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Primary Spontaneous Pneumothorax

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  • Primary Spontaneous Pneumothorax

    I've had a bullectomy and pleurodesis done on my left lung in 2010 and my right in 2019. The PSP on my left seemed to have no obvious trigger beside a particularly stressful and emotional event. I took up lifting some time in 2016/2017, and the first PSP of several afflicting my right lung happened in March of 2019. I'm almost certain it happened as a result of me trying a different breathing cue for an overhead press, but it could have just been the last straw for an event that was slowly building up over time. I had two more PSPs before I finally had a bullectomy and pleurodesis done, one of which seemed to show up after lifting, and another that was triggered by simply getting a pre-op CT scan of all things. I even needed to get the pleurodesis redone since I had a pneumo shortly after being discharged after the surgery.

    I got evaluated for Marfan's after the 2010 event, not through genetic testing, but through the scoring system. I've had a few echos done and there doesn't seem to be any aortic dilation. The opinion seems to be that I "probably" don't have it, or perhaps some mild form that doesn't have some of the worse symptoms. It just seems like I won a bad luck lottery and it got chalked up to me being tall, thin and male. After requesting some reports, I also found out that my left lung developed one smaller sized bleb adjacent to the staple/suture line of the bullectomy. The docs didn't seem to think it's worth mentioning, and after looking around it seems that this is a somewhat common place for the blebs to reappear, probably as that part of the lung experiences the most stress. Since that CT imaging was done in 2019 and the surgery was done in 2010, I'm not sure when or how quickly it developed.

    Having a chest tube inserted is an awful experience, and having had so many done (and redone) has been traumatizing, especially since I only got lucky with one of them being relatively painless. It's been months since the surgery and I'm only now gathering the courage to try lifting again. Most docs I discussed this with, including the thoracic surgeon, seem to think it's probably okay to continue lifting. There doesn't seem to be a particularly strong consensus on this though. I went looking for any sort of research on the topic and there didn't seem to be much. I think I did find one report published decades ago questioning the a link with the Valsalva maneuver and PSP cases, but that's about it.

    I'm not sure if I have the info needed to determine whether these blebs were present as part of my growth or worsened as a result of stresses like from doing heavy lifts. I could perhaps try to hunt down the CT imaging from 2010 and compare it to that of 2019, but I don't even know if it would be useful, and it's been difficult getting in touch with docs now that my situation has improved a bit. Just going by my own experience, I feel like it might be safer to adjust my breathing and bracing techniques though. I used to get as much air as possible into my lungs before bracing and committing to a lift. I combined this with trying to get air in at the top of the overhead press, and it was some time during the negative part of the movement that I think I felt the onset of my pneumo. I don't really understand the details of the lung anatomy or how it's affected by external/internal stresses generated from lifting. Would it make sense to do something like 80% of a full breath while bracing? Would that possibly create less pressure within the lung that might be stressing or stretching the tissue? Is this endeavour just going to compromise my lifts and endanger my back? Any thoughts in general about my situation?

    Sorry for the long post, and thanks in advance for any tips or ideas!
    Last edited by archm; 02-07-2020, 01:08 AM.

  • #2
    Sorry to hear about all this -- sounds very frustrating!

    I've passed this along to a pulmonologist colleague who will chime in as well.

    Would it make sense to do something like 80% of a full breath while bracing? Would that possibly create less pressure within the lung that might be stressing or stretching the tissue? Is this endeavour just going to compromise my lifts and endanger my back? Any thoughts in general about my situation?
    It's hard to say whether taking a smaller breath would have a significant effect here. On the other hand, I would not have concerns about your back safety here either.
    IG / YT

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    • #3
      Thanks for the quick reply and reaching out to your colleague!

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      • #4
        Hey! I am said pulmonologist. Before I begin, usual disclaimer applies - I'm not your doctor and virtually know nothing about you. These are just my musings as someone who knows things about lungs...

        This is an interesting case to be sure. Did you have a surgical lung biopsy? Do you have cystic lung disease? Cystic fibrosis or a variant thereof? I have to imagine you have had an extensive work up at least once. If not... You need one. I can understand the concerns you have and the predicament you are in. I think the safest guidance in this particular circumstance is that if happened once, and then again, it's quite possible to happen again. I'm not familiar with data regarding valsalva in particular but we do know that folks on mechanical ventilation at high pressure tend to develop lung injury. This is worse for folks predisposed to lung injury (i.e. those with connective tissue disease).

        So I guess you really need to be followed closely by a pulmonologist. You need to have a thorough evaluation. You may benefit from recurrent imaging with low dose CT or something like that to ensure you aren't developing blebs. As far as lifting, any doctor who says go ahead and lift whatever, however, because you are completely out of the woods... Is probably not a doctor. I think the safe thing to do is ensure you have had an appropriate evaluation, you have a decent lung doc, and you are just careful. Maybe that means you have to adjust your valsalva so it's not as vigorous as you'd like it to be? Maybe you need to change your approach to training overall? I really don't know and I can most promise with 100% certainty that there is no data to guide this specific scenario.

        That said, I will continue digging and if I find something I'll report back.

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        • #5
          Hey there, thanks so much for taking the time to make an account and comment Dr.CyGuy! Apologies in advance if I for the long reply and all the questions, irrelevant details or mangle terminology below.

          I should start by saying I'm male and was 19, 6'4" at about 165lb with my first case in 2010, and 29 at about 210lb with my recent batch of pneumos.

