Physical pain from pneumothorax & corrective lung surgery

Physical pain from pneumothorax & corrective lung surgery

Background:

I have spent considerable time researching my condition – spontaneously collapsing lungs (“spontaneous pneumothorax”) caused by congenital blebs – referred to as “bleb disease”, “blebs disease”, “congenital blebs disease” and even “bleb pop disease.”
I have read hundreds of stories from people whose lungs have collapsed. Overwhelmingly, two themes unify our experiences: 1. Physical pain and 2. Psychological Impact

In this chapter I discuss physical pain, which I break into three categories:

Primary Pain

Those who suffer from our condition have likely experienced intense physical pain caused by any or all of the following: a lung collapse, a chest tube insertion, any corrective lung surgery (pleurodesis, pleurectomy, thoracotomy) and the accompanying recovery.

My own lung collapses were almost always marked by an acute, sharp pain that began in the back of my lung, in the shoulder blade area. Over the course of seconds or minutes, the pain usually spread around to the front of my chest, and sometimes into my neck, shoulder, or down my arm. The magnitude of the pain was usually alarming and I always knew right away that I needed to get to an emergency room quickly.

The first step in treating a collapsed lung is usually a chest tube insertion, which is also very painful and unforgettable. The patient is awake during the procedure and although novocaine is administered, it does not reach deep enough to effectively numb the pain. Also, it is difficult to fit a chest tube between two ribs and into the chest cavity. Lastly, the patient is at the mercy of the resident in the ER, who may or may not be experienced at inserting chest tubes. In retrospect, I often wonder why pain medicines were not administered before or during a chest tube insertion.

If a chest tube does not solve the problem and further surgery is needed, the options are also difficult. The main solution to fixing a repeated lung collapse is to physically scrape and scar the surface of the lung with surgical tools (a “mechanical pleurodesis”), or to chemically burn the lung using antibiotics or Talc (a “chemical pleurodesis”), or to tear out the lining of the lung (a “pleurectomy”). I have undergone two mechanical pleurodeses, one chemical pleurodesis, and two pleurectomies. Each surgery caused significant pain and numerous complications, as chronicled in Part I of this website. Lung collapses and lung surgeries are notoriously painful because the lining of the lung (the “pleura”) is extremely well enervated and is highly sensitive to any disturbance. After lung surgery, two chest tubes are left in place for several days, adding to the discomfort of the surgery pain. The aforementioned surgeries are well known as brutal among pulmonologists and thoracic surgeons, but for now they are the only options available to treat recurring lung collapses.

Secondary (Chronic) Pain:

Unfortunately, the acute and distressing pains from an initial lung collapse and lung surgery are not the only type of physical pains encountered. Once the patient recovers from a chest tube insertion or a lung surgery, he or she often has continuing, chronic pain, due to the physical trauma of the surgery.

An article published in the European Journal of Cardio-thoracic Surgery reports that chronic pain is statistically very common after surgery to repair a collapsed lung. The article “Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax”, by Passlick, Born, Sienel, and Thetter, followed 60 patients who underwent a Video-Assisted Pleurodesis or Pleurectomy. Five years after the surgery, 31.7% of the patients still had chronic pain. The study also states “In the thoracotomy group the incidence of chronic complaints was 51.8%”.

The incidence of chronic pain after undergoing *one* lung surgery is very high, and unfortunately, many patients have to undergo two or more of these surgeries. I have undergone five of the above-mentioned pleurodesis and pleurectomy surgeries. The risk of chronic pain for each surgery is 31. 7%. Multiply that number by five (one for each surgery I’ve had), and there is a 158.5% chance that someone like me will have chronic pain.

