Dealing with Pneumothorax

Having had to deal with a number of spontaneous pneumothoraces over the years, I have spent a good deal of time online looking for information about procedure and pain. There are many articles online that detail exactly what a pneumothorax is, who is prone to it, why it happens and, indeed, what can be done about it, but there is very little that actually explains, in clear, laymen’s terms, what happens during the procedure, how much pain you are likely to be in, and what happens afterwards. Having been through a Pleurectomy and a Blebectomy very recently (I started writing the day I got out of hospital) I want to share with you the sorts of information that I was looking for before I went ahead with my operation.

There are a few caveats to deal with before we begin:

I had this operation done for free on the NHS in May 2012.

There was a large number of types of analgesia available to me at the start of my procedure, but as I used one option, other options became unavailable, so I can only talk about the ones I have used.

Most importantly:

I am not a doctor. I am simply a patient who happened to make a lot of notes during my stay. If you choose to use something I have said to inform, or infer a, for example but not limited to, medical decision, then you do so at you own risk. Consult a genuine doctor for such information.

What is a Spontaneous Pneumothorax?

Pneumothorax (or pneumothoraces, plural) is a fancy name for a collapsed lung. There are many different types and they happen for many different reasons and to varying degrees of severity. Thankfully, for me, my collapses, although numerous, weren’t hugely severe. In fact, so much so that I was able to lead a relatively normal life for 2 years in between being diagnosed with spontaneous pneumothorax and having the operation (in which time I had 4 confirmed pneumothoraces and several unconfirmed ones). The spontaneous part comes from the fact that it can happen at any time and for, apparently, no reason.

What does a Pneumothorax feel like?

For me, with my less severe, though numerous collapses, I consistently described it as being a cross between having a half-inflated balloon in your back, bobbing up and down as you walk, and a dislocated rib, also bobbing up and down. Breathing becomes difficult, you will be unable to fill your lungs to capacity and as a result you will have lots of paraesthesia (pins and needles). When it was really bad, I would get pins and needles in my face, teeth and ears.

Why has one (or both) of my lungs collapsed?

There are many reasons why a lung can collapse. They range from lung infections and diseases, like lung cancer, to chest trauma and congenital diseases and disorders, like Marfan’s syndrome, all they way to just being like me, a tall and thin male in his 20s.

Will my lung go back up by itself?

It depends. Mine did, and that is perhaps the reason why it took me so long to sort it out, however collapsed lungs can be, and often are fatal. Always err on the side of caution.

How is a Pneumothorax confirmed?

Usually by X-Ray of the chest, but sometimes your doctors might take a CT scan. If you’re not at a hospital, then your doctor will use a stethoscope to listen to your chest, and will then tap on your chest and your back at various points, listening to the sound of the reverberation. (Although this will normally be followed with “go to the hospital and get at X-Ray”.)

Do I have to go to the hospital?

Yes. I was a fool, and didn’t go the hospital, on many occasions, and simply tried to cope with it. Although I did manage to cope with it in most cases, I regret this now. Even simple things, such as sleeping, was made more difficult. For two years I was unable to lie on my back or on my left side due to lung pain.

What can be done to prevent future Pneumothoraces?

If you have only had one pneumothorax, then you will have a chest drain inserted. This is a plastic tube inserted into the Pleural space between your lung and the chest wall. On the other end of the tube is a plastic bucket with a small amount of water in it. The air that has escaped from your lung, or the secretions that have built up in the pleural space, causing the collapse, will drain out of the chest via the tube, and into the bucket. The water creates a vacuum, preventing the drained substance from going back into your chest. If you do have a chest drain, then it must be kept below the level of your lung, otherwise anything that has collected in to the tube, but is not yet in the bucket may flow back into your chest. This is called backflow, and this is not helpful.

Drain tube enters the chest.

If you have had multiple pneumothoraces, or recurring pneumothoraces, then there are operations available that try to minimise the likelihood of a collapse happening again in the future.

