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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.
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Thanks for the quick reply and reaching out to your colleague!
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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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.
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:
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.
I’ve read about this too which does worry me a bit… but I also have no idea how the two might compare.
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).
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…
Archm, roughly where do you live? You need to see a pulmonary specialist. I’m also a pulmonologist and would happily recommend a good center or maybe even a person near you.
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I live in BC, Canada, so I suspect this might not work out… but still appreciate the reply!
I assume a pulmonary specialist is just another name for a respirologist? Looking at the bio of the respirologist who helped me investigate my pseudo-AVM situation, it looks like he specialized in CF research specifically.
Hello, back again! Sorry, it has been a busy week. Without seeing you as a patient, it’s hard to get too in the weeds. I think you do need to see a pulmonologist (which is the same thing as a respirologist) who can listen to your story and do full pulmonary function testing, a serologic workup to assess for connective tissue disease and other conditions (ex: Alpha-1 Antitrypsin Disease) and likely, a repeat CT. They could then follow you longitudinally. Bottom line is that your story sounds somewhat concerning and there remain a lot of question marks. However, with an appropriate work up and follow up available, I see no reason why physical activity to include resistance training is out of the question but would stand by my initial statement regarding a potential need to modify your training depending on the results of a pulmonary evaluation.
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Just came off very busy week as well, sorry for delay. Completely agree with Dr CyGuy, see a respirologist. Someone at UBC or Univerosty of Washington would be fine I’m sure.
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