All right, good morning, everyone. It's around 8.29, we'd like to start on time. And first of all, thank you for joining us this morning. And welcome to Hawaii. Aloha. So, this session, as you have seen, is Pneumothorax, updates on incidents and management and treatment options. We have four speakers with us. My name is George Hing, I'm the chair of the session. And we're gonna hold the questions to the end of the session. And we do have a slight alteration in the schedule. So we are gonna look at the primary spontaneous pneumothoraces first, and then subsequently the second spontaneous pneumothoraces. And then Dr. Patel will actually present the management in special populations. And then finally, we'll talk about interventions and strategy for success. Okay, the last two sessions are switched, the last two talks. So, remember, the old sessions can be evaluated through your mobile app. So don't forget to evaluate the session. And also the faculties who are on the session. It's extremely important for CHESS and for us to actually know how the session are run. So please do take time to review the session. The presenter are required to verbally disclose any or all financial relationships during the presentation. And also all rights are reserved to the visual and audio content presented during the meeting. Our exclusive property of CHESS, no personal recording of the content is allowed. And please assist the CHESS staff to keep the aisles clear and exit clear. Silence all cell phones, please, at this moment, and your pager, if possible. Please make room for attendees to have a seat by moving forward to the center of the rows. And leaving empty seats in the aisle for the latecomers. And the CME Claiming will open on Wednesday, October 11th at noon, okay? All right, so, without further ado, I'd like to introduce our first speaker. Ladies and gentlemen, it's my pleasure to introduce Dr. Gary Lee, Professor Lee, a world-renowned leader in translational plural research. He's the founder of UWA's groundbreaking plural program, authored over 330 influential publications. Dr. Lee has transformed our understanding of plural disease. His commitment and innovation have not only challenged the traditional practices in plural management, but also set new global standard in plural medicine. It's such a pleasure to have you here. Please give us a warm welcome. Right, good morning, and thank you for the opportunity to come and talk about pneumophorex. My job today is to focus on primary spontaneous pneumophorex. This is my disclosure slide. And the learning objective is primarily to use these 12 minutes to convince you that conservative management of large primary spontaneous pneumophorex is feasible, the rationale, the data of support, and how you apply it to your everyday practice. Most of the literature on pneumophorex management focus on what size of drainage device to use, large bore drains, small bore tubes, needle aspiration. But perhaps the most fundamental question we should ask ourselves is, does primary spontaneous pneumophorex need to be drained? And that was the purpose of the New England Journal published trial, the primary spontaneous pneumophorex, or PSP trial. Conservative management, which is not draining it at all, for spontaneous pneumophorex is not a new concept. Back in the 1960s, there were several papers. The most cited is this one from Professor Strattling in London that shows that it is feasible. So what does that mean? If you think about pneumophorex as a hole in the balloon, what we want to do is to heal the hole. And to do that, we need to bring the edges of the hole closest to each other. But what are we doing nowadays in clinical practice? We want to treat the chest X-ray to make the X-ray looks better. To make the X-ray looks better, you need to put a tube in, expand the lung. And when you expand the lung, what you're doing is pulling the edges of the hole furthest apart. And God forbid, you can start suction and the constant bubbling of air through a pulled open hole. It is actually a miracle that any of these pneumophorex actually healed. So what is the alternative? The alternative is to allow the lung to stay down so that the edges of the hole come closest to each other. And it might just theoretically facilitate better and faster healing. So the PSP trial across 39 hospital in Australia and New Zealand is a non-inferiority trial for 316 adults patient with moderate to large pneumophorex, at least one third of the hemiphorex. So they're not small. They're randomized to either conservative of interventional arm. Everyone has analgesia, oxygen if required, which is uncommon. In the interventional arm, everyone has a saldinger drain. If there's no bubbling and the lung expanded in one hour, the drain is kept off. The chest X-ray repeated at four hours. If the lungs stay expanded, patient is discharged. If not, then the drain is connected to underwater sealed and the patient admitted under usual practice. In the conservative arm, the patient are observed and they're kept in the hospital for four hours for a repeat X-ray. If they're clinically and radiologically stable and importantly, walking freely around the emergency department, they can be discharged. If they're unstable, they will be admitted and for usual care. Unstable is defined if they're hypotensive, tachycardic, tachypneic hypoxic or the chest X-ray shows enlarging pneumophorex or they cannot walk around the emergency department. Perhaps the most important number you need to remember out of all my slides is this none. That if you use conservative management, 85% of the patients end up never requiring any drainage and it was successfully managed as such. But if you want to stick with the primary outcome, then it is non-inferior for conservative management compared with drainage in terms of full lung re-expansion on X-ray by eight weeks. There was no difference in time to symptom recovery which is when the patient has no pain or no requiring any analgesia. But if you look at all the other secondary outcomes, they were overwhelmingly in favor of conservative management. If you drained pneumophorex, the patient end up spending more days in hospital, 3.8 versus 0.2, more days of work, six versus three, 5.5 times more likely to still have a persistent air leak by day three, four times more likely to require surgery and three times more likely to have serious adverse events. Interestingly, if you look at the recurrence rate within the first 12 months, 17% in the interventional arm versus 9% in the conservative arm. So draining the pneumophorex may even increase the risk of recurrence. This was the first patient with complete pneumophorex that we managed in a conservative way. This is quite a few years ago now. First 21-year-old university student, first episode of spontaneous pneumophorex, no risk factors. He presented mainly with pain which settled with analgesics. He was not breathless. He was kept in the emergency department for four hours and the repeat x-ray shows absolutely no change. So I did what I usually do for these kind of situation. I asked the patient to jump out of bed, walk around the emergency department while I took history, showing that he can walk around, keep pace with me and establish that he lives near enough to any hospitals which is important in the geographic situations in Australia. He has good understanding of the problem and we discussed all the option and he was happy to be discharged without any intervention. This is the x-ray at day one, day four, day 10, day 28 and as far as I know, he never had a recurrence. If you ask your patients with PSP, what do they want? They will probably tell you that they don't want procedures and pain. Young people in particular avoids pain, avoids recurrence. They don't want to have it again. They want to go back to work, go back to school as soon as possible. No one has ever wanted me to make the x-ray better so the doctors feel more reassured although that is how we practice. So what are your options when PSP? Conservative care, needle aspiration, ambulatory van, chest tube drainage or surgery. So if you use conservative management as the first procedure no patient had any procedures but any other alternatives the patient already has to suffer one procedure. 