Resolution Of Persistent Air Leak Due To Secondary Spontaneous Pneumothorax With A Novel Atrium Suspension Technique

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Secondary Spontaneous Pneumothorax (SSP) related to Chronic Obstructive Pulmonary Disease (COPD) is a well-described phenomenon which designates advanced disease. Almost all patients should initially be treated with tube thoracostomy to decrease intra-thoracic pressure and re-expand the lung. 20% of patients will display Persistent Air Leak (PAL) lasting longer than 7 days (1). In cases of PAL, multiple strategies for management have been described including endobronchial therapies, thoracostomy tube treatments, and surgical approaches (2). For patients with severely decreased lung function, treatment options are limited. CASE PRESENTATION: A 66 year old woman with COPD and severe bullous emphysema presented with acute dyspnea preceded by a ‘popping’ sensation in her left chest. Initial evaluation demonstrated a large left pneumothorax which required two chest tubes on suction to completely expand her lung. She was not a candidate for definitive endobronchial or surgical treatments due to the severity of her lung disease. On day 14, the patient demonstrated PAL which was continuous and talc pleurodesis was performed through a 14F pigtail catheter. Due to PAL, the procedure was modified by hanging her pleural drain apparatus on an IV pole approximately two feet above the insertion site and leaving the drain open after talc instillation. The patient tolerated the procedure well, and over the course of 48 hours her air leak resolved allowing for removal of her thoracostomy tubes and discharge home. Six months later, the patient re-presented for similar symptoms and was treated with thoracostomy tube for L sided pneumothorax with evidence of partial pleurodesis from her prior procedure. After again demonstrating persistent air leak, she was treated with talc pleurodesis with atrium suspension twice on HD11 and HD12. After 48 hours she had resolution of PAL and was discharged home. DISCUSSION: In patients with large PAL, chemical pleurodesis through a thoracostomy tube presents a technical challenge because the procedure typically requires clamping of the chest tube for a period of time to allow for a sclerosing agent to remain in the pleural space. Clamping the chest tube in our case would have resulted in accumulation of air in the pleural space causing cardiopulmonary instability. We were able to overcome this challenge by physically elevating the pleural drainage system above the level of the patient’s thorax during talc instillation, allowing air to escape into the drainage system while talc remained in the thorax. CONCLUSIONS: The patient tolerated the atrium suspension technique and the procedure resulted in successful resolution of air leak on two occasions. We recommend that this modification of the standard chemical pleurodesis procedure be considered in patients treated for large PAL, especially in patients who are not considered to be good surgical candidates. Reference #1: (1) Light, Richard W. Pleural Diseases. 3rd ed. Williams & Wilkins; c1995. Chapter 19, Pneumothorax; p.242-277. Reference #2: (2) Dugan, K, Laxmanan, B, Murgu, S et al. Management of Persistent Air Leaks. Chest. 2017 Aug;152(2):417-423. DISCLOSURES: No relevant relationships by Zaith Bauer, source=Web Response No relevant relationships by Whittney Warren, source=Web Response