What are the causes of pneumothorax ?

1. Primary pneumothorax – the lungs are essentially normal but there are some weak areas which are called blebs or bullae. They break open like a ruptured blister and causes air to leak.
2. Secondary pneumothorax- in this condition there is usually some underlying lung condition that leads to tear in the surface of lung causing pneumothorax

Other causes for pneumothorax are post trauma/accident, post lung biopsy and women with endometriosis.

How is the pneumothorax treated ?

1. Observation – not all pneumothorax requires surgical treatment. Small and asymptomatic pneumothorax can be treated with observation. It may require serial x rays.
2. Insertion of chest drain – In patients who are symptomatic or a total collapse of lungs the air from the chest cavity is drained with needle aspiration or insertion of soft rubber chest drain to evacuate air
3. Surgery – It is done for patients who have more than one episodes of pneumothorax or have high likely hood of recurrent pneumothorax. It is also done for patients who continues to leak air as seen by bubbles leak out of chest drains. The other reasons for offering surgery depends on patient factors like previous life threatening episode, patients leaving away from metropolitan areas, pilots or high risk professionals.

What is the surgery for Pneumothorax ?

Surgery for pneumothorax is known as pleurodesis.

The purpose of pleurodesis is to create adhesions between chest wall and lungs. Therefore if patient develops futures episodes of pneumothorax lung collapse can be minimised. Most surgeons also try to identify area of lung with weakness/bleb/bullae and remove it with surgical staples to minimise future recurrence.

What does the surgery for pleurodesis involve?

Surgery is done with minimally invasive approach utilizing key holes and telescope assistance which is known as Video Assisted Thoracoscopic Surgery(VATS). The other approach involves thoracotomy which has some disadvantages compared to VATS( hyper link to difference between VATS and Thoracotomy approach)

VATS pleurodesis is done under general anaethesia meaning that patient is fully asleep and does not feel any pain/sensation nor aware of operation. Anaesthetist uses specialised technique that allows for patients to breath via lung that is not being operated upon. Urinary catheterization is not generally used. However, if patients fails to pass urine after surgery then catheterization may necessary.

Duration of surgery is generally less 30 mins for surgical part. Time for delivery of anaesthesia and preparation for surgery adds another 40 mins prior to surgery. Patients are woken up straight after completion of surgery. There is a drain inserted on the side of operation. The purpose of drain is to remove any fluid or blood that may have connected during surgery and also to remove any fluid or air after surgery.

Surgery involves 2 x 1 cm incisions and third 3 cm incision on the chest wall. After introducing telescope Dr Joshi will inspect lungs and chest wall. After identification of weakened area of lung, he removes with surgical staples. Surgeons use surgical stapler to divide lobe from rest of the lungs. The stapler uses 3 rows fine titanium staples to seal the division of lungs. Following this pleurodesis is achieved with spraying medical talk or removing inner membrane( Parietal pleura) of chest wall which known as pleurectomy. The purpose of this is to cause inflammation which assists in creating adhesions between chest wall and lung to prevent future collapse.

When patients starts to breath from the side of operated lungs, he/she starts to breath air on that side. Some of the air can leak from the holes created by raw of staples. Majority of them seal straight away but sometimes it can take longer for the tiny holes to seal. If this air is not evacuated by placement of drain then the air accumulates in the chest and collapsed the lung. So, one of the most important purpose of drain is to remove air that my leak from the staples hole after lung resection surgery. Most surgeons will remove drains in 6-24 hrs after air leak has stopped.

Hospital stay post VAT pleurodesis

After surgery the patient stays in recovery room until anaesthetic wears off. After that patient is shifted to ward. Typically, the stay after surgery is expected to be between 2-4 days. It takes about 2-3 weeks to become independent and get back to work. You should not drive for 2 weeks.

During your ward stay

For First two days, the most important thing that patients have to deal with is pain from the operation and drains. Pain control methods includes oral tablets, intravenous infusions and infusions around spinal cord. Depending on the patients background history the anaesthetist decides the pain control method. Some of the methods include patient initiated analgesia regimen which may include infusion that patient can control or on demand tablets for pain control.