15% of the conservative care will end up with a chest strain, we accept that but so does 20 something percent of most of the other alternative treatments. So if you have 100 patients with pneumothorax and you treat them with conservative care you end up doing about 15 procedures for the whole cohort but 120 something procedures if you do other measurements, treatments. The chance of recurrence was lowest with either surgery or conservative care but about 20 something percent for other modalities. Risk of complication was lowest with conservative care and surgery. Initial hospital days was lowest with ambulatory van and conservative care as you would expect. So treat the patient, don't treat the x-ray but we do understand that physicians typically struggle with change especially if we are suggesting that you should do the exact opposite of what you were taught. So many people have raised concerns, people would say patients in the trial must be the rare asymptomatic ones but they are not asymptomatic because they are asymptomatic enough to go and line up in the emergency department and wait for hours. They must have small pneumothorax and that's not true. The median size of the cohort was 64% of the pneumothorax of the hemiphorax which is by the Collins method so this will be a typical example of someone with a 64% hemiphorax pneumothorax. So we've been using conservative management for whatever size of the pneumothorax and this is one of the complete pneumothorax patients that we have managed successfully with conservative management and he seems to become a strong advocate on the online community of patients and I asked him what does he wants me to tell the physicians around the world. He said tell them that every person I've spoken to with a pneumothorax has some form of intervention like a chest tube or vax. It's scary and a lot of them still talk about ongoing health complaints and medical anxiety but in place of drainage I had a period of being slightly out of breath. I felt safe the entire time but was extremely grateful to have conservative treatment over an immediate fix. Some people would argue that the patient is symptomatic. How can you not do anything? Let me urge you to look at the patients or ask them more carefully next time you see someone with primary spontaneous pneumothorax. The presenting complaint is almost always pain and pain is analgesia, not a chest strain and pneumothorax by definition occurs in people with normal lungs. These are young people who have adequate reserve even if you want to do a lobectomy or pneumonectomy so breathlessness cannot be a predominant feature for these patients and they typically walk into the emergency department not coming in ambulance or wheelchairs and we do usually walk them around the emergency department and the ones that I fail to walk them around the emergency department, every time I scan them on CT scan they have underlying lung diseases. Not draining a pneumothorax is unsafe. That's a cowboy approach. Well, we didn't ask you to just send them all home. We do have safety criteria as we stated before and I think importantly the data at the moment only applies to primary spontaneous pneumothorax. There are going to be studies in England to extend them to secondary and traumatic pneumothorax but I urge you to use caution before we extend that to those other populations. Radiologists said it is tension. Well, tension pneumothorax is actually defined by hemodynamic instability not mediastinal shift so unless the radiologists come and measure the blood pressure or pulse rate of the patient they have no rights to call it tension pneumothorax. You need to educate them and tell them that only one in 10 patient with mediastinal shift actually have hemodynamic compromise. This is another patient that we have recently treated with significant pneumothorax and also some mediastinal shifted contralateral side. I have no difficulties convincing him not to have a chest tube. I have a lot of difficulty convincing my fellow not to put a chest strain in him. And what this patient wants to tell you, he said tell the audience a clear explanation of what was happening helped put my mind at ease explaining the anatomy and what the pneumothorax make me is, make me understand what conservative approach is about and that is sensible. I felt comfortable and was glad that I was given that choice. So in the year 2023 when you want to drain a primary spontaneous pneumothorax you need to inform your patient of the usual risks that you would always do for any approval procedures but you would need to tell them that by putting a chest strain you are putting them at a higher risk of having persistent air leak and requiring surgery. They're needing to go and stay more times in hospital and delay their return to work and school and have a slightly higher recurrence risk in the next 12 months. So that would be your informed consent if you want to drain someone in primary spontaneous pneumothorax in 2023. Thank you. All right, it's my pleasure to introduce our next speaker, Dr. Joseph Marapallali. Did I pronounce that right? I'm so sorry. A distinguished and well-regarded leader in cardiothoracic imaging at Duke Health. He serves as a director of thoracic interventions. He completed his fellowship at Duke University and holds two dual degrees, MD PhD, MD from Texas Tech and PhD from University of Kansas. And currently he is at the forefront of research in the innovative use of Xeon MRI technique to look for lung functions and IOD. So it's a pleasure to have him here to speak to us about secondary spontaneous pneumothorax. Thank you, Dr. Chang. All right, well, I already feel vindicated as a chest radiologist, Dr. Lee, because I have never said tension pneumothorax on a radiograph. God, I was worried. Thank you, thank you. All right, so we're gonna have fun with this talk. So it's a pleasure to be here at a poem-dominated conference. Myself, Dr. Jonathan Chang, we love being here as chest imagers to talk to you about specific imaging findings that we think we love to impress on our pulmonologists, our trainees, our thoracic surgeons. So today we're gonna talk about secondary spontaneous pneumothorax. I'm gonna really make this image heavy. We're gonna talk about radiographic diagnosis and nuances. I've got no relevant disclosures for this talk. Outline for this talk, we're first gonna define what secondary spontaneous pneumothorax is. We'll talk about case-based approach to evaluating a secondary spontaneous pneumothorax. I'm gonna show you a bunch of cases that I was directly involved with, and we'll show you some mimics. I really wanna get into the mimics of a pneumothorax and potentially the things that you may see on plain film, and a couple nuances that have really helped me in my career. Okay, so secondary spontaneous pneumothorax, this is gonna be a pneumothorax that occurs in the presence of underlying