How is pneumothorax managed in patients with interstitial lung disease (ILD)?

From the Guidelines

Management of pneumothorax in patients with interstitial lung disease (ILD) requires prompt intervention with chest tube placement, as these patients have higher risks of complications and recurrence compared to the general population. Initial management involves supplemental oxygen, pain control with medications like acetaminophen or NSAIDs, and insertion of a small-bore chest tube (typically 8-14 French) connected to a water seal or Heimlich valve system, as recommended by the British Thoracic Society guideline for pleural disease 1. The chest tube should remain in place until complete lung re-expansion and cessation of air leak, usually requiring 3-7 days. For persistent air leaks beyond 5-7 days, chemical pleurodesis may be performed using agents such as talc (4-5g), doxycycline (500mg), or tetracycline (20mg/kg).

Some key considerations in the management of pneumothorax in ILD patients include:

• The use of ambulatory treatment using a purpose-made device containing a one-way valve, or Heimlich valve attached to chest drain, which has the potential to allow outpatient management of pneumothorax 1
• The role of thoracic surgery in the management of recurrent pneumothoraces or persistent air leaks, with procedures such as video-assisted thoracoscopic surgery (VATS) for pleurodesis or pleurectomy 1
• The importance of optimizing underlying ILD treatment, smoking cessation, and pulmonary rehabilitation in the long-term management of these patients

It is also important to note that the management of pneumothorax in ILD patients should be individualized, taking into account the patient's underlying disease, comorbidities, and preferences. Surgical intervention with VATS for pleurodesis or pleurectomy is recommended for recurrent pneumothoraces or persistent air leaks despite conservative management, as it has been shown to be effective in reducing the risk of recurrence and improving outcomes in these patients 1. Post-procedure, patients should avoid air travel and strenuous activity for 2-4 weeks. These aggressive approaches are necessary because ILD patients have fragile, fibrotic lung tissue that heals poorly and is prone to persistent air leaks and recurrence.

From the Research

Management of Pneumothorax in Patients with Interstitial Lung Disease (ILD)

• Pneumothorax in patients with ILD is often difficult to treat and requires careful management 2.
• The treatment options for pneumothorax in ILD patients include chest tube drainage alone, pleurodesis, bronchoscopic treatment, and surgery 2.
• A study found that among 129 patients with pneumothorax caused by ILD, 77.5% were curatively treated, 20.9% died, and 2 patients were transferred without chest tube removal 2.
• The outcomes of surgery for pneumothorax in patients with ILD were good, with 96.0% of patients who received surgery being cured 2.

Treatment Options

• Pleurodesis is a common treatment option for pneumothorax in ILD patients, with a mean number of pleurodesis treatments of 2.4 (range, 1-9) 2.
• Blood-patch pleurodesis is a safe and effective treatment option for secondary spontaneous pneumothorax in ILD patients, with a cure ratio of 72.7% 3.
• Surgery, including bullectomy, lung cyst ligation, and pleural covering with oxidized cellulose sheet, is also an effective treatment option for pneumothorax in ILD patients 2.

Prognosis

• The prognosis after the onset of pneumothorax in ILD patients is poor, with a median survival time of less than 9 months in patients with idiopathic interstitial pneumonia (IIP) and around 3 years in patients with other types of ILD 3.
• Concomitant pneumomediastinum is an independent predictor of death in ILD patients with pneumothorax 3.

Current Practices

• Current practices in the management of patients with pneumothorax include immediate management based on the extent of cardiorespiratory impairment, degree of symptoms, and size of pneumothorax 4.
• Guidelines have been produced to outline appropriate strategies in the care of patients with pneumothorax, and video-assisted thoracoscopic surgery is a successful tool to prevent recurrence in selected individuals 4.