In my view, chronic pain falls into a category of its own, a separate casualty of suffering from collapsed lungs. Once the lung has been “fixed” through surgery, chronic pain sufferers are then directed to a completely new team of doctors and health care specialists in the field of Pain Medicine. Now that the lung problem has been resolved, it feels as though the patient is left with an entirely different problem requiring new doctors, treatments, medicines, and a distinctly new course of action. Unfortunately, chronic pain following a collapsed lung / lung surgery is sometimes serious or debilitating, and in some cases greatly limits the patient’s quality of life.

Unexplained Pain:

In high school, a classmate of mine, Greg, suffered a collapsed lung and had a chest tube inserted. He quickly returned to good health, but one year later, Greg experienced the exact same pain as during his first collapse. He rushed to the hospital, but a chest X-ray showed that his lung in fact was not collapsed. He was bewildered by the experience, as was I when I heard his story. Since then, I have heard this exact phenomenon described by scores of individuals, and I later experienced it myself on several occasions.

It is a confusing and frustrating situation. It feels as if your lung has collapsed, but an X-ray shows that it has not. Doctors neglect to offer any possible suggestion, tell you that your lung is “fine”, and send you home, confused and thinking that your mind is playing tricks on you. Deep down you know something is wrong with your lung, but nothing can be done about it.

One possible explanation is that a bleb has leaked air, *without* causing a lung collapse. This can and does happen frequently to people with our condition. If a congenital bleb (weak spot) leaks air, it will cause significant chest pain, even if the lung has not collapsed. I mention this because I know there are many people out there who are frustrated by what their doctors might describe as “unexplained pain”. For years I felt gurgling in my lung, followed by chest pain and pressure, and I knew my lung was leaking air. Unfortunately, ER doctors dismissed my complaints because a chest X-ray showed no collapse. I wish I had known at the time that I likely had actively-leaking blebs. When a bleb breaks, it leaks air from the lung. If the lung has already been surgically scarred to the chest wall, the escaping air will likely have no effect on the lung. Instead, the air will follow the path of least resistance. Air may enter the center of the chest (the mediastinum), or seep into other areas of the chest cavity, up into the neck or just below the skin tissue in the collar bone / clavicle area. Regardless, if you have actively leaking blebs, you will have significant pain.

I once exchanged emails with a thoracic surgeon who had published many papers on chronic pain caused by lung surgery and repeated pneumothoraces. He said he saw patients with “leaky lungs” quite frequently. He explained that doctors often miss this diagnosis because an air leak does not show up on an X-ray unless there is a collapse of the lung (or unless a very, very large quantity of air has escaped). He also said that even if a doctor realizes that there are actively leaking blebs, not much can be done, because surgery is not warranted unless the lung is collapsing. Even though I was disappointed that nothing could be done to help, I felt better knowing there was indeed a plausible explanation for my “unexplained pain”.

Lastly, you should also be aware that a small lung collapse is very difficult to spot on an X-ray. I once had a 5% lung collapse that an ER doctor couldn’t see on X-ray (the radiologist later spotted it). I also had a 40% lung collapse that an ER doctor did not see on my X-ray (in that case the ER doctor ordered a CT scan which showed the huge collapse). Any air leak or small collapse can cause terrible pain. There’s not much doctors can do to help though. In such cases, I was told to rest and hope the lung healed on its own.

I have a feeling there are a lot of people out there with a history of collapsed lungs who now experience random episodes of “unexplained pain” and I empathize greatly with all of you.

Overview of Spontaneous Pneumothorax | Counseling

How is a collapsed lung treated? Very small lung collapses (less than 5% collapsed) require little treatment and will get better with time and rest. In most cases, a chest tube is inserted to re-expand the lung. Chest tubes remove air that has been trapped outside of the lung. Chest tubes are typically left in place for several days. If the lung does not heal from the chest tube, additional surgery is required.