lung disease. What are some of those lung diseases? Well, of course, you all know. Our patients with lots of emphysema, these are the kind of patients that may present with a secondary spontaneous pneumothorax. Those patients that may have infection, it could be chronic, including TB, and other forms of infection, those patients can develop pneumothoraces. Sarcoidosis, if you've got a patient with end-stage upper lung predominant sarcoidosis, you can really tear the parenchymal abnormalities that we do see with sarcoidosis and create a fishless connection to the pleural space. Of course, our patients with malignancy. I've had a couple that have shown up with pleural mets that all of a sudden have gotten new pneumothoraces. And of course, our patients with interstitial lung disease. That's been a lot of the patients that I've been involved with. All right, case number one is a 72-year-old male with a history of COPD and with new onset shortness of breath. All right, so this is a presentation radiograph. And man, this looks just like the case that Dr. Lee showed. And this is giving me chest pain. When Dr. Lee was showing those cases, I was having chest pain, but luckily he wasn't. But this patient showed up symptomatic and probably didn't meet the criteria that Dr. Lee was talking about. And if you look here, none of us are gonna miss this pneumothorax, right? So I really wanna impress upon you the imaging findings. I know we're like, oh, I can easily see a pneumothorax. So I'm gonna show you some cases that were difficult for myself and our residents. This is the sharp pleural nine, right? Most of the right lung is completely atelictatic. And this is a very large pneumothorax. Of course, I would never say tension physiology. And so after chest tube placement, this is the radiograph that we do see. So you've got a right-sided chest tube in place. So ask yourself, I tell my residents and fellows, anytime you're looking at an image, try to find that pneumothorax after you've placed the chest tube. Really hard here. So we're looking here at the right lung apex, looking for a pneumothorax. I'm gonna zoom in here. And if you look here, if you start here looking for a pneumothorax, I promise you it will be difficult to find a pneumothorax because you're dealing with the clavicle, you're dealing with the posterior ribs, you're dealing with the anterior ribs. So where's the pleural line? It's right there. And we're gonna show you a nice case about how I actually go and find the pleural line. But this is a status post right lung, chest tube placement with significant improvement in this right-sided pneumothorax. This is the follow-up CT that the surgeon did want because they were looking for what could be the parenchymal abnormality in this patient. We've got axial and sagittal images here. And what we can see is there are true parenchymal abnormalities, right? There's a lot of cystic or lucency within that right upper lobe. What are we dealing with here? We had a great talk yesterday on cystic lung disease. Dr. Chung showed a couple cases about this. And so ask yourself, are you dealing with cystic lung disease or are you dealing with emphysema? I think most of us would say this is pretty bad emphysema. We see a lot of central dot signs. Destroyed alveolar parenchyma with a central dot sign is a great look for significant amount of central alveolar emphysema in this patient with a right lung pneumothorax. The green arrows show you, that's where our pneumothorax is, status post chest tube. The coronal imaging, again, confirms a small apical and a basilar component. This is a great case for an underlying secondary spontaneous pneumothorax due to emphysema. Here's a companion case. I do want to kind of share some nuances when we talk about these cases in a 60-year-old male with a newly placed subcutaneous defibrillator. Okay, so subcutaneous defibrillator. Let's take a look at this post-procedure radiograph. So here's, this actually came, we do a little M&M where we talk about cases where we've seen over the past couple months. This actually came to us in our M&M radiology group last month. And we saw this and everyone was very interested and left-sided subcutaneous. You know, we're not even in the thorax. Well, there was concern from the clinical team that this patient was becoming unstable. And we actually missed the finding. So there's the subcutaneous defibrillator that had just been placed. And we missed the finding that there was a right apical pneumothorax. And so really, really subtle finding here of a right apical pneumothorax. I don't even know how this happened, but the clinical team was worried about it. Let's just leave it at that. And there was a right-sided pneumothorax, which we initially missed. They called down and we looked at it again. So I'm gonna show you my little nuance for finding a pneumothorax. And I'll tell you, the first time I was, when I was a fellow at Duke, was the first time I was reading inpatient radiographs. I had like 100. I was all excited and I was ready to staff them all out. And on that deck, I probably missed 50% of the pneumothoraces in an inpatient setting because of small apical pneumothoraces that I was just missing. So I'm gonna show you my technique to be able to do this. I'm hoping I can play this. Oh, so this is, oh, that's my kids in the background. Okay, so that is a, that's me with my iPhone showing you to find the pleural line at the base and just go all the way up to the apex. Find that pleural line, which you see right there. And I promise you, you will not miss the number of pneumothoraces I missed in my first readout. And so this is really, really important here. This is how this one was actually missed. If you just start at the apex, I promise you, you will miss small pneumothoraces. In this situation, super important, right? This is a patient that was symptomatic. This is a patient that did not have any intervention on that side that we know of, and all of a sudden now shows up with a pneumothorax. If we focus there on the right lung apex, you can also appreciate the pleural line. But I'm telling you, you guys are looking at monitors on the floors, really difficult to see unless you're in a great dark room like me. And if you don't start at that right lung base and use that technique, which has helped me tremendously, you may miss a small symptomatic pneumothorax. All right, case number two is a 39-year-old female with a history of lymphangioleumyomatosis, LAM, who doesn't love saying that. And so here's a presentation radiograph. This patient actually came to me from our surgeons who were like, hey Joe, can you take a look at this radiograph and see if you can put it in a chest tube for this patient? So this patient had LAM, and if we look here at this presentation radiograph, take a look at the right lung, and you're gonna see a sharp line there. So that's actually partial atelectasis of the right lower lobe. And if you also appreciate the right lung base, we also see a sharp pleural line as well. You can see lucency below that. So we're dealing with a right-sided pneumothorax, and that's confirmed in the lateral view as well, right? Night sharp line there in the right lower lobe. And so they asked us, hey, can you put it in a chest tube for this patient? And so this was the follow-up CT guide to chest tube that I actually did. It was amazing to me. So this patient came to me now about three hours later, and I kid you not, the entirety of the right lung was atelectatic. This patient with this history of LAM, I'm sitting there saying, are you okay? And she's