Thoracoscopic talc poudrage of the entire pleural surface constitutes happy treatment of recurrent pneumothorax in cystic fibrosis (CF); however.

Thoracoscopic talc poudrage of the entire pleural surface constitutes happy treatment of recurrent pneumothorax in cystic fibrosis (CF); however, after lung transplantation is seriously jeopardized owing to the development of extensive pleural adhesions. We describe a 27-year-old patient with CF with periodical right-sided pneumothorax, refractory to chest tube drainage and to chemical (tetracycline) pleurodesis, who was prosperously treated with a localized, apical thoracoscopic talc poudrage, thereby preserving the possibility of after lung transplantation.

(Chest 1994; 106:262-64)

CF=cystic fibrosis; LT=lung transplantation

Pneumothorax is a resort to frequently and potentially life-threatening complication of cystic fibrosis (CF) occurring in up to 19 percent of patients with CF who reach adulthood.(1) The treatment of pneumothorax in CF as well as in other underlying chronic pulmonary diseases(2), remains a cause of debate in the literature; simple observation, chest tube drainage, chemical pleurodesis with intrapleural instillation of irritants, thoracoscopic talc poudrage, and surgical pleural ablation(3)(4)(5)(6) all have been advocated. However, since the advent of lung transplantation (LT) for patients with CF(7) treatment of pneumothorax should, whenever possible, aim to avoid growth of extensive pleural adhesions which take the part of a relative contraindication for after LT. We present a patient in whom simple chest tube drainage and tetracycline instillation failed to achieve pleurodesis, whereas local thoracoscopic talc poudrage (which was limited to the lung apex, thereby avoiding extensive pleural adhesions) was successful

CASE REPORT

A 27-year-old patient with CF with exocrine pancreatic insufficiency, diabetes mellitus, and respiratory pulmonary insufficiency requiring long-term oxygen therapy, was admitted to the hospital for unforeseen increase in dyspnea and a torpid right thoracic pain. He was extremely dyspneic and cyanotic with reduc breath hales over the right lung. Arterial posterity gases showed an acute-on-chronic respiratory acidosis and censorious hypoxemia (pH, 7.32; [PaCO.sub.2], 74 mm Hg; [PaO.sub.2], 51 mm Hg; bicarbonate, 39 mEq/L; total [COsub2] 41 mEq/L; base exces +102 mEq/L; and oxygen saturation, 75 percent upon 7 L/min supplemental oxygen). Chest radiograph showed a unimpaired right-sided pneumothorax (Fig 1). A chest tube was immediately inserted and active suction (-20 cm [Hsub2O] was applied. There was immediate clinical improvement; arterial life-current gases were as follows: pH 739; [PaCO.sub.2], 68 mEq/L; [PaO.sub.2], 50 mm Hg; bicarbonate, 42 mEq/L; total [COsub2] 44 mEq/L; base exces +14 mEq/L; and oxygen saturation, 82 percent

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Since respiratory tract infection was suspected (low-grade agitation abundant purulent sputum, elevated C-reactive protein plains and erythrocyte sedimentation rate), intravenous antibiotics were added (ticarcillin, 5 g three times a day; amikacin, 675 mg one time daily). Two days later, the active tube suctioning was discontinued for 24 h without resort or air bubbling. The chest tube was remov the nearest day. Nine days later, there was a quickly prepared and dramatic increase in dyspnea befitting to recurrence of the right-sided pneumothorax, followed by dint of ventricular fibrillation and respiratory arrest. Cardiopulmonary resuscitation and electrical defibrillation were begun, together with insertion of a of the present day chest tube with active suction. There was quick and consummated cardiorespiratory recovery. Two days later, chemical pleurodesis with tetracycline, 20 mg/kg intrapleurally, was performed. Forty-eight hours later, again after 24 h of discontinued suctioning, the chest tube was remov without immediate return However, 8 days later, there was a inferior recurrence of a symptomatic right-sided pneumothorax. This time, sum of two units chest drains (one apical, common posterolateral) were inserted.

Despite active suction (-20 cm [Hsub2]O) at the couple chest tubes, apical pneumothorax persisted with a persistent air leak at the apical tube. When suction was interrupted, there was a significant increase of dyspnea and oxygen desaturation. Since, at that time, the patient was still a possible candidate for LT we decided to perform thoracoscopy with talc poudrage limited to the lung apex to limit the volume of pleural adhesions.

in a less degree than general anesthesia and controlled ventilation via an endotracheal tube, the thoracoscope (Storz, Germany) was inserted by means of the fifth intercostal space at the midaxillary line. A stiff, sternly deformed lung was seen, as well as multiple organized pleural adhesions. Inspection of the upper lobe showed important scarring and deformation, nevertheless no individual or ruptured vesicles or bullae were seen. A next to the first 5-mm trocar was inserted a hardly any centimeters anteriorly from the first insertion; talc poudrage of the lung and thoracic apex using 25 g of sterile, asbestos-free talc was performed between the walls of the second entrance, after careful dissection of apical adhesions. Thereafter, a 28Fr chest tube was inserted into the apex beneath direct vision. Postoperative recovery was quick and commonplace There was complete reexpansion of the right lung Ten days later, the chest tube was remov (Fig 2) There were no the having recourses of pneumothorax in a 2-month follow-up period. The patient ultimately decided against HLT

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