Talc pleurodesis via rocket pleural vent in secondary spontaneous pneumothorax: a case series

SESSION TITLE: Disorders of Pleura Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Pleurodesis is indicated for secondary spontaneous pneumothorax(SSP) given the high recurrence rate, with talc as most effective(1) for patients who cannot undergo surgical pleurodesis. Rocket Pleural Vent(PV) is an ambulatory device designed for primary spontaneous pneumothorax(2), but more treatment failure compared to chest tube in SSP(3). It can be an alternative for management of SSP where chest tube insertion in anterior axillary position is not technically feasible, due to anatomical position at apical region with possible pleural adhesion or patients’ preference. We describe three cases of SSP with successful resolution of pneumothorax after PV insertion followed by talc pleurodesis. 4g talc powder was mixed with 10ml 1% lignocaine and 50ml saline and inject through the port(Figure1) followed by 10cmH2O suction. PV is removed when lung expands after 12 hours on chest x-ray(CXR). CASE PRESENTATION: Three patients aged 35 to 70 years old were admitted for unilateral SSP, presented with shortness of breath. The underlying lung disease were non-specific interstitial pneumonia, pleuroparenchymal fibroelastosis and silicosis respectively. Patient 3 experienced pneumothoraxes on both sides at two different episodes. All are apical pneumothoraxes with size ranged from 3.4 to 4cm apex to cupola distance. Areas of pleural adhesions were demonstrated on pleural ultrasound in patient 3.In view of symptomatic SSP, PVs were inserted due to apical location and patients’ preference. Time from drainage to lung fully expansion ranged 4 to 25 days. Surgical pleurodeses were not performed due to either physically unfit for surgery or patients’ preference. Talc pleurodeses were performed on all three patients. 12 hours later, lungs fully expanded in patient 1&3 hence PVs were removed. In patient 2, PV was kept for drainage as failed lung expansion and off after 14 days upon lung expansion. Patient 1 did not have pneumothorax recurrence upon follow-up. Patient 2 had left pneumothorax recurred 265 days later. Patient 3 had recurrence of left pneumothorax after 56 days and right pneumothorax after 8 days. Cases are summerized in Table1. DISCUSSION: This is the first case series of talc pleurodesis via PV as alternative treatment of SSP. Talc pleurodesis was shown to have lower recurrence rate than tetracycline(1). It was comparable through 8Fr/10Fr pigtail and chest drain size 18Fr/20Fr/24Fr(1). Talc is in powder form and cannot be completely dissolved. Drain blockage is the commonest complications for small bore chest drain(1) which may lead to failure in drainage, and is the major concern for talc pleurodesis. Our case series demonstrated feasibility and safety of talc pleurodesis via PV with dilution as per FDA recommendation. PV was either removed or used for continuous drainage without blockage. It is a feasible treatment alternative for SSP. Concerning long-term successful rate of talc pleurodesis via PV, only one patient showed no pneumothorax recurrence. Predictive score for application of chemical pleurodesis was proposed for patients with different underlying lung diseases with ours. Further studies are needed to show the long-term efficacy for talc pleurodesis via PV. CONCLUSIONS: When PV is inserted for SSP, talc pleurodesis is feasible and safety is demonstrated in our case series. REFERENCE #1: MacDuff A, Arnold A, Harvey J; BTS Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii18-31. REFERENCE #2: Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet. 2020;396(10243):39-49. REFERENCE #3: Walker SP, Keenan E, Bintcliffe O, Stanton AE, Roberts M, Pepperell J, Fairbairn I, McKeown E, Goldring J, Maddekar N, Walters J, West A, Bhatta A, Knight M, Mercer R, Hallifax R, White P, Miller RF, Rahman NM, Maskell NA. Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial. Eur Respir J. 2021 Jun 24;57(6):2003375. DISCLOSURES: No relevant relationships by King Pui Florence Chan No relevant relationships by Ka Yan Chiang No relevant relationships by Wang Chun Kwok Speaker/Speaker's Bureau relationship with AstraZeneca Please note: 12.2022 Added 04/04/2023 by David Chi Leung Lam, source=Web Response, value=Travel No relevant relationships by Hiu Ching Lau No relevant relationships by Jackson Ka Chun Leung No relevant relationships by Mei Sze Lui No relevant relationships by Terence Tam