like, yeah, I'm really not that symptomatic. A little shortness of breath. I decided to get a chest X-ray. Next thing I know, I was putting in a chest tube. That was one of the things that really stood out to me. A patient with parenchymal lung disease with this type of pneumothorax, and she'd had them in the past, may be relatively asymptomatic as opposed to those patients who have never had a pneumothorax. We put in a right basilar chest tube, and you can see here at the right lung base, most of that pneumothorax is resolved. There's a little bit of lucency at the right lung base. Not gonna spend too much time on LAM. We had a great discussion of it. You all know it's a low-grade destructive tumor. Essentially, we have proliferation of LAM cells in the lungs and also in the kidney. Specific findings for that as well. Almost exclusively in women, and this can be associated with a tuberous sclerosis complex. All right, so I do wanna show you this patient's baseline CT so you can appreciate the imaging findings of LAM. Dr. Chung showed a really nice case of this. I ask you when you're looking to determine, am I dealing with emphysema or cystic lung disease? I deal with this every day. What exactly am I dealing with? Find the area that you're concerned at. We're gonna pull out one cyst here, and take a look and see if you feel like there's a central dot sign or if you feel like it's displacing vessels. And in this situation, there's a tiny little vessel seen anteriorly. This is true cystic lung disease, displacing vessels. You may be the person that actually gives a patient cystic lung disease, whereas your chest radiologist or your radiologist who wasn't chest trained may have been calling it emphysema forever. So here's a baseline minute, and this is basically an image where we focus in on the low attenuation within the lung. Again, we had a bunch of images of this yesterday. But you can appreciate in this chronal image as we just sort of zero in on what's low attenuation, there are a bunch of cysts there, like truly well-defined cysts in this patient with LAM. This can be helpful for you to make that diagnosis of cystic lung disease. All right, so here's a companion case, a 67-year-old female admitted with an abdominal plane film with an inpatient radiograph. And this actually came to our M&M as well. So this was read overnight by our resident. So take a look at this image to the left. And so there was concern by this resident, and I'm just gonna show you what the concerns were. There was concern that there was a left-sided pneumothorax. So this is a patient with abdominal pain who showed up, all of a sudden shows up with this, concerned that there was a left-sided pneumothorax. And the next morning we were sort of like, hmm, we need to think about that. So we need to think, is there actually a pneumothorax? So the attending read it out in the morning, and was like, hmm, I don't think this is pneumothorax. Let's repeat this. And so this was the follow-up AM chest radiograph. And you can see there's no abnormality there, no pleural line. Difficult with plane films, right? Difficult AP imaging. Our patients are laying on the floor, we're sticking the cassette under them. What are we actually looking at? I would just get a repeat if you are concerned. We did in this situation, this ended up being a skin fold. And so skin folds are a big thing that we see in our inpatient population. This is a great reference for skin folds. This is a paper that came out of ATS in 2015. I absolutely love this paper because it has this image here, which really shows you the difference between a pneumothorax and a skin fold. And really, if you look at the image number one, the cartoon image, the big deal there is the distinction between the pleural line and that air cavity and the chest wall. You get a sharp line that you see in image number five. You get that clear distinction of a pleural line. The other thing that can help you know it's not a skin fold is the vessel stopped to that pleural line. If we look at the skin fold, I want you all, when you're worried about a skin fold or a pneumothorax, trace that line out that you're worried about. If it extends past the pleural space into the chest wall, you're probably dealing with a skin fold. We don't need to be superheroes here. If you are concerned, just get a repeat, especially if it doesn't make any sense. Great reference article here to look for skin folds. All right, case number three is a 49-year-old female with a history of connective tissue disease associated ILD. I love to talk about fibrotic lung disease. And so this is this patient's baseline imaging here. And so let's just point out the findings of fibrotic lung disease, right? Anteriorly there in the right lung, we see reticulation. What else do we see there in the lingula? We see a little bit of traction bronchiectasis, right? Fibrotic lung disease really stretching those airways out. This is 100% pulmonary fibrosis. And if you take a look at this image here in coronal imaging, a beautiful look of the straight edge sign, right? You kind of get fibrosis right at the lung bases. You feel like there's a sharp distinction that essentially separates into normal lung. A great look for straight edge sign. Oftentimes we see this in connective tissue associated ILD. This is this patient's presentation radiograph here. And I was contacted by one of our ILD docs. And so look and see, can you make the finding? And if you look there at the left lung base, there is a lot of lucency here at the left lung base. There's actually a sharp line there. And there's actually a line in the left lung apex as well, right? This person has a small left-sided pneumothorax. They were asking, hey, they're getting kind of symptomatic. Can you take a look at this? And so this was the follow-up radiograph about 48 hours later. And I think you can appreciate that that left basilar pneumothorax has increased in size. There's an apical component as well, and also a medial component if you look over the descending thoracic aorta as well. So three days after the initial presentation radiograph, you can see that pneumothorax is getting bigger as well. At this point, they wanted us to intervene. And so I put in a CT-guided chest tube for this patient. Here, really large pneumothorax. Unlike my LAM patient, this patient actually was a little bit symptomatic, and I basically had to get that chest tube in faster than I would have wanted to. This was a follow-up radiograph where we upsized that chest tube to a large bore chest tube, and there was significant improvement in the pneumothorax. Still a small left basilar pneumothorax. This patient actually went on for pleurodesis, and her pneumothorax had completely resolved. All right, case number four is a 38-year-old female with new onset shortness of breath. This is the patient's presentation radiograph. I had to find this case, and it is amazing. Okay, so if we take a look at this patient's radiograph, there's a frontal radiograph there. And so ask yourself, can you see the pneumothorax? Well, the first thing I would point out to you is there's an air fluid level there at the right lung base. Anytime I see an air fluid level on a plain film, I'm thinking this patient probably has a pneumothorax, and that physiologic fluid has just dropped to the right lung base. So that is another little nuance, another great clue to identify if you actually have a pneumothorax. Well, in addition to that, she also has got a soft tissue mass, right? Big soft tissue mass there in the right lung. What are we dealing with here? And we all