Perfusion disturbances existed mainly in the apical lung parts, both at the affected and healthy side. The frequency of disturbed perfusion in the affected lung compared with the non-affected lung is greater in this group than in the SHP-group. Basal perfusion defects existed only in two cases, only in the affected lung. Beside apical and basal lung parts, diminished perfusion in this group existed in central lung zones affecting diseased side in one and the healthy side in two patients. Ventilatory disturbances also affected apical lung parts. Comparing the affected and non-affected lung, perfusion disturbances were more frequent at the diseased side, whilst ventilatory disturbances did not follow that pattern.

Results of the same investigation in the SHP-group are shown on the table 6.

Table 6. Perfusion and ventilatory lung scan in the SP-group

In this group, perfusion of the apical lung regions is decreased both in the healthy and in the affected lung. Only in one case decreased perfusion of the basal parts of the lung at the affected side was found, without the same finding at the healthy side in any patients. Ventilatory disturbances more frequently existed in the apical parts of the lungs on both sides with basal hypoventilation in the affected lung in 3 patients. Neither perfusion, nor ventilatory differences between the affected and non-affected lung were statistically significant in this group.
Using the Fisher’s test, no significant differences were found between the SP-group and the SHP-group concerning the aforementioned analysed parameters.

In both groups pulmonary clearance was determined and expressed as T/2 i.e. the time that is necessary for the radioactivity to decrease to the half of the maximal value. This parameter reflects the lung epithelial permeability. Values of the pulmonary clearance in both groups are shown on the table 7.

Table 7. Lung clearance

The analysis of this parameter in both groups showed that there were no differences between the affected and non-affected lung among non-smokers. In the smokers group, the obtained values were lower comparing with non-smoker, that is not surprising.
 

Discussion (back to Quick Links)

What is the aim of assessing regional lung function changes in patients with healed SP and SHP and what is the reason for treating these two condition as separate groups?

First, it is not still established whether there is one single factor contributing to blebs isolation or if it is the consequence of the combination of many factors; is it the consequence of simple obstruction of small airways by mucous plugs or may be of its combination with regional lung function disturbances.

Second, in most scintigraphic studies in the acute phase of SP regional lung volumes are usually expressed as fractions of regional TLC. In lungs with SP, TLC is decreased so that at TLC level, units in the lung with SP are less expanded than those on the contralateral side. This fact also supports the usefulness of data obtained after full lung reexpansion has been achieved.
Third, emphysematous valve vesicles develop through local emphysematous changes representing frequent residual of many pathologic conditions in the lungs and may occur as solitary vesicles on the lung borders ¹⁰. Localised emphysema, found in all age groups and usually asymptomatic, is caracterised by this type of vesicles representing an important cause of SP ¹¹.
Finally, having in mind that the source of intrapleural bleeding in SHP are torn adhesions between the chest wall and the collapsed lung, the aim of treating of SHP as a separate group is to reveal eventual differences in regional lung function distribution between SP and SHP that could be the cause of different effects of the elastic lung recoil - in most cases lung collapse without tearing adhesions, and only in few cases tearing of adhesions supplied by the systemic circulation.
Unlike  SP, where different imaging procedures together with the analysis of the operative specimens renders insight in the etiologic factors ( 762 pts in a 5-years period - table 8), SHP represents potential  life-threating condition, usually requiring urgent treatment. That’s why regional lung function assessment in the stable phase is practically the only possible method contributing to the better comprehension of pathophysiology base of this condition.

Table 8. Etiologic factors

Obtained results of the respiratory function tests in both groups indicate the existence of some degree of lung hyperinflation that confirms similar results of other authors (Lesur, Delorme, De Troyer, Jernault). Some authors even state that a certain degree of lung hyperinflation exists up to 3/4 patients with spontaneous pneumothorax ¹².
Concerning the type of the ventilatory disorder, difference between the two analysed groups is the lack of obstructive ventilatory disorder in SHP group. The cause of this difference is not clear if taking account about the similar age of patients in both groups.
Existence of obstructive ventilatory disorders in the SP-group does not differ from similar investigations in which Tiffenau-index is rarely under 60-70%. Of course, such a finding is characteristic for the primary SP, while in selective analyses depending on the existence or absence of COPD, Tiffenau-index can be significantly lower.
Among all analysed parameters, statistically significant difference between groups existed only for diffusion capacity. Diffusion disorders, registered in many published series, are by most authors attributed to the existence of multiple bullae or blebs, but not to the diffuse lung emphysema. Galy ¹³ states that even localized bullous lesions can induce the decrease of diffusion capacity without coexisting diffuse emphysema.
Results of scintigraphic evaluation in both groups support the literature data with more frequent difference between the affected and non-affected lung in the SP-group in terms of perfusion defects. Finding of ventilatory disorders that are most prominent in apical lung zones, and without significant differences between sides, are in some disagreement with the literature data, the latter comprising decreased ventilation at the affected side.
 

Conclusion (back to Quick Links)

Obtained results, although indicating the existence of some degree of lung hyperinflation, and supporting generally expected distribution of ventilatory and perfusion disturbances, do not render enough data for regional lung function disturbances to be considered a contributive factor in the occurrence of SP and SHP. Besides, the analysis of the pulmonary clearance did not confirm the existence of impaired integrity of the alveolo-capilary membrane.
 

References (back to Quick Links)
 

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10. Ohata M., Suzuki H. Pathogenesis of spontaneous pneumothorax (with special reference to the ultrastructure of emphysematous bullae)
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11. Perry M.A.  On spontaneous pneumothorax  Quart J Med 1939; 8: 1. (back to text)

12. Lesur O., Delorme N., Fromaget M.J., Bernadec P., Poly M.J.  Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax
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13. Galy P., Brune J., Dorsit G., Wiesendanger T., Brune A.  Interpretation de l'abaissement de DLco/Va dans les emphysemes radiologiquement bulleux
Bull Physiopathol Resp 1968; 4: 749-62. (back to text)

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