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Ann Thorac Surg 2005;80:1859-1863
© 2005 The Society of Thoracic Surgeons

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Original article: General thoracic

Spontaneous Hemopneumothorax Revisited: Clinical Approach and Systemic Review of the Literature

^a Division of Chest Surgery, Department of Surgery, China Medical University Hospital, Taichung
^b Division of Thoracic Surgery, Department of Surgery, Taichung Veterans General Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China

Accepted for publication April 26, 2005.

^_* Address correspondence to Dr N-Y Hsu, Division of Chest Surgery, Department of Surgery, China Medical University Hospital, 2, Yuh-Der Road, Taichung, 404 Taiwan, Republic of China (Email: h440506{at}ms15.hinet.net).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: Spontaneous hemopneumothorax, defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax, is a rare entity occurring in young patients and may be life threatening. Although many reports of case studies and series have been published in the world literature, the lack of consistent intraoperative findings and varying surgical methods require a review study.

METHODS: We discuss the clinical features, management, surgical findings, and outcomes of our own patients with spontaneous hemopneumothorax.

RESULTS: From September 1997 to September 2003, 488 patients with spontaneous pneumothorax were treated at our hospital. Of these patients, 27 (5.5%) had spontaneous hemopneumothorax develop. These 27 patients were comprised of 25 men and 2 women ranging in age from 15 to 39 years (mean age, 22.3 years). The amount of blood that was drained ranged from 400 to 1,700 mL (mean, 1,012 mL). Twenty-one patients underwent video-assisted thoracoscopic surgery within 1 day after admission; the remaining 6 patients were treated conservatively with tube thoracostomy alone. On arrival at our emergency room, 9 patients (33.3%) experienced hemodynamic instability with hypovolemic shock. In a review of 6,396 patients with spontaneous pneumothorax in the literature and in our current study, 201 patients (3.1%) had spontaneous hemopneumothorax develop. One hundred seventy-six patients (87.6%) were treated surgically, whereas video-assisted thoracoscopic surgery has been performed in 48.9% of patients (86 of 176). There was no recurrence of hemopneumothorax in any of the 201 patients with spontaneous hemopneumothorax after treatment during the follow-up period.

CONCLUSIONS: Thus one-third of the patients with spontaneous hemopneumothorax had shock symptoms develop. Video-assisted thoracoscopic surgery may be considered as an initial treatment procedure for patients with spontaneous hemopneumothorax, whereas conservative treatment is effective and may be performed in selected patients.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Although spontaneous pneumothorax (SP) is frequently accompanied by a limited amount of blood in the pleural cavity, spontaneous hemopneumothorax (SHP) is a condition in which more than 400 mL of blood has accumulated in the pleural cavity in association with SP [1]. Spontaneous hemopneumothorax is a rare entity occurring in young patients and may be life threatening when hemodynamic instability with hypovolemic shock attacks. Because the disease was first recognized by Laennec in 1828 during an autopsy [2], and was first managed successfully by Whittaker in 1876 with repeated pleural aspirations reported by Muraguchi and colleagues [3], there have been many case studies [4–15] and series reports [16–23] published in the world literature. Because of the lack of consistent intraoperative findings and varying surgical methods, we conducted a retrospective review and compared our experience with 8 series reports [16–23] published in the world literature.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment References

 
From September 1997 to September 2003, 488 patients with SP were treated in the China Medical University Hospital. Of these patients, 27 (5.5%) had SHP develop. Twenty-one patients underwent video-assisted thoracoscopic surgery (VATS) within 1 day after admission; the 6 remaining patients were treated by tube thoracostomy alone. The patients were treated by conservative therapy according to the discretion of the surgeons who closely observed the vital signs of the patients after tube thoracostomy. Our VATS technique has been previously described [20].

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
Clinical characteristics of 27 patients with SHP were summarized in Table 1. There were 25 male and 2 female patients, ranging in age from 15 to 39 years (mean age, 22.3 years). All of the patients had initial symptoms of sudden onset of chest pain or dyspnea. Spontaneous pneumothoraxes associated with the air fluid line were diagnosed by roentgenograms. Subsequent SHPs were confirmed by insertion of a chest tube for removal of blood and air in the pleural cavity. The amount of blood drained ranged from 400 to 1,700 mL (mean, 1,020 mL). On arrival to our emergency room, 9 patients (33.3%) experienced hemodynamic instability with hypovolemic shock; symptoms included cold sweating and hypotension (systolic pressure less than 90 mm Hg), and the patients were stabilized with fluid resuscitation and blood transfusion. All 9 patients received a 500 to 1,500 mL blood transfusion; the mean hemoglobin was 10.3 g/dL (range, 8.4 to 13.2 g/dL) and the mean hematocrit was 30.1 % (range, 25.2% to 38.8 %) before operation. These 9 patients with hypovolemic shock at the time of admission and another 12 patients with persistent output (> 100 mL/h) during the same hospital day underwent VATS; whereas the remaining 6 SHP patients in whom vital signs and blood leakage were stabilized after tube thoracostomy did not undergo VATS.