can see that pleural line, right? Sharp line there, pretty large right side pneumothorax. This patient was symptomatic. We're gonna take a look at the lateral radiograph, and that's also gonna show us this air fluid level. And again, for me, that's a little nuance that, hey, am I dealing with some little subtle pneumothorax? That might be small, and that might be the only thing that tips you to really study that right lung apex and see if there actually is a pneumothorax. So this is a follow-up CT for this patient here, which confirms the findings on the plain film. Billy didn't need this. I just wanted to show it because I was so excited that I found this case in our repertoire. And so we've got a right lung lesion, a big kind of mass lycopasty there, which ultimately is probably causing a fishless connection to that pleural space and giving us this large pneumothorax there. There was also a right lobe, so that was a right upper lobe lesion. There was also a right lower lobe lesion. This is an amazing case of catamenial pneumothorax. And so this is a rare situation. Again, we don't have many of these in our system, but this can ultimately lead to a spontaneous pneumothorax, secondary to endometrial implantation into the pleura. This occurs in women, typically 72 hours after menstruation. And diagnosis and treatment is accomplished by vats. I'm looking forward to someday doing a percutaneous biopsy on one of these, but the literature tells us that diagnosis and treatment, you can do it all at once with a vats. So conclusions for this talk. I think we've talked about some of the etiologies for secondary spontaneous pneumothorax. We've defined it, and I've really tried to show you the imaging findings for being able to detect a pneumothorax. So important to make those findings. These patients can be symptomatic. Some of my residents and fellows blow that off, but I'm telling you, those little subtleties that I showed you can be really, really helpful and can make a difference in patients. Nuances and mimics, please try to use my little system where you're at the right lung base and go all the way up to the apex. Find that plural line, and it will help you when you're trying to look for new authorities. Thank you all for having me in this session. I appreciate it, hope it was helpful. Thank you, and our next speaker is Dr. Priya Patel. She's one of the rising stars in the field of interventional pulmonology. She trained at multiple institutions, Harvard University and Mayo Clinic at Rochester. And since joining Inova Healthcare System in 2020, she's been leveraging her extensive clinical expertise for advancing care for lung cancer patients and various lung conditions. So, pleasure to have you. Thank you guys for having me. Thanks, George, for that introduction. I'll be talking today about special populations. I do not have any disclosures. And the goal of my talk is to identify diseases with a propensity for higher pneumothorax recurrence rate and determining the timing of definitive treatment. So, I'd like to say, you know, what makes up these special populations? Joe went into this really nicely. Secondary spontaneous pneumothoraces or pneumothorax is typically the special populations that we're talking about. There's a few exceptions to the case. Majority of these patients typically present with their first episodes with significant symptoms and usually definitive intervention is required. The reason for this is due to a high recurrence rate of over 50% and the likelihood of a threatening event occurring on recurrence. I'd like to stop there and just mention the ACCP and BTS guidelines, the older guidelines, and then touch base a little bit on the new guidelines. They differ slightly in the definitive management with regards to the first episode versus second episode, respectively. In general, the BTS guidelines appear to take a little bit more of a conservative approach, an ambulatory approach, if possible. One thing to consider is the patient's symptoms and how they're presenting. There's a lot of patients who present asymptomatically and things can be treated on the second occurrence, but if there's significant symptoms, one can argue that the BTS guidelines can also be suggestive of definitive treatment on initial episode. So, keep that caveat in mind when I'm speaking here. A few exceptions to this population with requiring definitive intervention on initial episode are either asymptomatic patients or patients with a small pneumothorax. Definitive treatment includes VATs or medical thoracoscopy, either with chemical or surgical pleurodesis. This is highly effective. An alternative could be medical chemical pleurodesis. Malignancy, Joe also showed some nice images relating to malignancy. Primary lung malignancy is typically one that presents with pneumothorax. More commonly in terms of metastatic disease, sarcomas are very commonly known to cause cystic lung disease and present with pneumothorax. In an interesting case series of 150 patients with sarcoma, 15% of these patients actually presented with pneumothorax that subsequently led to their diagnosis. The recurrence rate in these patient populations was 46%. 10% of these patients actually had higher rates of recurrence after chemotherapy, and unfortunately, the prognosis in these patients once a pneumothorax was developed was significantly poor. 25% of these patients actually dying by 30 days. This image here is actually of a patient who presented with bilateral pneumothoraces, severe shortness of breath, and was subsequently found to have cystic lesions that were actually caused by angiosarcoma. Management in these patients is really on a case-by-case basis. Things to consider are the potential for recurrence as well as the patient's surgical candidacy. Diffuse cystic lung diseases are a common cause of spontaneous pneumothoraces. 10% of these patients present with spontaneous pneumothorax. A high-resolution CT scan can help facilitate the diagnosis of underlying disease as well as appropriate management. Diffuse cystic lung diseases with a sentinel pneumothorax, something very symptomatic, typically lead to a high rate of occurrence, especially if these are managed conservatively. Here's an image of a patient with a significant severe LAM. Pleurodesis should be considered following the initial episode in these patients, especially if they're symptomatic. Prior pleurodesis can, you know, there is thoughts that it could lead to, it's a contraindication to lung transplant, but this has actually not been found in studies, as well as the impact on mortality and length of stay has not been proven to be significantly worse. One thing that has been found is that it does increase the risk of bleeding and prolongation of operative time. Now, on that note, when discussing pleurodesis in these patients that are potential for lung transplantation in the future, a multidisciplinary discussion is highly valued with your surgeon. LAM, as Joe mentioned, young to middle-aged women, typically they present with dyspnea, and pneumothorax can sometimes be their presenting finding. These patients have multiple bilateral thin-walled cysts, typically diffusely distributed. 