Figure : Patient controlled analgesia infusion system

While recuperating in ward patients are visited by physiotherapist. The patients are encouraged to participate in regular physiotherapy and mobilization. Apart from drains, patient is connected with infusion system to control pain. It is quite cumbersome to move in and out of bed while drains and infusions are connected. Nursing staff will provide you with assistance. The patient can also call for the staff if they want to move out of bed. Accidental disconnection of drain system or infusion can cause complications and its better avoided.

Your drain site has dressing on it. Occasionally it can stain with blood-stained fluid. You need to inform your staff. This is due to fluid collected in chest leaking around the drainage pipe. To experience this is uncomfortable but this is not a complication. Nurses may need change dressing frequently and will discuss with Dr Joshi. Dr Joshi will advise further course of action.

Dr Joshi will visit you on alternate days and his practice nurse will also visit you while you are in ward. The staff stays in regular communication with Dr Joshi about your progress. Your recuperation plan is guided by Dr Joshi. He will discuss with you regarding your discharge plan. Prior to you being discharged you will be given discharge instruction that includes

• Discharge letter
• Instruction for removal of sutures and dressings
• Advise regarding care of wounds and how to seek medical attention or advise in case of any potential complications.
• Advise regarding making appointment with Dr Joshi, your referring specialist and GP

Complications

It is not uncommon to cough blood-stained phlegm for few days after surgery. It is due to surgical handling of airways or lungs during surgery. You should inform your surgeon but generally it subsides on its own.

You may experience fever in first 48 hours and your blood counts are expected to rise. This is not a sign of infection. However, if fever persists then some additional tests may be carried out and treatment will be commenced if infection is suspected.

Nausea, vomiting and constipation are common side effects of pain medications and anaesthetic medications. Your staff will titrate the dose of pain medications for you to get optimum pain relief and to minimize side effects of pain medications. Pain does not completely disappear but the goal is to keep pain within the limit of tolerance and allowing for carrying out exercise and physiotherapy.

Infection of wounds, chest cavity and airway stump( divided end of airway) can occur however, very uncommon unless specific risk factors are present in patient (e.g. Patients on steroids, immunosuppressants, Diabetes, advanced cancer etc. )

Life threatening complications are very rare but worth noting. Heart attack can occur in patients with risk factors. Major bleeding is very unlikely in this operation. Patients are at risk of developing blood clots in the legs which has a risk of migrating to heart. Patients are given injections of weak blood thinner to prevent the occurrence of clots in legs.

One of the important long term side effects to note is nerve pain. With VATS surgery, the incidence of nerve pain is less likely however can occur. Nerves underneath each ribs are sensitive and delicate and can occasionally damaged while removing lung specimen. This will manifest as numbness over the front of chest or breast. Women may feel heaviness in breast. This side effects is likely to improve over period of time. Some patients may require pain killers.

Follow up after VATS Pleurodesis

You will be advised at the time of discharge for follow up. It is not always necessary to follow up with Dr Joshi in his rooms. However, if you wish to see him please notify the ward staff to book an appointment at the time of discharge or call his rooms. If you arrange to visit Dr joshi’s rooms then you will need chest x ray 1 week prior.

You should visit your GP after your discharge from hospital. You will be discharged with drain sutures which will need to be removed at GP practice after 5-7days. You should arrange a review with your referring specialist.

If Dr Joshi has removed the weak portion of lung, it is sent to Pathology lab for examination. The results will be sent to your referring doctors.

Life after VATS lobectomy

One of the common worry most patients have is whether they will be able to breath normally and get back to their normal life. In this surgery the portion of lung that is removed is very small and unlikely to affect your breathing. Patients who have borderline lung function test are likely to experience breathing problems long term but Dr Joshi will discuss this with you prior.

Most patients are able to resume their normal life, activity and exercises after about 4 weeks. Your exercise capacity will continue to improve with time. There are restrictions on some activity after pleurodesis and you should discuss this with your specialist. If you are deep sea diver, then you need to consult respiratory specialist for fitness especially if you had VATS pleurodesis instead of thoracotomy( recurrence rate of pneumothorax are slightly higher – upto 10%). For professional pilots and long distance train drivers should also discuss with there specialist about their fitness to return back to profession.