First is a Pleurectomy. This is where the pleural lining is removed from either the interior of the chest wall or the lung itself (I’m not sure). The lung is then re-inflated, I assume naturally, and sticks to the pleural wall, meaning that it is harder for the lung to collapse in future. Access is gained by either VATS (Video Assisted Thoracic Surgery), essentially keyhole surgery, or by open access surgery, where an incision is made below the ribs, and all surgery is performed through that.

Also available is a Blebectomy. On the top of the lung are little blebs which aren’t as strong as the rest of the lung. These blebs are prone to bursting, and when that happens they let small amounts of air in between the lung and the chest wall, causing a collapse. In a Blebectomy, the surgeon removes the affected area, and staples the lung back together. Access is the same, via VATS or open surgery.

I had both of these operations. It is important to note that these operations do not stop pneumothoraces completely; there is still a chance that it will happen again, although that chance is much lower than if you don’t have any of the operations.

How painful is the operation going to be?

The short answer is; very painful. On the plus side, there are lots of options available for pain relief.

Paravertebral block. Similar to an Epidural, a line is put in your back and blocks one side or the other with pain relief. The downside is that there is no way to be sure of which side of the chest the paravertebral will block.

Another option is the Epidural. A line is fed into your back, in between two vertebrae. Analgesia is fed into a small area in the back, and the result is that both sides of the chest are blocked from pain. In most cases. My anesthetist and I decided that an epidural would be the better choice, thinking that it would be better to block both sides from pain, rather than risk only one side being blocked, and that side being the wrong side. As it happened, after two days of having my epidural in, it stopped blocking on the affected side of my chest, and left me in a considerable amount of pain. Luckily there are still other options available.

Oxycontin can be introduced into your system either orally or by intravenous drip. In the beginning, I took Oxycontin orally every 12 hours, and Oxynorm orally every 2 hours. This worked well until an X-Ray showed that my lung still hand’t fully raised, and I needed a second operation to drain the fluid, and possible clot, that had collected in my pleural space, preventing my lung from fully inflating. For some reason a paravertebral was no longer an option, I think something to do with a now lack of pleural lining. So after explaining to my anesthetist that I didn’t want another epidural, in case the same thing happened again, the decision was taken that an intravenous drip of morphine, combined with lots of anti-sickness, would be the next best option.

What is Morphine like?

Oxycontin, Oxynorm and Fentanyl (the drug that was in my epidural) are all based on Morphine. Morphine is a very good pain killer, but that is where its goodness stops. It made me very nauseous. The combination of morphine and general anesthetic made me very ill as I came out of recovery the first time. It also makes you itch like you’ve had an all-over tattoo on-top of a 1 day old all-over tattoo, and lastly, it gives you very strange dreams. The only one I came out of hospital remembering involved Michael Cera and Sue Perkins having a fight around the cheese counter at my local Morrison’s supermarket. Although I do remember lots of other Escher-esque, frightening and vomit inducing dreams. To combat this, hospitals do have lots of anti-sickness medications, but like all drugs, there is only a certain amount of those you can take an hour.

Morphine will also make you constipated. So on top of all your pain and anti-sickness meds, you’ll also be taking laxatives.

What is going to happen after the operation, and how long will it take?

Expect your stay in hospital to last a minimum of 5 to 7 days, but don’t be surprised if you end up staying in longer than 10 days.

Once out of theatre, and once fully conscious, you’ll find that your chest will be attached to at least one chest drain. You may also find that the drain is attached to a ‘Thoracic Suction’ tube. This tube creates a vacuum, helping to pull out any air, liquid or anything else in your chest that should’t be there.

1 Jar per tube.

If you are on suction, then you won’t be able to move any further than the length of the tube, this means that you won’t be allowed to use the toilet, and will have to use bottles and commodes. Nobody likes using bottles or commodes, but the sooner you realise that everybody else on the ward is also on suction, it should become a little easier for you.

It is important to get up and mobilise, so as soon as you feel able, get out of bed and march on the spot. It may look a little silly, but the quicker you can stretch out your lungs to their fullest extent, and fill them with as much air as possible, the quicker you’ll get off suction, and get home. As soon as you do get off suction, try to walk around as much as you can.