55 to 73% of LAM patients will have a pneumothorax in their lifetime. And pleurodesis, again, should be performed due to the high recurrence rate of anywhere from 70 to 85%. This pleurodesis does decrease the recurrence. In patients with an ipsilateral pneumothorax, 66% recurrent rates when treated conservatively versus 27 to 32% recurrent rate when treated with chemical or surgical pleurodesis. The first-line treatment in these patients is serolimus. It allows for stabilization of lung function. However, there's no impact on pneumothorax recurrence that has been found, and this does need to be studied. Pulmonary Langerhans cell histiocytosis, another rare smoking-associated disease affecting young patients. These patients have severe dyspnea, constitutional symptoms, and also pneumothorax rate of anywhere from 15 to 20%. Due to their high recurrence rate of over 60%, pleurodesis is also recommended here. This does allow for decreased recurrence, 58% recurrent ipsilateral pneumothorax in those treated conservatively versus 0% with surgical pleurodesis. Smoking cessation is first-line in these patients, and it does allow for stabilization and improvement of the disease. Unfortunately, smoking status has not been shown to affect pneumothorax rate. Burkhak-Debay, this is an autosomal-dominant and can be familial disease. It affects the chromosome coding for folliculin. This patient here, as you can see, has skin lesions, fibrofolliculomas. Oftentimes, this is the most common presentation for these patients. A CT chest is valuable in this case to notate for multiple bilateral small, thin-walled cysts, mostly in the midzones. The caveat here, diagnosis of Burkhak-Debay is important because this allows for you to plan for surveillance imaging of associated kidney lesions that could potentially be cancer. These patients also have a high recurrence rate with a patient, on average, between three to four pneumothoraces in their lifetime. The burden is dependent on the volume of cysts as well as the number that they have. Similarly, as the other diseases, this pleurodesis does decrease the pneumothorax rate by about 50%. Pleuroparenchymal abnormalities that can also lead to pneumothorax development are things like Marfan syndrome, Ehlers-Danlos. Both of them have abnormalities in elastin and collagen development. Marfan syndrome, this is a patient, you know, very thin, tall patient. These patients typically have apical pulmonary blebs, can also develop emphysematous changes as the patient noted here. Only four to 11% of these patients typically have a pneumothorax, bilateral or recurrent can occur. A bilectomy and pleurodesis are recommended. These patients are also highly encouraged to avoid contact sports, high altitude sports, scuba diving, or anything that allows for breathing against resistance. Cystic fibrosis. Three to 4% of patients in this will have an episode in their lifetime of a pneumothorax. The incidence does increase with the severity of disease as well as concomitant infection. The goal in these patients is really treating the underlying infection. If they have a large pneumothorax, chest tube drainage is recommended. Unfortunately, due to the stiff lungs, sputum retention, these patients take a lot longer to re-expand and actually heal, and the recurrence is high in this patient population. Pleurectomy, pleural abrasion, as well as pleurodesis are recommended to decrease the recurrence of pneumothorax, and if unable to surgically undergo these chemical pleurodesis is an alternative. Necrotizing lung infection. So this is an excellent image that shows direct invasion and necrosis of the lung tissue, and this is done by the bacteria or the agent of infection. Bacterial pneumonia, we've got staph, klebsiella, your routine players. These are usually unilateral and can also be associated with embyema. In the era without antiretroviral therapy, PJP used to cause significant unilateral or bilateral pneumothoraces. Now with the presence of antiretroviral therapy, the incidence has decreased to five to 10%. TB is also known to cause pneumothoraces, usually due to the rupture of a tuberculous cavity. This is more commonly seen in endemic areas. Coronavirus, don't need to mention that. I don't think too much. Treatment in these patients, typically patients with necrotizing lung infections, obviously includes treating the infection and chest tube drainage, drainage of the fluid that may be associated, but oftentimes these patients develop significantly persistent air leaks with slow and decreased expansion of the lung and poor healing. So this would definitely require, these are definitely one of those cases that require multimodal therapy and treatment, which can include an assessment with surgery. Women in pneumothoraces, so we mentioned LAM as one of the potential causes of pneumothoraces in women. Pregnancy also can contribute if a patient has underlying blebs, just the process of pregnancy with increased oxygen consumption and accelerated breathing can lead to rupture of these blebs. In these patients, if the patient is asymptomatic or if the pneumothorax is small, observation can be completed, but if there is any fetal compromise or if the patient's symptomatic, aspiration or chest tube drainage is recommended. An assessment of the underlying lung parenchyma should be done in a timely fashion, typically after delivery, and if there is underlying parenchymal lung disease, pleurodesis is recommended. Catamenial pneumothorax, this is actually one, a picture of a chocolate cyst, as they're known, of an endometrial implant on the diaphragmatic pleura. The incidence in these patients is unknown. There is a study that was looking at recurrent pneumothoraces in women who underwent surgical pleurodesis, and they found that surprisingly 25% of those patients actually had catamenial pneumothoraces. Again, they coincide with menstrual cycle anywhere from 48 to 72 hours after cycle. VATs as well as plus or minus hormonal therapy is recommended in these patients. Changing gears just slightly here, we're gonna talk briefly about persistent air leaks. So an air leak is basically continued airflow from the endobronchial tree to the pleural space. This can be an alveolar pleural leak or a bronchopleural leak. Bubbling is seen in the water seal chamber of your device, such as in this picture here. When it's persistent, it's usually something that's larger than five to seven days. Severity can be assessed with a variety of ways. One is looking at the numbered columns in the water seal chamber using the serfolio classification, which was created to be used in post-operative patients. This looks at the degree of leak as well as the phase of respiration to quantify severity. New digital chambers are actually pretty amazing to see. They're precise, they're continuous, and they're able to quantify the severity of the leak. These are, unfortunately, pretty expensive. Several randomized trials have actually shown benefit into using them. Allows for earlier removal, decreased chest tube duration, length of stay, as well as cost. The ACCP and BTS guidelines previously suggested observation period for spontaneous closure in persistent air leak management. Again, these are the older guidelines. They did suggest recommendation of a surgical evaluation at four days for pleurodesis. There was no specific recommendations made when surgery was not an option. The newer, more recent BTS guidelines actually added the recommendation of autologous blood patch pleurodesis and endobronchial therapies, but this is an ungraded recommendation. With persistent air leaks, the lack of studies, there's multiple confounding factors, and the small sample size really make drawing reliable conclusions quite challenging in this patient population. And well-done studies evaluating the effectiveness of treatment, as well as the safety and cost, are obviously difficult to perform. Just to touch base on this briefly, George will go a little bit more over it in detail, but