Pneumothorax: drainage, surgery and healing process

If the lungs don’t heal or if a person has recurrent pneumothorax, surgery can help prevent further complications.

If the cause is a lung injury, it is necessary to proceed quickly.

Drainage of the pneumothorax

Drainage of the pneumothorax with a trocar (medical aid for the introduction of instruments)
The required materials, which can be seen in the figure, from right to left:

• Atropine injections: to be used in bradycardia by activating the vagus reflex during surgical intervention,
• Shear
• Scalpels
• Clamp.

Placement of thoracic drainage

The installation is carried out under local anesthesia via the intercostal space.

There are 3 possible access routes where an incision can occur:

1) Anterior – the surgeon makes an incision in the middle clavicular line (imaginary line perpendicular to the collarbone, starting from the center of the bone) and the second intercostal space, at the same level of the Angulus Ludovici.

The middle clavicular is located 4 cm from the sternum, so there is no risk of severing the internal mammary artery, which is 1.5 cm from the sternum.
This involves cutting into the large pectoral muscle, which is used with every arm movement, which is why the patient will have severe pain.

2) Lateral – in the middle axillary line, at the level of the III or IV intercostal space. The muscles located on the side of the thorax are:

• anterior sawtooth muscle (in which the fibers are separated),
• the deeper internal and external intercostal muscles.

On this lateral access path, the anterior sawtooth muscles are separated from each other, only the intercostal muscle undergoes an incision: the patient tolerates the pain much better than with an incision in the anterior thoracic wall.

3) Posterior – at the level of the scapula angle: is poorly tolerated and occurs only in rare cases, when it is absolutely unavoidable.

Drainage technology

• A sterile covered bed is prepared.
• The point at which the drainage is applied is determined.
• An anesthetic is injected up to the pleura.
• Under aspiration, one penetrates into the pleural space, which becomes apparent when air enters the syringe.
• Sufficient anesthetic must be injected into the pleural area to prevent the triggering of a vagus reflex with the risk of bradycardia.
• This is where the incision is made with a scalpel and the preparation of a tobacco pouch seam (a seam in which the stitches are applied in a circle, as for closing a tobacco pouch). One enters at one cut edge and exits again at the other, then is closed with a loop.
• In this area of the circle, drainage is introduced.

After opening the skin with a clamp, the muscle fibers of the anterior sawtooth muscle are separated from each other until you get to the rib.

e is introduced up to its final position.
Then everything is sewn.

Then drainage is introduced through the intercostal muscle.

If the drainage reaches the pleura, the trocar is pulled and the drainage

Drainage can also be laid during pregnancy.

Collection systems with one-way water valve

The drainage systems are connected to a unidirectional and irreversible water valve. This is used to drain the pleural cavity into a water container to create a negative pressure inside.

The air can only escape.
The drainage allows the air to escape while the injury scarred on the chest.
The restoration of pleural pressure and the development of the lungs is manifested in the following way:

1. There are no more blisters in the water-filled container into which the drained material passes, even if the patient coughs. However, this is not sufficient in certain cases.
2. You have to evaluate the deflection of the mirror in the tube (i.e. the rise of the water in the outer part of the tube).
3. The height of the mirror increases with the decrease in pressure in the pleural space.
4. The mirror shifts as the pressure in the pleura changes during breathing, and the doctor evaluates the rash of the small column to follow the healing process of the pneumothorax.
5. Sometimes you see blisters and the disc shows no visible movement, but the doctor can still determine whether the lungs are functioning by auscultation of the thoracic side.

Duration and removal of thoracic drainage

80% of pneumothorax cases heal through drainage.
The criteria for removing drainage are:

• No more air escapes from the drainage.
• The lung tissue is completely and continuously in contact with the thoracic wall.

Procedure for “safe” drainage removal:

1) X-ray as soon as no more air escapes.
2) Disconnecting the drainage (the drainage is disconnected to prevent air from escaping from the pleural space).
3) Repeated X-ray after the tube has been closed for at least 12 hours.
4) Removal of drainage (if the lungs are in contact with the thoracic wall and no air escapes after the tube is opened).

A few hours after the closure of the drainage, another X-ray check is performed. If this is negative, the patient is considered cured.

Surgical intervention for pneumothorax

The doctor may advise pleurodesis in laparoscopy. This is the artificial union of the two pleural sheets to prevent lung collapse in the future.

This operation can be performed:

• chemical
• mechanical (pleural abrasion).

Indications

1. The 20% of patients who have experienced a recurrence after drainage. With scarring adhesions between the two pleural sheets, the pneumothorax can recur with each rupture of a bladder (air bubble).
2. Pneumothorax that has been drained for more than 5 days.
3. Bilateral pneumothorax and bilateral synchronous pneumothorax: very rare. Already in the first bilateral episode of a pneumothorax, the right lung is operated on, as it has a larger volume and represents 60% of the respiratory surface. In the event of a recurrence, surgery is also performed on the left side.
4. In some cases, the pulmonologist advises patients to have surgery if many air bubbles can be seen on both sides in the CT.

Surgical pleural abrasion

Performed under general anesthesia.

