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We have an HBOT candidate with a remote history of pneumothorax after central line placement (10 years ago) and subsequent pleurodesis. Would there be any issues or increased risk with treatment in a monoplace chamber for a non-urgent indication? I would think that since his plural space is scarred & collapsed, he would not be at risk for pneumothorax.
Nov 10, 2021 by Bill Khoury,
5 replies
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Hi, Bill! Thank you for your question. This is a frequent concern, so it is good to address it …

1) The original pneumothorax was traumatic due to a central line placement. It was NOT a spontaneous pneumothorax. (I’m laying the groundwork for a conclusion based on the facts.)
2) I really question why the patient had a formal pleurodesis after trivial trauma. That’s the real concern in this case. Are you sure it wasn’t just a pleural drainage tube for several days then removed?
3) Scarring of the pleural space. Has there been a fine or ultra fine spiral CT of the chest? In the presence of iatrogenic scarring, there may be residual air pockets that would not be seen on routine CXR. That could/might be an issue with repeat pneumothorax risk. Rare, but I have a paper on pneumothoraces associated with diving with this etiology. And, it was after a pleurodesis caused by lung trauma.

OK … conclusion coming …

If the patient has a well formed scar on CT and no residual pleural air pockets (caused by the pleurodesis), then no worries at all on going into a monoplace chamber.

We all have assumed that every pneumothorax in a hyperbaric chamber leads to tension pneumothorax. That isn’t so. I have three cases where an unheralded pneumothorax simply caused mild to moderate “chest pain” after hyperbaric exposure. All three were picked up by incidental XR for the pain workup or (in one case) PICC line insertion.

So, the answer for me is usually … prove to me why this patient should NOT go into the chamber. My only concern is an untreated spontaneous pneumothorax.

Hope that helps. Gene
Nov 10, 2021
Thanks for the response and help!
Nov 10, 2021
Thanks for the response and help!
Nov 10, 2021
Hi Dr. Worth,
Just a follow-up on this case. We were able to get further records regarding his history. He had a spontaneous pneumothorax and ultimately underwent a mechanical pluerodesis. It is not clear in the notes why this was required. The patient had a CT chest performed which only showed postsurgical and fibrotic post-radiation changes with no air pockets or blebs. Postsurgical change of the right upper lobe and lower lobe suggestive of prior wedge resection.

Although I think he would be at some risk, are their any issues you could see with proceeding with treatment?

Much appreciated
Nov 29, 2021
Elaine Horibe Song
MD, PhD, MBA
Good morning! Posting the message below on behalf of Dr Worth:

Dr. Khoury:

You have done due diligence and have a perfect plan, in my opinion. I think the risk for HBOT and recurrence of a spontaneous pneumothorax is minimal to none. I would document your medical thinking process for the record …

1) Long ago history of spontaneous pneumothorax,
2) Repaired by mechanical pleurodesis,
3) No recurrence
4) Spiral CT showed only scar tissue, and no blebs or air pockets seen,
5) Based on the above, we will proceed to treatment. Patient has minimal risk of recurrence for hyperbaric therapy.

Now, if this were a diver patient, this patient is a no/go for diving. That risk, I’m not willing to take for the sake of repeat pneumothorax with positive pressure breathing from SCUBA tanks.

All the best!

Gene
Nov 30, 2021
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