During your stay, you’ll be visited by a physiotherapist. Their job is to get you up and about, and get your lungs fully expanded. The sooner you do this, the sooner you get to go home. One of your exercises will be to cough. Coughing helps get rid of anything accumulating in your lungs and trachea. It will hurt to cough, but if you don’t do it, you’ll end up with pneumonia. Getting pneumonia is a very real danger, so much so that one of the patients in my ward who was unable to cough anything up, had to have a tracheotomy so that the nurses could use a machine to suck the phlegm out of him. So it is very important to cough up as much stuff as you can.

Another one of your exercises aimed at expanding your lungs will be regular deep breathing. While I was in hospital, I was given an Inspired Volume SPIRO-BALL, which measures your lung capacity in millilitres. It was 6 1/2 weeks after I got out of hospital before I was able to breathe in the full 4000ml, so while it’s important to try to breathe in as much as possible, don’t try too hard, it’s going to take time.

It was 6 1/2 weeks after leaving hospital before I could reach 4000ml

Aftercare

When you do finally get out of hospital, there are a few different scenarios you could be faced with. You could be all sealed up and ready to go, you’ll probably still have your pain killers, but if this is your scenario, then you shouldn’t have too bad a time of it. Another scenario is that you will go home with a Portex bag – a portable chest drain. If this is the case, then you will almost certainly still have your pain pills, and you’ll have a lot of trouble sleeping with that tube still in.

Portable chest drain

DON’T FORGET TO KEEP THAT BAG LOWER THAN YOUR LUNG!

On the day that your tube finally comes out, you’ll be very relieved, but there is a downside. I’m not going to pussyfoot around it, when they take the tube out, it is going to hurt, so make sure you take some painkillers with you. In order to make sure that no air gets into the chest when they remove the tube, they have to pull the tube out very quickly and, doubly quickly, pull the suture completely closed and tie it shut. This, for me, was one of the single most painful 5 seconds I have ever endured–and I once crushed my thumb in the hinge of an oak door! Once the tube is out, that’s not the end. You have to wait around the hospital for a period of time, for me an hour, in order to have a delayed X-ray to check the lung hasn’t collapsed again.

Even then, this is not the end. After 5 days, your suture has to come out, regardless of whether or not your wound has closed, it must come out. In my case, the first wound, which was the last to have its tube removed, hadn’t closed in that time, and I was left with a . . . less of a hole, more of a crater. (Which can be seen here if you wish to see it.) Sadly this wound got infected, twice, which required penicillin and generally slowed down the healing and closing process. Even now, 7 weeks later, I have only just switched from having to see the nurse everyday to change the bandage, to being able to do it at home.

Regardless of the which entry method they use, you’re going to end up with at least 1 scar. This endeavor has left me with 3 new ones to add to my existing 5.

Conclusion

With hindsight, I can now say that I am glad I finally had it done. Even though the procedure for dealing with it was just as bad, if not worse than the collapses themselves, as long as it stops them happening again, then it will have been time well spent.

If you want anymore information, or have questions about things I haven’t covered, then please email me using this form  (UPDATE: As of 03/06/13 this form is now working correctly. Thanks for letting me know.)

Related Links

http://www.medicinenet.com/pneumothorax/article.htm

http://www.patient.co.uk/doctor/Pneumothorax.htm

http://www.nursingtimes.net/nursing-practice-clinical-research/evaluating-the-treatment-options-for-spontaneous-pneumothorax/204220.article#

There is another surgery option available called Pleurodesis. This method involves puffing talc onto the lung in order to induce scarring, and subsequently stick the lung to the chest wall. I did not discuss this method because I don’t know a great deal about it, however, there is a lot of useful information here: (note that Pleurodesis treatment is NOT limited for use solely where a Cancer is present.)

http://cancerhelp.cancerresearchuk.org/about-cancer/cancer-questions/pleurodesis-treatment

A helpful forum:

http://blebinfo.co.uk

Author: Dan

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