The patient is laid on his side and the operation is performed in two stages of video-assisted thoracoscopy.
The access routes used for the procedure are the same as for drainage and are required to insert the video camera and surgical instruments into the chest.
With pneumothorax, 2 openings may be sufficient:

• one for the telephoto camera,
• one for staples and scalpels.

The two moments in which the procedure is performed are:

1. Treatment of sub-pleural blisters.
2. The blisters are air-filled whitish formations, the pleura is thickened.
3. The surgeon cuts them in and then sutures this structure.
4. The blisters are removed using a staple suture device (a surgical gripper). If no blisters are found, there is an indication to excise the dystrophic (degenerate) area.
5. In a second moment, surgical pleural abrasion occurs: practically a scraping of the parietal pleura takes place here. The result is a loss of gloss, the parietal pleura also becomes wrinkled or rough. This condition favors adherence with the visceral pleura.
6. The two pleural sheets stick together and the lungs can no longer collapse because no more air can enter the pleural cavity.
7. However, the problem can recur in less than 3 percent of cases, especially pneumothorax that is very localized to a small area.
8. This surgery can be performed on all chest walls except the diaphragm to prevent damage to the diaphragm. Even after surgery, there is a possibility of recurrence, the characteristics of a postoperative recurrence are:
9. Apical pneumothorax
10. No complete collapse of the lungs
11. Here, only drainage under bed rest of the patient is required

Complications of pleural abrasion:

• bleeding,
• infections,
• Chest pain.

Convalescence:

• Duration of drainage: 1-2 days
• Duration of postoperative course: 2-3 days

Chemical pleurodesis with talc

Talc is a mineral used in the second half of surgery to increase adhesion between the two pleural sheets.
Pleurodesis with talc is a treatment that causes the adhesion of the two pleural sheets (parietal and visceral) through a typical inflammatory and granulomatous reaction.
The process is similar to pleural abrasion, but instead of the mechanical roughening of the pleura, a chemical substance is introduced.

According to some authors, this procedure is especially dangerous for young people (17-20 years), since they then have a mineral in their pleural cavity for at least 60 years.
There is no scientific evidence, but it is believed to be carcinogenic like asbestos, which can cause mesothelioma.

Secondary pneumothorax (for example, in COPD, emphysema and bullous dystrophy)
In this case, there is a constant escape of air or incomplete reexpansion of the lungs.
The procedure is indicated only if the patient:

1. is able to tolerate the operation,
2. is not in the final stage.

The recovery time is longer than with spontaneous pneumothorax.

Pulmonary tip resection or apical pleurectomy

The surgeon’s preferred procedure is drainage, but pulmonary tip resection may be indicated for:

• pneumothoracic recurrence,
• recurrence in the other lung,
• bilateral pneumothorax,
• Bullous emphysema,
• Lack of lung expansion after pneumothorax.

The procedure is performed by thoracoscopy with three incisions.

Procedure:

1. It is necessary to determine the area to be removed, there are scars or blisters under the pleura.
2. The surgeon inserts the mechanical staple device at the level of the relevant pleural area.
3. With the staple device, the surgeon cuts off the tip of the lung.
4. The lung tissue is taken out.

In a second moment, apical pleurectomy occurs.

1. The pleura is grasped and the thoracic fascia is severed.
2. Then it is completely removed.

Surgical removal of the tip of the lung eliminates the cause, and therefore the possibility of recurrence.

Postoperative convalescence and recovery time after pulmonary tip resection

• It takes 2-3 weeks to return to everyday activities, but you should wait 3 months to do sports again.
• Postoperative pain and swelling in the wound area gradually subside and usually disappear within 2-3 months.
• You may feel increased sensitivity in the operated area or tingling for a few months because some nerves were stretched during the procedure.
• Mild fever (about 37.2°C) is normal in the evening for a few weeks, it is a reaction of the organism to favor healing.
• Breathing exercises and gradual habituation to physical activity are crucial to speed up the return to everyday life.

Pneumothorax in newborns

In newborns, cracks in the alveoli and lung ulcers can cause pneumothorax.

After birth, spontaneous pneumothorax (1% of births) may occur due to increased pressure in the lungs that builds up at the first breaths.
Other common causes of pneumothorax in newborns include:

• meconium aspiration syndrome,
• Respiratory distress syndrome (IBS).

The risk is greater for:

• premature infants,
• Children with lung disease.

Premature babies have a very weak respiratory system that is not yet fully developed.

For this reason, the newborn’s breathing is supported by a machine that pumps the air into the newborn’s lungs.
The ventilation pressure of the machine and the vulnerability of the respiratory organs can lead to tears in the alveoli.

Treatment of pneumothorax in newborns

With spontaneous pneumothorax, the newborn’s lungs can heal spontaneously without treatment.
In other cases, surgeons must use a cannula to suck the trapped air out of the pleural cavity (drainage), otherwise the child may suffocate.

Prognosis of pneumothorax

In most cases, the trapped air can be easily removed, but there is a 50% chance that air will accumulate again.

People with a clinical history of lung disease should seek appropriate treatment and consult the physician to prevent pneumothorax.

Prevention of repeated pneumothorax consists in refraining from smoking, because smoking cigarettes or cannabis aggravates the general condition of the patient.

• Spontaneous or trauma pneumothorax: symptoms and causes
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