          Originally posted by Dr.CyGuy View Post
          Did you have a surgical lung biopsy? Do you have cystic lung disease? Cystic fibrosis or a variant thereof?
          My understanding is that the resected parts of the lung from the bullectomy were sent to pathology. Is that sufficient to rule out those issues like a biopsy would? I never got pathology details back about my 2010 surgery. None of my docs mentioned cystic lung disease this time around either, aside from listing it off as possible causes of pneumothorax in the academic sense.

          There were two bonus findings that I skipped over above. First, my thoracic surgeon described a part of the lung that "didn't look good / was red", so he removed it to be safe. This had me in a bit of a panic thinking about what horrible things it could be, so I requested the pathology report for it:

          Code:
          A) Right upper lobe wedge resection:
          1) The microscopic examination demonstrate pleural bleb/bulla formation with reactive changes
          2) Findings are consistent with clinical history of spontaneous pneumothorax
          
          B) Right lower lobe wedge resection
          1) The microscopic examination demonstrates foci of pleuritis and mesothelial hyperplasia.
          2) Findings are consistent with clinical history of spontaneous pneumothorax
          
          Paraphrasing:
          Container A
          7.5 x 4 x 3 cm, at least 6 bleb/bullae identified  on the pleural surface ranging from 0.5cm to 2.5cm in greatest dimension. Remainder of pleural surface is tan/dark brown, smooth and glistening. No discrete masses/lesions. Staple line is intact and measures 8.2cm in length. The specimen is sectioned serially and perpendicular to the staple line. The lung parenchyma is tan to brown, homogenous, no discrete masses identified
          
          Container B
          6 x 2 x 1.2cm. Pleural surface is tan, smooth and glistening, no discrete masses or lesions. Staple line is removed and measures 6.3cm in length. More stuff about sectioning and colours, nothing interesting.
          The terminology sounds scary, particularly "mesothelial hyperplasia". I looked up the terminology and to the best of my understanding it just sounds like part of the lung/pleura was irritated. I figured it could have just been from all the poking and prodding I took with the previous 4-5 chest tubes, but maybe that's a dumb theory. Assuming it's benign, it sounds like part of my lung was sacrificed overzealously. My surgeon reassured me I won't miss such a small part of my lung, but those sections sound quite large to me without any context for what normally gets resected.

          There was also an incidental finding on my left lung in the initial chest CT. A different doctor (a respirologist) took care of me for that. He described it as being sort like an AVM, but it wasn't clear from imaging. I did another CT with contrast, apparently with different timings(?) to make the image more clear, and also did a bubble study. As I understand from his description, the lungs can act as a filter for clots, air and possibly other things in the blood, which I have never heard of. Apparently this strange interwebbing of blood vessels could potentially bypass that mechanism presenting a risk of (brain) stroke. He seemed happy with the results and decided no further treatment was necessary. Apparently the treatment would have been some sort of coil insertion to kill off those vessels.

          I wanted to figure out if it was congenital since I read that's the case with AVMs, so I asked if it was present in the 2010 CT imaging. Apparently my lung was so deflated at the time that it wasn't possible to discern anything. The doc told me this type of structure can possibly present itself following resection/pleurodesis or other types of trauma, but I haven't found anything written about this. I really liked this doc since he took a lot of time to explain everything to me, so I'm hoping everything he said was correct. Have you seen anything like that in the literature or your experiences?

          Aside from that, I've had biennial echos for my aortic measurements and see an ophthalmologist to check my lens/retina health just in case I have other CTD issues. Aside from being severely myopic things look fine, the echo reports fluctuate a few mm here and there but it seems to be within error of measurement.

          Originally posted by Dr.CyGuy View Post
          We do know that folks on mechanical ventilation at high pressure tend to develop lung injury.
          I've read about this too which does worry me a bit... but I also have no idea how the two might compare.

          Originally posted by Dr.CyGuy View Post
          You may benefit from recurrent imaging with low dose CT or something like that to ensure you aren't developing blebs.
          I haven't thought to ask about this, and none of my docs mentioned that option. I figured the only way to know if lifting is unsafe is to just do it and find out if I get another pneumothorax. Maybe even just one more CT would be a good idea after lifting returning to a safer routine, but I have no idea how long to space it out. Any thoughts? I'm also not sure if I'd be able to convince the docs it's worth the use of resources. I do know I have one bleb on my left lung adjacent to the staple, but for all I know that could have been there since the surgery... I'm also a little concerned about radiation, since I've had something like 4 chest CTs (2 with contrast), and probably hundreds of chest x-rays (basically 4 every time I think I have a pneumo, every day in recovery at the hospital, etc).

          Originally posted by Dr.CyGuy View Post
          As far as lifting, any doctor who says go ahead and lift whatever, however, because you are completely out of the woods... Is probably not a doctor.
          Haha, that's a bit worrying since the consensus among them all did seem to be "return to living your normal life", with maybe one or two mentioning the usual concerns about scuba diving or skydiving which I don't think I'm going to miss anyway.

          I'm also wondering... how screwed am I if I get another pneumothorax again? Is it possible to get surgical access to perform another bullectomy now that I've had a pleurodesis done? I've seen people speculate that air pressure changes in a cabin could potentially rupture a bleb, but I haven't found evidence to support that. It sounds like an existing pneumothorax can get bigger and pose a threat, but apparently they are very rarely fatal in otherwise healthy people. I do have some anxiety about travelling long distances since I'm not sure if I could get an emergency needle decompression or something like that done mid-flight with whatever is available in the medkits on planes...
          Last edited by archm; 02-12-2020, 01:29 AM.

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