention is advisable as also
recommended by Javed et al.16
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