Currently, there are two main types of surgical procedures used to treat a spontaneous pneumothorax: a pleurodesis (physical or chemical) and a pleurectomy. During a physical pleurodesis, the surface of the lung will be scraped to cause bleeding and scarring. Although this seems counterintuitive, the hope is that once the scar tissue heals it will prevent the lung from collapsing in the future even if new blebs develop. Any blebs found during the surgery will also be removed. It is important to realize that this does not prevent additional blebs from developing in the future. This surgery is usually conducted with a small video camera and is called VATS (Video Assisted Thoracic Surgery). The video scope is placed through a small, roughly one-inch incision while the surgeons operate their tools through few other small incisions. During a chemical pleurodesis, tetracycline or other chemicals are used to burn the surface of the lung, again in the hopes of scarring the lung so that it can no longer collapse.

After this surgery a patient may have two chest tubes to help with recovery. These tubes are attached to a machine called a Pleurovac, which helps keep the lung inflated while it heals by lightly suctioning air through the tubes. Another purpose of the chest tubes is to allow blood to drain from the chest cavity. Normally a lung will heal after about four or five days. The chest tubes will be removed at this time and the patient is free to leave the hospital. Within a month most people can return back to their normal activities. This is the normal course of a pleurodesis. If complications occur, additional procedures may be required and thus more time to heal will be needed. Patients can be incorrectly told that they are “cured” by the pleurodesis and that their lungs will not collapse again. Unfortunately this is untrue. According to a prominent thoracic surgeon from Cedars Sinai Hospital in Los Angeles, about 10% of patients who undergo a pleurodesis will eventually experience another collapsed lung.

Another surgery used to treat a collapsed lung is called a pleurectomy. This procedure has been described as “brutal” by surgeons and is only used if a patient experiences several repeat lung collapses or if other attempts to repair a lung have failed. The pleura lining of the lung is literally torn from the lung in order to produce more extensive bleeding and scarring. The hope is that this additional scarring will create an even stronger lung, thus decreasing the likelihood of future collapses if a bleb develops. This procedure is more painful than a pleurodesis and will take a longer time to heal from. Unfortunately, a lung collapse could still occur after this surgery despite being declared “cured.” While these are the two most common surgical treatments, its important to check with your surgeon about any updated treatment options.

Are patients cured after surgery?
A prominent thoracic surgeon from Cedars Sinai Hospital in Los Angeles believes that roughly 90% of patients who undergo a pleurodesis will not experience another collapsed lung. While these patients may be viewed as “cured,” they may still have to deal with chronic pain. A collapsed lung, chest tube(s), or a pleurodisis surgery can cause chronic pain. In addition, these surgeries do not prevent new blebs from developing and therefore many people still suffer from pain when new blebs rupture and leak air. Patients less fortunate will experience additional lung collapses from new blebs. Unfortunately the only treatments available at this time are the surgeries discussed above. However check with your surgeon or doctors about any updated treatments.

Once you heal from surgery, are you pain free?
Unfortunately this is highly unlikely. Understand that the surgeries cause permanent scarring and damage to some of the most sensitive tissues in the human body. Often patients experience chronic pain from the physical trauma of surgery. A study by Passlick, Born, Sienel and Thetter, published in the European Journal of Cardio-thoracic Surgery found that chronic pain was very common even after minimally invasive surgery for patients with spontaneous pneumothorax. This study followed 60 patients who underwent a VATS Pleurodesis or Pleurectomy. Five years after the surgery, 31.7% of the patients still had chronic pain. It is important to consider that in this study the patients had only undergone one surgery (2001, p. 355-359). With patients who have undergone several surgeries, their chance of experiencing chronic pain is likely even higher.
While some people may experience positive results after surgery as far as preventing their lung from collapsing, surgeries cannot remove the pain associated with blebs or pain as a result of the surgery. Often after surgery, when the lung is declared “fixed,” a patient must then learn to cope with chronic pain. They are then directed to a new team of doctors who specialize solely in pain medicine. Patients can often feel frustrated and angry once they realize the surgery has left them with a whole new problem requiring a new team of doctors, treatment, medicines and direction. The chronic pain can be so severe that it can greatly limit a patient’s quality of life.