autologous blood patch pleurodesis was first used post-operatively by Robinson in the 1980s after surgery. There are three RCTs looking at success of the persistent air leak due to spontaneous secondary pneumothorax. One study, 47 patients with ABP versus control, control being chest tube drainage. At day seven, the air leak resolved in 78% of the blood patch group versus 8% of the control. Another study looking at 150 patients with endobronchial blood patch versus control. At 14 days, the air leak resolved in 82% of the blood patch group versus 60% in control. Both studies showed a decreased hospital stay, a statistically significant decrease in hospital stay, as well as days and duration of air leak. Endobronchial valves, these are one-way valves placed with a flexible bronchoscope. They are used for a number of reasons, bronchoscopic lung volume reduction, as well as have been given FDA approval for the spiration valve system for humanitarian device exemption. These essentially limit the airflow to the distal portion of the lung, allowing the healing and resolution of the air leak. There are two major retrospective studies that looked at the benefit of endobronchial valves. Both had variety of success, but 93% success in the Travalene group looking at 40 patients, and the Gilbert group about 58 to 100%, depending on the etiology. Both studies showed improved mean time to chest tube removal, as well as discharge. The Gilbert group interestingly found that 55% actually had an air leak removal within one day. So in summary, acknowledging other causes of secondary spontaneous pneumothoraces other than COPD and pussima, presentation oftentimes leads to the diagnosis of underlying lung disease, understanding the propensity for recurrence in variety of lung diseases, and definitive management typically is on initial presentation in patients with lung disease and symptoms. Again, at the end of the day, what's most important is individualized care. All right, everyone, so now you have heard about the primary spontaneous pneumothoraces, how we diagnose secondary spontaneous pneumothoraces with radiographic findings, and also special populations. We're gonna try to put it all together in the next five to 10 minutes, and we'll also have some time for questions. So again, my name is George Chang. I'm from UCSD, I'm the medical director for interventional pulmonology there. These are my financial disclosures. And I think one of the major take-home message that we have here is the following two message. Less is more. And treat the patient, not the x-ray. Just a commentary that I generated from chat GPT, so it's pretty wild. And I think if you look back in the past five years, 2020 has been a really large year in how we're changing our approach to primary spontaneous pneumothoraces. These two landmark studies have shown us at least the initial evidence to suggest that conservative management is appropriate in certain populations, specific selected population. And now in the last year, in fact in this year's, in June of this year, this paper came out. It's examining in 31 French ED, examining simple aspiration versus drainage for a complete pneumothorax, and these are the pneumothoraces that you've seen already, completely separation of the visceral pleura from the chest wall. You see that there's the primary outcome for the studies to look at lung expansion after 24 hours. And I stress lung expansion, not patient-indicated factors, but lung expansion. And they did find, unfortunately in this case, that the treatment failure is more so in the aspirations cohort as compared to the drainage cohort as you would imagine it would. However, I do want to point out that the recurrence in the aspiration cohort is much less than the drainage cohort. So perhaps suggesting there's a signal there. And finally, also highlighting what Dr. Lee have mentioned, that patients don't really like procedures. We might, but the patient won't. And it's important to also think about the patient-oriented factors, in this case, pain. And in this particular study, they've shown that pain is much less with aspirations compared to the chest tube. Now, let's think about how we can implement conservative management in a clinical setting. And this is the BTS guideline that just came out this year. I suggest everyone, if you have time to please look at it. It's a 42-some-odd document. That's the primary document. Along with it comes about 21 supplemental material together totaling over 150 pages for this one particular document. So a lot of work has been put into that. In this particular flowchart, I do want to point out that a lot of it, a lot of it, three out of the four boxes down below, where you see conservative out-management treatment, conservative approach, ambulatory care approach, or needle aspiration can all be considered to be non-drainage-related or non-catheter-related. Now, the key to develop a robust pleural service is to have multidisciplinary approach, working with your radiologist, working with your ED physicians and thoracic surgeons, and really having a patient-centered focus to look for patient's goals and patient's preference. And I do want to point out, in this particular flow diagram, right in the middle, right in the center, is what is the patient main priority. For the first time, we start seeing we're incorporating what the patient want. And finally also, do keep in mind about the high-risk population, which is highlighted in the red. Now, in order for us to actually deliver a outpatient-oriented care for pleural disease, we do need a robust outpatient pleural service. And that involve a team of physicians, APPs, schedulers, coordinators, and also you need to think about location where you can do this, a clinic space, a bronc lab, a pleural space lab, potentially, where you can potentially have an ultrasound that you can use in addition to chest x-ray. So there are a lot of different pieces to how you can implement this in real life. We already went through about this so for Leo's evaluation, so I'm not gonna belabor the point. Do keep in mind about the problem that we're speaking about. And I love what Dr. Lee has shown with his animation, which really breaks down this idea of perhaps when we're draining the pneumothoracy, we're actually pulling apart the defect that is happening on the visceral pleura. And by not being aggressive, by conservative monitoring, we are actually allowing the visceral pleural defect to touch each other and to heal appropriately and therefore creating a stronger, stronger heal, heal the visceral pleural defect and reducing the potential for future recurrence of pneumothoraces. Now, in this case, this is usually what I describe to my patient, air goes through your mouth, into the windpipe, into the lung, out through a defect on your lung, into the chest, and now we're gonna put a chest tubing and we're gonna drain that air out so your lung can come up, but then that air will then go into the suction drain and that circuit is now complete and we're just gonna promote that defect. So I want to, it's a shifting way of thinking of not being aggressive. So interestingly, there are people who are now using a pleural manometry to look at, to see, you know, is there a way for us to predict that there is a drainage dependency in the defect, in the visceral pleural defect versus drainage independent. So on the top graph, when you clamp the chest tube, it shows a drainage dependent visceral defect, whereas on the bottom graph, it shows a drainage independent when the pressure actually continues to increase if you