The mean duration of postoperative chest drainage in patients managed by VATS and in patients managed by tube thoracostomy alone was 5.2 days and 6.5 days, respectively, whereas the hospital stay was 7.2 days and 8.5 days, respectively. There were no cases of hemopneumothorax recurrence after the initial VATS intervention to remove blood clots, control bleeders, and provide a subsequent bullectomy. No recurrence of SHP or any other complications occurred with these 27 patients during the follow-up period (range, 5 to 82 months; mean, 24.5 months).

To date, in a review of 6,396 patients with SP in the literature and our own study, 201 patients (3.1%) had SHP develop. The demographics and clinical features are summarized in Table 2. Among 176 operated patients, 116 (65.9%) patients (including 72 with hypovolemic shock) were operated on within 1 day of admission. Video-assisted thoracoscopic surgery was performed in 48.9% patients (86 of 176). During the operation, sources of active bleeding were recorded in 92 patients of 7 series reports including our study; 51 patients (55.4%) were from parietal pleura, 21 (22.8%) from an aberrant vessel, 14 (15.2%) from visceral pleura, and 6 (6.5%) from both parietal and visceral pleurae. Interestingly, among the 201 patients with SHP, no recurrence of hemopneumothorax was reported after the operation or tube thoracostomy during the follow-up period (between 5 months and 8 years).

	Comment

Top Abstract Introduction Material and Methods Results Comment References

Spontaneous hemopneumothorax has been defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax [1]. Clinically, SHP should be considered a life-threatening emergency when a patient with known pneumothorax has otherwise unexplained shock symptoms develop. In our series, the amount of blood aspirated from 9 SHP patients with hypovolemic shock ranged from 640 to 1,700 mL (mean, 1,283 mL). Thus we suggest that it is a clinical caveat of hypovolemic shock if aspirated blood measuring more than 1,200 mL is noted.

We previously proposed three mechanisms of bleeding in hemopneumothorax cases [20]. First, hemorrhage can result from a torn adhesion between the parietal and visceral pleurae, as reported in 6 of 8 series reports [16, 18–22], and as was found in the current study. Second, bleeding can result from a rupture of vascularized bullae and underlying lung parenchyma, as reported in 3 of 8 series reports [16, 19, 20], and as was found in the current study. Third, bleeding can result from torn congenital aberrant vessels branching from the pleural cupola and distributed in and around the bulla in the apex of the lung. Spontaneous hemopneumothorax with aberrant vessels were found to be the source of bleeding as first reported by Muraguchi and colleagues [3]. This condition was identified in only 2 of 8 series reports [19, 21], and in the current study. Furthermore, although Kimura and colleagues [22] found that the source of bleeding of all 6 patients with hypovolemic shock resulted from torn parietal pleura, we found that bleeding in 7 of 9 patients with hypovolemic shock resulted from an aberrant vessel, and the source of bleeding was from torn parietal pleura in the remaining 2 patients.

Conservative therapy with tube thoracostomy alone for SHP was reported by De Perrot and colleagues [25]. In addition, Kakaris and colleagues [17] have reported that 16 of 71 of their patients with SHP (ie, the largest series report in the world literature) were treated conservatively by tube thoracostomy alone. In our studies, 6 patients were treated by the same method. The indications for operation included emergency operations for hypovolemic shock and continuous bleeding (> 100 mL/h) and elective operations for persistent air leak and clot empyema [16–23]. We advocate tube thoracostomy alone when patients do not present with any of the previously named surgical indications, such as patients who are hemodynamically stable, those who have no persistent air leak, and those with no continuous bleeding and no impaired lung expansion.

We suggest that VATS may be superior to thoracotomy because it leads to less postoperative pain and decreases postoperative analgesic requirements, entails a shorter hospital stay, and consequently reduces hospital costs [26]. In addition, bleeders can be controlled effectively by VATS with the 3-port technique. As for solving the problem of removing blood clots through the port incision, we advocate irrigating the pleural cavity with warm sterile water to break up the blood clots, which can then be removed adequately by wall sucker or ring forceps. Taken collectively, we strongly advocate VATS to serve as a useful modality for the management of SHP.

In our series, the rate of recurrence in 461 patients with SP who underwent VATS was 5.2%; however, it has been reported to range from 3% [27] to 8.3% [28] in the literature. Interestingly, no evidence of recurrence was reported in the 9 series reports containing 201 patients who were managed either by operation (86.8%) or by tube thoracostomy alone (13.2%) during a follow-up period ranging from 5 months to 8 years. We think that minimal residual blood clots remaining within the pleural cavity may have caused substantial pleurodesis, which may have prevented subsequent attacks.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

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