How can blebs be treated?
Blebs can be very painful even if they do not cause a collapse. Many patients will experience “unexplained pain” caused by blebs which do not always show up on an x-ray. Even if a doctor is able to determine that there are leaking blebs, nothing can be done. Surgery is only warranted when the lung collapses. Thus, a patient must simply wait patiently. A leaking bleb will either heal or unfortunately grow larger and cause the lung to collapse, then requiring surgery. Patients in this scenario are often greatly limited by pain.

Why should I consider therapy if I have bleb disease?
Going to counseling will not fix your bleb disease. However therapy can help you cope with having bleb disease. Sometimes the experience of having a collapsed lung and undergoing the medical treatment required can be traumatizing. It is helpful to process these experiences with a therapist, especially if you continue to need medical treatment. A therapist can also help you with the grieving process around losses you have experienced due to bleb disease. It is important to know that people with chronic pain often experience depression. If you experience chronic pain due to bleb disease and/or the treatment of bleb disease consider seeking therapy to help you cope with the chronic pain and any accompanying depression. Therapy can also help you negotiate role shifts you may be experiencing due to new limitations. Learning how to more effectively manage your stress is another benefit of going to therapy.

“Alex” Caroline Robboy, CAS, MSW, ACSW, CSTS, LCSW, FOUNDER & Executive Director

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A rare complication of primary spontaneous pneumothorax

Primary spontaneous pneumothorax occurs at an incidence of 1 to 18 per 100,000 population per year (depending on sex). It usually appears in tall, thin young people (asthenic type) between the ages of 10 and 30 and rarely occurs in people over 40 years of age. In most cases, primary spontaneous pneumothorax occurs at rest. Almost all patients complain of chest pain on the side of developed pneumothorax and acute shortness of breath. The intensity of the pain can vary from minimal to very severe, and is most often described as sharp and later as aching or dullness.

Diagnosis of primary spontaneous pneumothorax is based on history and identification of the free edge of the lung (i.e., a thin line of visceral pleura becomes visible) on an x-ray or computed tomogram of the chest. The recurrence rate of spontaneous pneumothorax ranges from 39 to 47%. Treatment of pneumothorax is to evacuate air from the pleural cavity and prevent recurrence. The best treatment for pneumothorax is pleural drainage. To prevent recurrence, surgery is performed on the lung either through a thoracoscopic approach or by thoracotomy. The choice of access depends on the volume of pneumothorax, the severity of clinical manifestations, the intensity of air inflow into the pleural cavity, and whether the pneumothorax is primary or secondary [1-4].

However, primary spontaneous pneumothorax is not always standard. In our practice, we have encountered a rare complication of this disease. When studying domestic and foreign literature, we did not encounter a description of such a complication.

Patient A., aged 15 was admitted to the 3rd surgical department of the clinic of faculty surgery of the First Moscow State Medical University. THEM. Sechenov 12.01.11.

On admission, he complains of dry cough, constant pain and discomfort in the left half of the chest, the pain is aggravated by movement, deep breathing, episodic coughing, swelling, swelling of the upper part of the left half of the chest, shortness of breath during exercise, occasional discomfort feeling in the chest.

History of the disease: 11.01.11 at 24:00 the patient felt moderate pain in the left side of the chest, there was a constant dry cough. Over time, the intensity of pain increased, an ambulance was called, and no pathological changes were detected on the ECG. The patient went to the medical center, where computed tomography of the chest revealed a minimal left-sided apical pneumothorax (Fig. 1). Figure 1. Computed tomography of the chest. Left-sided apical pneumothorax.

Computed tomograms of the patient were consulted in several medical institutions: taking into account the minimal radiological signs of left-sided apical pneumothorax, dynamic observation was recommended, surgical treatment was not offered. Due to the increase in pain and the deterioration of the general condition, the patient turned to the clinic of faculty surgery of the First Moscow State Medical University. THEM. Sechenov and was hospitalized.

