**5. Conclusion**

*Pneumothorax*

[40]. The devices utilized in this study could not only remotely deliver information to providers regarding suction power and volume of air leaks, but they could also allow the providers to remotely control settings on the suction device. In keeping with the growing reliance on mobile technology in our society, clinicians were able to monitor and control device parameters using a smartphone app. Findings in this randomized control trial were consistent with previous studies which showed a statistically significant decrease in chest tube duration, length of stay, and, consequently, overall cost. The investigators established the safety and feasibility of managing pleural drains remotely opening the possibility of discharging patients home with the drains in place and monitoring their progress at home. One limitation of this particular study was that investigators elected not perform any form of pleurodesis to limit the postoperative parameters, thereby reducing the generalizability of the data onto patients who received the gold standard of treatment for spontaneous pneumothoraces, namely, resection and pleurodesis. Despite this limitation, recurrences in this study with 6 months of followup data remained low at about 3.4%. Given the rapidity with which mobile technology is advancing, it is not hard to envision a time when physicians can monitor the character and volume of effluent from these devices as well, thereby decreasing the need for inpatient care to that of reaching a stable level of analgesia with only oral agents.

There are also financial implications that should be considered when evaluating the differences between open and minimally invasive approaches to the management of pneumothorax and use of adjuncts. In a small Italian study from 1996 comparing VATS versus thoracotomy for management of recurrent spontaneous pneumothorax at a time when reusable VATS instruments were not yet widely available, VATS was still found to have a 22.7% cost savings compared to thoracotomy even when expensive disposable VATS equipment was used. The cost savings at that time were realized in the decreased duration of postoperative hospitalization seen in patients treated with VATS compared to open thoracotomy [10, 41]. A more recent study identified these cost savings in complication, ICU admission, length of hospitalization, operative time, and chest tube duration [42], further supporting

As application of robotic techniques become readily available to thoracic surgeons, it is likely the technology could be developed in pinpointing air leak and precision application of treatment during surgical intervention. Furthermore, there is an increasing interest in using computerized chest drainage systems to allow for an early and safe

the argument of minimally invasive intervention compared to open.

removal of chest tube or remote management of the tube in outpatient settings. Anesthetic concerns are typically left out of discussion of surgical treatment. However, one paper that deserves mention evaluated the feasibility of performing awake VATS bullectomy and abrasion. In this randomized control trial in Rome, Italy, patients were randomized to undergo either awake VATS with thoracic epidural anesthesia or traditional VATS with general anesthesia and single-lung ventilation [43]. The sample size was relatively small to be sure, with 21 in the investigational arm and 23 in the control arm, but the results of the trial were striking nonetheless. Not only was awake VATS technically feasible, with all cases being completed as planned and zero conversions to general anesthesia, but pain scores and patient satisfaction with anesthesia favored the awake approach over the traditional VATS. What is particularly interesting in this study is that the cost data also favored the awake technique (2540 ± 352 € vs. 3550 ± 435 €, p < 0.0001). This is mostly because anesthesia time (25.0 ± 6.0 min vs. 35.5 ± 10.0 min, p < 0.001), recovery room time (20 ± 15.0 min vs. 30 ± 15.0 min, p = 0.001), global OR time (78.0 ± 20.0 min vs. 105.0 ± 15.0 min, p < 0.001), and hospital stay (2.0 ± 1.0 d vs. 3.0 ± 1.0 d, p < 0.0001) were all shorter for the awake group [43]. With a significant portion of the debate over how best to control rising health-care costs with focus on resource utilization and hospital stay, it is a wonder why this technique is not more widely utilized, let alone discussed.

**34**

Despite differences in etiology of pneumothorax, the management should be directed at expeditious bedside and, ultimately, surgical management for patients who do not completely resolve their pneumothorax non-operatively [45]. We advocate for bedside chest tube placement under local anesthetic for nearly all patients who present with spontaneous pneumothorax, except those with small pneumothorax that remain stable on follow-up radiographic imaging. Following chest tube placement, if the pneumothorax fully resolves and there is no ongoing air leak, these patients can have their chest tube water sealed and subsequently removed as early as the day after hospital presentation. Patients with recurrent bilateral pneumothorax, patients who present for the first time without ready access to medical care, patients with profession or hobbies that make them at higher risk from developing recurrence, or patients with persistent air leak should undergo surgical intervention whenever possible. The operative approach should favor VATS over open thoracotomy for both pleurodesis/pleurectomy and resection of blebs. Our approach is always to perform pleurodesis following the blebectomy or remove the source of the air leak. Our preferred approach in younger patients is mechanical pleurodesis, and in patients above 65 years of age, use graded talc. In patients presenting with recurrences following a previous pleurodesis, we reserve the apical pleurectomy. In patients with secondary pneumothorax, we have lower threshold to reinforce staple line or perform pleural tent in addition to the above. This overall strategy will facilitate timely treatment in this patient population and accomplish it in a minimally invasive manner that aligns with other modern surgical approaches in the field of thoracic surgery.
