76 Dear Editor,
Treatment of pneumothorax in patients with idiopathic pulmonary fibrosis (IPF) is often problematic. Especially in elderly patients with IPF, treatment of pneumothorax may often be unsuccessful due to unexpected compli- cations. We would like to share our experience in pneumothorax treatment in a very elderly patient with IPF.
An 84-year-old man was referred to our hospital with an exacerbation of dyspnea. Ten years prior to this presentation, the patient was diagnosed with idiopath- ic pulmonary fibrosis (IPF) (Figure 1-A). In addition to bilateral diffuse ground-glass opacities, traction bron- chiectasis and honeycombing, right pneumothorax was found in the chest radiograph (Figure 1-B). Arterial blood gas on room air revealed PaO2 38.3 mmHg, PaCO2 45.3 mmHg and pH 7.47 (O2: 5L/min). A tho- racic tube was inserted and deaeration was attempted.
Reactive pleural effusion was discharged in large quan- tities, but air leak continued. Taking poor respiratory state and general condition of the patient into consid- eration, pleurodesis was not carried out. The pleurode- sis by autologous blood was also considered, but the air leak disappeared on the 21st after inserting the thoracic tube and the tube could be removed on the
23rd day (Figure 1-C). Two months after the removal of the chest tube, the respiratory condition of the patient does not deteriorate.
Pneumothorax is a common complication in IPF patients, who can present increased morbidity caused by exacerbation of the respiratory manifestations of the disease, which can lead to respiratory failure and death (1). Pneumothorax in patients with IPF, air leaks from complicatedly modified lungs are sustained, and pul- monary re-expansion is difficult to achieve due to contraction tendency. If the lungs are re-expanded, fortunately, pleurodesis is a conceivable effective treat- ment, but this is also problematic. Many of the drugs used for this treatment are accompanied by fever and pain, but it is presumed that many elderly patients cannot tolerate these complications. By performing pleurodesis in patients with IPF, dyspnea apparently develops due to decreasing respiratory function (2).
Although surgical therapy may be selected as a treat-
Difficulty in management of
pneumothorax in an octogenarian with pulmonary fibrosis
doi • 10.5578/tt.66527 Tuberk Toraks 2018;66(1):76-77
Geliş Tarihi/Received:03.02.2018 • Kabul Ediliş Tarihi/Accepted: 19.02.2018
EDİTÖRE MEKTUP LETTER TO THE EDITOR
Shinichiro OKaUchi1 hajime OSawa1 hiroaki SaTOh1
1 Division of Respiratory Medicine, Mito Medical Center, Tsukuba University, Mito, Japan
1 Tsukuba Üniversitesi Mito Tıp Merkezi, Solunum Bölümü, Mito, Japonya
Dr. Hiroaki SATOH
Division of Respiratory Medicine,
Mito Medical Center, Tsukuba University, MITO - JAPAN e-mail: hirosato@md.tsukuba.ac.jp
Yazışma adresi (address for correspondence)
Tuberk Toraks 2018;66(1):76-77
Okauchi S, Osawa H, Satoh H.
77 ment for pneumothorax of patients with pulmonary
fibrosis, there are also problems in surgical treatment.
There are patients who do not have re-expansion of the lung due to contraction tendency in fibrosing lung. In addition, some patients lead to fatal acute exacerba- tion of IPF triggered by pleurodesis or surgical treat- ment (3-5).
In our patient, some favorable factors existed:
No deterioration of nutritional condition during the treatment period, absence of delirium, no infectious complication, no deterioration in activities of daily living and cognitive function. In fact, albumin level before insertion of the thoracic tube was 2.5 g/dL, and that at the day of removal of chest tube was 2.8 g/dL.
Long-term placement of the tube must be a great stress for elderly patients, and long-term bed stay may also cause deterioration in activities of daily living and cog- nitive function. To our best knowledge, there has been no previous report on a pneumothorax that was suc- cessfully treated with conservative medical manage- ment in an octogenarian with IPF. Our experience might provide some clinical information on the treat- ment of pneumothorax in very elderly patients with IPF.
RE FE REN cES
1. Panos RJ, Mortenson RL, Niccoli SA, King TE Jr. Clinical deterioration in patients with idiopathic pulmonary fibrosis:
causes and assessment. Am J Med 1990;88:396-404.
2. Lange P, Mortensen J, Groth S. Lung function 22-35 years after treatment of idiopathic spontaneous pneumothorax with talc poudrage or simple drainage. Thorax 1988;43:559- 61.
3. DiBardino DJ, Vanatta JM, Fagan SP, Awad SS. Acute respiratory failure after pleurodesis with doxycycline. Ann Thorac Surg 2002;74:257-8.
4. Rehse DH, Aye RW, Florence MG. Respiratory failure following talc pleurodesis. Am J Surg 1999;177:437-40.
5. Elsayed HH, Hassaballa A, Ahmed T. Is video-assisted thoracoscopic surgery talc pleurodesis superior to talc pleurodesis via tube thoracostomy in patients with secondary spontaneous pneumothorax? Interact Cardiovasc Thorac Surg 2016;23:459-61.
Figure 1. Chest radiograph taken half a year before this hospitalization showing bilateral diffuse ground-glass opacities (A). Right pneumothorax was found in the chest radiograph which was taken at the time of hospitalization (B). Chest radiograph taken two months after removal of the chest tube showing no recurrence of pneumothorax (C).