Upon admission, the general condition of moderate severity, the position of the patient is forced. Integuments of normal coloring, normal humidity. Body temperature 37 °C. Peripheral lymph nodes are not enlarged. Heart sounds are clear, rhythmic. Heart rate 75 in 1 min, the rhythm is correct. BP 120/80 mm Hg The abdomen is soft and painless on palpation. Local status: the frequency of respiratory movements is 20 per 1 min; on examination, an increase in size and swelling of the area of ​​the pectoralis major muscle on the left, the left shoulder joint and the area of ​​the left shoulder blade is determined. On palpation and percussion of the left half of the chest, there is a pronounced sharp pain, percussion over the right and left lung fields there is a clear pulmonary sound, breathing is hard, on the right it is carried out to all parts of the lungs, wheezing is not heard, on the left in the upper parts of the lung breathing is not heard, in other parts the left lung breathing is carried out, hard, the mobility of the lower pulmonary edge on the right ± 2 cm, on the left is practically absent.

X-ray examination of the chest: in the upper parts of the left pleural cavity there is a limited amount of air (narrow strip), intermuscular emphysema in the region of the pectoralis major and trapezius muscles on the left.

On the basis of the patient’s complaints, the history of the present disease, the data of subjective and objective research methods, the diagnosis was made: spontaneous primary left-sided pneumothorax, complicated by increasing intermuscular emphysema. The patient is shown emergency surgical treatment.

Given the presence of a limited apical pneumothorax, local pleural puncture and drainage of the left pleural cavity in the region of the apex of the lung are technically extremely complex and may be accompanied by severe complications (damage to large vessels and development of bleeding). Carrying out a pleural puncture or drainage of the underlying sections of the pleural cavity due to the lack of air there also poses a high risk of damage to the lung. It was decided to perform the imposition of an artificial pneumothorax at the first stage and subsequently to make adequate drainage of the left pleural cavity.

Under local anesthesia in the fifth intercostal space along the anterior axillary line with great technical difficulties, a thin drain 3 mm in diameter was introduced into the left pleural cavity between the parietal and visceral pleura, through which about 600 cm3 of air was injected with a syringe. X-ray of the lungs revealed 1/3 collapse of the left lung (Fig. 2, a). Figure 2. X-ray of the chest organs. direct projection. a – superimposed left-sided pneumothorax.

Subsequently, a thin drain was removed from the pleural cavity and a new drain with a diameter of 0.6 cm was installed along the old drainage canal. Air was aspirated from the left pleural cavity with a syringe until it was empty. Control X-ray examination of the chest: the left lung partially expanded, the established drainage with its distal end is located in the region of the apex of the left lung (Fig. 2, b). Figure 2. X-ray of the chest organs. direct projection. b – drainage, standing in the left pleural cavity.

Subsequently, the drain was connected to a permanent air aspiration system. During the first day after drainage of the pleural cavity, the patient’s condition returned to normal, he had no complaints, swelling and an increase in the size of the area of ​​the anterior pectoral muscle and scapula on the left significantly decreased. On the drainage from the 2nd day, the discharge of air stopped, there was no discharge. 7 days after the control X-ray of the lungs (with preliminary clamping of the drain for a day), the drain from the left pleural cavity was removed. Control computed tomography of the lungs: the left lung was straightened, no pathological changes were detected in the right and left lungs, slight intermuscular emphysema on the left remained (Fig. 3).

In a satisfactory condition, the patient was discharged under the supervision of a surgeon at the place of residence. Recommended dynamic x-ray examination of the lungs after 3 months (in the absence of complaints). When examined after 3 months, the patient is healthy.

