**9. Complications of pneumothorax treatment**

Getting the treatment of pneumothorax right is of paramount importance. The decision of which procedure to go for might not be crucial to fit patients but might endanger the lives of compromised patients. Patients with cardiopulmonary compromise, severe COPD and emphysema might have very little cardiopulmonary reserve, so much so they tolerate lung collapse poorly. Air leak is known to be a killer after lung volume reduction surgery for severe COPD patients. Assessment for general anaesthesia is essential for compromised patients. Consideration of alternative local or spinal/extrapleural analgesia might be required.

Insertion of intercostal tubes under non-sterile conditions leads to infection and empyema with formation of a thick rind over the visceral pleura, trapping the lung in a collapsed position. Lung re-expansion is formidable in this scenario. Formal thoracotomy and lung decortication might be required to re-inflate the lung and prevent chronic empyema with a permanently infected cavity. We never push an intercostal drain few centimetres into the chest (as possibly suggested by the chest X-ray). Pushing a bit of the unsterile part of the tube inside the chest leads to empyema. It is, however, safe to shorten a drain by pulling it out and re-anchor it with a fresh stitch.

Severe surgical (subcutaneous) emphysema could complicate insertion of a chest drain. The clinician should be aware of the position of the last lateral holes of the tube, which should always be inside the bony chest (**Figure 6**). Until the advent of the digital systems, which tell us exactly how much air is leaking, quantifying air leak visually was a subjective bias. No leak, countable bubbles, and coalesced bubbles were the measures of air leak in the underwater seal systems. This subjective assessment leads to days of unnecessary drain dwell time. Urgency of this complication is highlighted in ventilated patients in the intensive care. Insertion of a second large intercostal drain, subcutaneous cannulae and subcutaneous smallbore drains on suction has all been tried with varying success. It should be noted that fixed wall suction in these cases might lead to tension pneumothorax and the drain must be on gravity mode without suction. Information about how to deal with surgical emphysema is very sparse, and the management of severe air leak and surgical emphysema is controversial.

**65**

long run.

**Figure 6.**

**10. The future**

immediate postoperative period [86, 87].

*Controversies in Pneumothorax Treatment DOI: http://dx.doi.org/10.5772/intechopen.87141*

Should the need arise for a second drain to replace a dysfunctional one due to, e.g. blockage or kinking, the second drain should not be introduced at the site of the removed first one to reduce the risk of empyema. A fresh stab wound is better in the

*Lateral holes of the intercostal drain are outside the chest, a common cause for surgical emphysema.*

And last but not the least is the question of pain and analgesia which should be carefully worked out before and after surgical procedures or ward bedside pleurodesis. Talc pleurodesis is known to cause severe pain that can result in cardiac arrest, and it is, therefore, prudent to pre-empt it by administration of opioid analgesia before introducing the talcum powder or slurry [85]. The question of whether postoperative non-steroidal analgesia (NSAID) is detrimental to pleurodesis is not resolved. RCT have shown a negative predictive effect of such drugs to pleurodesis and increased incidence of recurrence. Therefore, it is best to avoid them in the

There is a trend for single-port VATS procedures under sedation/epidural anaesthesia [88]. The so-called tubeless surgery has a lot to commend, avoiding the risk of general anaesthesia, early recovery and discharge from hospital. However, they have the inherent caveat of suitability for selected patients. Understanding of the technique and cooperation in case of conversion to general anaesthesia is mandatory. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having a primary spontaneous pneumothorax. This allowed different managements from that of simple pneumothorax. A good example of this is demonstrated in secondary SP. The choices for lung reduction surgery and the advent of valves have revolutionised the options for this category of severe COPD [89]. Bronchial valves have been used to treat prolonged air leak, especially in ventilated patients in the intensive care, with

*Controversies in Pneumothorax Treatment DOI: http://dx.doi.org/10.5772/intechopen.87141*

*Pneumothorax*

be required.

with a fresh stitch.

surgical emphysema is controversial.

**8. Genetics and pneumothorax**

embarking on such treatment [84].

**9. Complications of pneumothorax treatment**

A lot of work needs to be done in the field of spontaneous pneumothorax that runs in families. Genetic profiling in patients presenting with pneumothorax might be indicated, in the hope of finding defective genes that expose conditions such as Marfan, Ehler Danlos and Birt-Hogg-Dubé syndromes [82]. These have one thing in common, defective connective tissue. Patients may or may not have pre-existing lung cysts before their pneumothoraces, which can be bilateral and recurrent. Risk stratification of other siblings needs to be calculated and predicted [83]. The importance of this subject is realised by frequent flyers, pilots, airhostesses and scuba divers. They need to know the risk and whether prophylactic procedures would be a wise thing to go for. By the same token patients who are expected to require lung transplantation at one stage in their life, such as cystic fibrosis patients, require special consideration of treatment. Pleurodesis seems to render transplantation a difficult task, but this is not a prohibitive contraindication. It might be prudent to discuss the case with a lung transplantation centre before

Getting the treatment of pneumothorax right is of paramount importance. The decision of which procedure to go for might not be crucial to fit patients but might endanger the lives of compromised patients. Patients with cardiopulmonary compromise, severe COPD and emphysema might have very little cardiopulmonary reserve, so much so they tolerate lung collapse poorly. Air leak is known to be a killer after lung volume reduction surgery for severe COPD patients. Assessment for general anaesthesia is essential for compromised

patients. Consideration of alternative local or spinal/extrapleural analgesia might

Insertion of intercostal tubes under non-sterile conditions leads to infection and empyema with formation of a thick rind over the visceral pleura, trapping the lung in a collapsed position. Lung re-expansion is formidable in this scenario. Formal thoracotomy and lung decortication might be required to re-inflate the lung and prevent chronic empyema with a permanently infected cavity. We never push an intercostal drain few centimetres into the chest (as possibly suggested by the chest X-ray). Pushing a bit of the unsterile part of the tube inside the chest leads to empyema. It is, however, safe to shorten a drain by pulling it out and re-anchor it

Severe surgical (subcutaneous) emphysema could complicate insertion of a chest drain. The clinician should be aware of the position of the last lateral holes of the tube, which should always be inside the bony chest (**Figure 6**). Until the advent of the digital systems, which tell us exactly how much air is leaking, quantifying air leak visually was a subjective bias. No leak, countable bubbles, and coalesced bubbles were the measures of air leak in the underwater seal systems. This subjective assessment leads to days of unnecessary drain dwell time. Urgency of this complication is highlighted in ventilated patients in the intensive care. Insertion of a second large intercostal drain, subcutaneous cannulae and subcutaneous smallbore drains on suction has all been tried with varying success. It should be noted that fixed wall suction in these cases might lead to tension pneumothorax and the drain must be on gravity mode without suction. Information about how to deal with surgical emphysema is very sparse, and the management of severe air leak and

**64**

Should the need arise for a second drain to replace a dysfunctional one due to, e.g. blockage or kinking, the second drain should not be introduced at the site of the removed first one to reduce the risk of empyema. A fresh stab wound is better in the long run.

And last but not the least is the question of pain and analgesia which should be carefully worked out before and after surgical procedures or ward bedside pleurodesis. Talc pleurodesis is known to cause severe pain that can result in cardiac arrest, and it is, therefore, prudent to pre-empt it by administration of opioid analgesia before introducing the talcum powder or slurry [85]. The question of whether postoperative non-steroidal analgesia (NSAID) is detrimental to pleurodesis is not resolved. RCT have shown a negative predictive effect of such drugs to pleurodesis and increased incidence of recurrence. Therefore, it is best to avoid them in the immediate postoperative period [86, 87].
