From the Guidelines
Lung blebs and loculated pneumothoraces require prompt evaluation and management, with consideration for chest tube placement and potential surgical intervention, such as video-assisted thoracoscopic surgery (VATS) with bleb resection and pleurodesis, as recommended by the British Thoracic Society guideline for pleural disease 1.
Initial Management
For patients with lung blebs and loculated pneumothoraces, initial management includes:
- Oxygen supplementation
- Pain control
- Consideration for chest tube placement, with image guidance to ensure proper positioning within the loculated space
Loculated Pneumothoraces
If initial chest tube drainage fails, intrapleural fibrinolytics like alteplase (10-20mg in 100ml saline daily for up to 3 days) may help break down loculations, as supported by studies on the management of malignant pleural effusions 1.
Surgical Intervention
Persistent or recurrent pneumothoraces may require surgical intervention, typically VATS with bleb resection and pleurodesis, as recommended by the British Thoracic Society guideline for pleural disease 1.
Pleurodesis
Mechanical pleurodesis or chemical pleurodesis using talc (4-5g) can prevent recurrence, with studies showing the effectiveness of talc pleurodesis in preventing recurrence of pneumothorax 1.
Monitoring and Complications
These conditions require close monitoring for complications including:
- Tension pneumothorax
- Respiratory compromise
- Infection The underlying pathophysiology involves disruption of the visceral pleura allowing air to escape into the pleural space, with inflammatory processes potentially causing loculations that prevent complete lung re-expansion with standard drainage techniques.
Key Considerations
- Patient choice and individual assessment should inform the decision for surgical intervention, weighing the benefits of reduced recurrence risk against potential risks and complications, as recommended by the British Thoracic Society guideline for pleural disease 1.
- Transthoracic ultrasonography (TUS) can be useful in identifying septations and guiding interventions in loculated collections, as supported by studies on the management of malignant pleural effusions 1.
From the Research
Lung Blebs and Loculated Pneumothorax Consideration
- Lung blebs are a common pathology associated with primary spontaneous pneumothorax, as noted in a study from 2.
- The formation of fibrous adhesions resulting in a multiloculated effusion can diminish the efficacy of drainage and make successful pleurodesis impossible, as discussed in 3.
- Intrapleural fibrinolytic therapy has been investigated as a possible therapeutic approach for managing multiloculated malignant pleural effusion, with a case series reported in 3.
- Autologous blood patch intraparenchymal injection has been shown to reduce the incidence of pneumothorax and the need for chest tube placement following CT-guided lung biopsy, according to a systematic review and meta-analysis in 4.
- Pleural blood patching has been associated with a significantly higher success rate than simple aspiration in treating pneumothorax associated with CT-guided lung biopsy, as found in 5.
Treatment Options
- Therapeutic options for primary spontaneous pneumothorax include conservative, intermediate, and invasive procedures, as outlined in 2.
- Intrapleural fibrinolytics combined with image-guided chest tube drainage have been used to treat pleural infection, with a retrospective review of 30 consecutive patients reported in 6.
- The use of autologous blood patch intraparenchymal injection during CT-guided lung biopsies has been shown to be highly effective in diminishing both the incidence of pneumothorax and consequent chest tube placement requirement, as concluded in 4.