Thus, this observation once again confirms the high information content of the physical examination of the patient, in particular, examination, palpation, percussion and auscultation, which are an obligatory stage of diagnosis. In this particular observation, this made it possible to assess the severity of the patient’s condition, to diagnose the complicated course of primary spontaneous pneumothorax – increasing intermuscular emphysema, and to perform adequate surgical treatment in a timely manner. Radiation methods of diagnostics made it possible to establish oneself in tactics and control the effectiveness of each stage of treatment.

Spontaneous pneumothorax in Kyiv – private clinic Oberig. Pneumothorax, spontaneous

Pneumothorax is an accumulation of air in the pleural cavity. With pneumothorax, the lung collapses. Lung collapse can be partial (limited) or complete.

Spontaneous pneumothorax is not associated with lung injury, infectious destruction of lung tissue, or medical procedures. There are primary spontaneous pneumothorax, which develops in patients without clinically significant signs of lung pathology, and secondary – arising against the background of existing lung diseases.

Rarely, pneumothorax occurs due to a non-pulmonary pathology, such as catamenial pneumothorax. It occurs 24 hours before or within 72 hours after the onset of menstruation, and is caused by foci of endometriosis in the chest cavity.

Bullous emphysema is the cause of primary spontaneous pneumothorax in 90% of cases. With this disease, so-called bullae are formed in the lungs – small thin-walled cavities filled with air. The bullae may rupture, and then air enters the pleural cavity. In the prevention of pneumothorax, smoking cessation is of great importance, which contributes to the development of chronic lung diseases, including bullous emphysema.

DIAGNOSTICS OF SPONTANEOUS PNEUMOTHORAX

The main diagnostic method for spontaneous pneumothorax is radiography. In most cases, radiography is sufficient to confirm or exclude the diagnosis of pneumothorax. The doctor sees on x-ray a thin line of visceral pleura that is separated from the chest, or other signs of pneumothorax.

If in doubt, computed tomography (CT) is performed. This method is useful for the diagnosis of small pneumothoraxes, as well as the differential diagnosis of large bullae and pneumothorax. CT is also used to determine the cause of secondary spontaneous pneumothorax.

SYMPTOMS AND SIGNS OF SPONTANEOUS PNEUMOTHORAX

Spontaneous pneumothorax usually occurs suddenly, against the background of normal health. Although in some cases it can be provoked by physical activity, coughing, sudden movement.

The main symptoms of spontaneous pneumothorax are shortness of breath, chest pain, dry cough. The pain can be both sharp and aching, weak. It is most pronounced in the first hours after the collapse of the lung. The pain is caused by the irritating effect of air on the pleural sheets. Gives to the neck, less often to the stomach or arm. The disease is easily confused with intercostal neuralgia.

The consequences of pneumothorax can be dangerous. If a large amount of air accumulates in the pleural cavity, the mediastinal organs, including the heart, are displaced. Other complications include hemothorax, an accumulation of blood in the chest cavity.

TREATMENT OF SPONTANEOUS PNEUMOTHORAX

A patient diagnosed with pneumothorax is admitted to a specialized thoracic unit. Treatment includes three stages: expansion of the lung, determination of the causes of pneumothorax, and surgery.

Drainage of the pleural cavity is used to evacuate air and expand the lung. At the same time, diagnostic thoracoscopy is performed, which allows you to examine the chest organs and identify the cause of pneumothorax.

Spontaneous pneumothorax often recurs (in 30-50% of cases). Each episode increases the risk of the next relapse exponentially. Therefore, with spontaneous pneumothorax, surgery is indicated to prevent re-collapse of the lung.

Surgical treatment includes removal of the altered area of ​​the lung and pleurodesis – the formation of an fusion of the lung and chest wall, which protects the patient from relapses.

Video-assisted thoracoscopic surgery is currently the method of choice. The intervention is carried out through small punctures and is less traumatic. Rehabilitation after videothoracoscopic surgery for spontaneous pneumothorax is faster.

The duration of disability and return to normal life is reduced by 3-4 times. Also, thoracoscopy provides an excellent cosmetic effect, which is especially important for women.