actually have a cough. So about persistent air leak, we already mentioned that it's greater, defined greater than five days. Place the chest tube on a water seal for the patient and then actually see the patient, whether are they tolerating the fact that they're on water seal or if they're unable to tolerate on water seal. Now, there are two different kind of approaches if you think about how we can manage these patients. If the patient are able to tolerate being on water seal and off suction, then we're game. We can actually potentially do, take care of the patient as an outpatient with Heimlich valve or outpatient drainage devices. I'm also gonna show you a variety of different devices we're gonna have. And then finally, we also have various different modalities in tumor treatment for blood patch, pleurodesis, various valves that you have heard about and potentially looking at different endobronchial approaches. I don't know if the next slide is projecting correctly. Unfortunately, it is not. It is a variety of drainage devices that we can use for our patients. So in this case, the Heimlich valve everyone knows about, but keep in mind that there's no fluid drainage capacity with the Heimlich valve. You actually have to hook the Heimlich valve up to a secondary drainage device. The duration of the drainage is low and also the fluid port patency is not applicable. So the following four different devices we have will have different capacities of holding fluid collections. So they will have a pneumostat and you also have an ambulatory chest drainage device or a bag. And you can use these for a longer period duration. And finally, we also have two separate ambulatory devices that we can place in the ED setting where you have thorovent or pleurovent and these are small catheters that you can place directly and they actually adhese to the chest wall. Keep in mind, conservative outpatient drainage devices may need troubleshooting in the office because they're often smaller caliber. So they're more prone to develop clotting or kinking and also it requires a pleural service to assist you in the management of the patient, especially when close follow-up is required. By a show of hands in the room, who have done blood patch before? Okay, good. What is the biggest challenge about getting the autologous blood? Well, I think some of the tips that we have here are kind of resonate, will resonate with you. Keep in mind, we are trying to draw a patient's own blood. So you need a good IV to draw the blood. If you ever drawn blood from the patient and you're looking to draw about 150 cc's of blood from a patient, that IV better be big and short. Ideally an A-line, potentially even. The blood volume that we use for blood patch is highly debatable. Most people actually say about two cc's per kg, which translates to somewhere around 150. Our own anecdotal experience is greater than 150 to 200 cc's right around that range, it's a sweet spot for this. Do keep in mind, small bore chest tubes have to be looped around, especially the silicone tubing, is have to loop around an IV pole so you can continue to suck out the air, but allowing blood remaining in the chest cavity. Now we do use small bore chest tubes much more often now than large bore, and if you are to perform a blood patch with a small bore, it's likely to pose an issue in terms of clotting, so you have to keep in mind. And there's also a risk for infection, because blood is the best cultural medium for any type of infection. Now finally, an essential key to remember, keep everything above the patient, otherwise the blood you put into the chest tube will just flow out of the patient, and that kind of defeats the purpose. Now pleurodesis, a couple of comments about different agents we use for pleurodesis. People have used talc, they have used popinid iodine, silver nitrate, even mistletoe extract for some of the more adventurous ones. But keep in mind that the largest data we have is really regarding talc. It does not appear to cause any blockages when we deliver talc slurry through small bore chest tubes. Pain control is needed. NSAIDs can be used for pain control without compromise, extrapolating from data from MPE, from malignant pleurifusion data. And also, repeated talc may be needed, so it's not a single-time procedure. You may need to talc that pneumothorax or pleurifusion into submission. So keep that in mind. And there are other agents as well. So talk to your surgeons, especially for patients who may require transplant later on. Different surgeons have different agents of preference, so definitely talk to your surgeons about which agent to use. Finding the air leak can also be challenging, and there are multiple different modalities. Here I present three different modalities. You could use a 4DCT, which is an advanced imaging modality that you can actually reconstruct to look for the air leak at the defect on the CT scan. You can also inject methylene blue into the pleural space and look on the bronchoscope side to see which side of the airway that you start seeing the methylene blue that comes out. And then finally, you can also use balloon occlusion tests to see when we can reduce the air leak. When we place the valves, it is important to remember sizing, sizing, sizing is the key. And often, the valve studies are done too late. So potentially early entertaining of when to place the valve for the patient is better. So I want to point out this one particular thing. This is actually one of the advertisement images for the valves that they have on their website, but if you look very closely on that valve where I have that star, that valve is actually kinked. So you see that that's actually a leak, that valve is not appropriately sized. So larger is not better for valve. Montanabi spigot is oftenly being used for creating a plug for the airway of interest. And there are different sizes, however, they're not available in the United States and placement can be challenging. Variety of chemical and ablative techniques have been used, but they're often anecdotal. So if you do have local expertise to use these, please talk to them. And we used, we're using certain cases, a combination of valve and glue to assist our patient. And finally, thoracoscopy, whether surgical or medical, can be considered for the suitable candidate, but keep in mind that there is, the clinical data is limited. And of interest, AMPL-3 is currently underway. I hear very soon you'll be concluding its recruitment. It is gonna address this question of thoracoscopy versus IPC-TALC, but again, not in the pneumothorax population, but in MPE population. So more data to come, very exciting. So finally, the summary for the talk is really less is more. Treat the patient, not the x-ray. Tailor the treatment to the patient. And remember, you need a robust pleural program in order to deliver the outpatient conservative care. And it is a rapidly changing field. In fact, ERS is gonna put out their statement on pneumothoraces very soon. So look out for that publication in the next one to two month. And finally, one plug for building services, building pleural services. This talk tomorrow, that's gonna look for blueprints for creating a future proof pulmonary procedural service. I do encourage people to show up to that talk. It's gonna talk about a lot of things we didn't have time to address. Thank you very much for your time.

management

primary spontaneous pneumothorax

conservative management

evidence

patient preferences

definitive treatment

recurrence

pleurodesis

persistent air leaks

multidisciplinary approach