Scott Webb (Host): Spontaneous pneumothorax or collapsed lung is probably more common than you'd think. My guest today is here to discuss the symptoms, risk factors, and treatment for this condition. I'm joined today by Dr. Mary Maish. She's a Thoracic and Fore Gut surgeon, Board Certified by the American Board of Surgery and the American Board of Thoracic Surgery, and an independent provider who chooses to practice at Franciscan Health.

 This is the Franciscan Health Doc Pod. I'm Scott Webb.

Doctor, it's nice to have you here today. We're going to talk about spontaneous pneumothorax, and those are just not things that I say. I've definitely never said pneumothorax out loud before, but we're going to cover symptoms, risk factors, treatment, all of that. So let's start with the most obvious one. What is spontaneous pneumothorax?

Mary Maish, MD, MPH: Thank you, Scott. Spontaneous Pneumothorax is just a fancy name for collapsed lung. That is where your lung, which is basically like a balloon inside a box, has collapsed. So now the balloon has shrunk and has no air in it, and there's a lot of space inside the box. In the human body, the box is the chest wall made up of ribs and muscle tissue, and it really is just a box.

And we breathe air into our lungs, which is like the balloon, and allow our lungs to be inflated and fill the entire box. So the spontaneous pneumothorax is where the lung collapses spontaneously for no known really good reason.

Host: Yeah. Even being a lay person, I was like, all right, I know what spontaneous means. It means it's probably pretty unexpected, but the pneumothorax part. Got it. So a collapsed lung. So then what are the symptoms that someone might experience? Is it shortness of breath? Like, how does someone know if they're suffering from this?

Mary Maish, MD, MPH: Right. So some people, because the collapse of the lung can happen very slowly,

Host: Hmm.

Mary Maish, MD, MPH: Some people can actually accommodate to the change in the size of their lung as it happens slowly over time and will have no symptoms, until it kind of reaches a threshold. And then once the lung has collapsed past a certain threshold, then you would experience things such as shortness of breath or chest pain, especially pain kind of concentrated on the side of the chest where the lung has collapsed.

So if it happens on the left side, sometimes it can be confused with having a heart attack. It is distinctly different pain for people who have had both. But it is something that usually presents with pain and or shortness of breath.

Host: Right. Yeah. And so when you say spontaneous, that doesn't necessarily apparently mean suddenly. Do we know why these, this condition this collapsed lung? Like do we know why it happens?

Mary Maish, MD, MPH: Yeah, so you're exactly right. The spontaneous nature of it is not necessarily sudden and can kind of come on over a long period of time, but there are things that can make it happen suddenly. So common things are traumatic accidents. So for instance, it's not so uncommon for young kids playing football to have a pretty hard hit and then the lung will collapse quickly and spontaneously and then cause the collapsed lung.

But other things that can cause collapsed lung other than trauma and trauma can include also things like a car accident or a fall off of a horse, or a bike riding accident, where you may not even have any broken ribs that would puncture the lung and allow the air to escape into the chest cavity causing that balloon or the lung to collapse.

But it can just be blunt force trauma or trauma that causes no break of the skin or break of the bones, that can cause that lung to collapse. So that's one very common thing. The other would be, penetrating trauma. So, a gunshot wound or a knifing or even, if you fall off of a horse or you fall off of your bicycle or in a car accident and you break a rib.

The rib can quickly, break and the point of the broken rib can then pierce the chest wall cavity and cause the lung to collapse, allowing air to kinda get inside that box and put that lung and have it collapse. There are some other things that can cause lungs to collapse and more commonly now, we're seeing a lot of people, especially young people that are vaping that can cause lung collapse. And this is because the amount of pressure that is created inside the lung can sometimes be too much that causes those lungs to collapse. It also can create a condition called bleb disease. And vaping is not the only thing that can cause bleb disease, but it is a common thing that can cause bleb disease. When this occurs, these blebs are like soap bubbles just underneath the skin of the lung. And when you cough really hard or, as in somebody, smoking marijuana, for instance, if they're taking in a big hit of smoke or even cigarettes, it can cause them to cough. And that force can then cause those small, thin celled soap bubbles or what we call blebs to pop.

And then that creates air inside the chest cavity or inside that box that causes that lung to collapse. So substance abuse is common in the lung collapse, for causing the lung collapse. All kinds of substance abuses, but most specifically ones that are inhaled, so such as cigarette smoking or vaping or marijuana smoking.

 So those are common. There are other things that can cause collapsed lungs. For instance, you could be on an airplane where, you may have bleb disease that you just don't know about or even COPD. COPD is where, or emphysema, which we also commonly know. COPD is called emphysema, where over time you kind of get these larger holes in your lung and now instead of having mostly lung tissue, you have mostly space. And then the change in cabin pressure as you're going up and down in an airplane can sometimes cause your lung to collapse. Although not commonly, but it is something else that can cause. So that pressure differential can cause the lung to collapse.

And that would also be true of scuba diving. So if you're going in the opposite direction.

 And then lastly, there can be tumors that grow in the lung and on the chest wall. So in the, both in the balloon and in the box. And when they get big enough, sometimes they will pierce the membrane of the lung or the chest cavity and cause that lung to collapse.

So those are the kind of areas that, you know, the kind of the common things that we see, causing collapsed lung. But by far the most common reason for a spontaneous pneumothorax is either trauma or in a young person who's using substances.

Host: How about some of the things that we can't outrun, you know, like gender, age, family history, or any of those things factors?

Mary Maish, MD, MPH: There's a slight trend in family history for people that are very tall, so young, mid to older teens or young adults who have had a really sudden growth spurt. They kinda have a mismatch between the size of their chest cavity, which has grown very quickly. So the skeletal growth versus the lung growth, which takes a little bit longer because it's meatier.

And so the tension created between the lung and the chest wall, is pulled on so that that can cause a spontaneous pneumothorax. So in the family history arena, that's really, really the only one. There is kind of a rarer disease out there called alpha one antitrypsin disease, which is also a genetic disorder that can be carried on through the family, which also has a predisposition for having a collapsed lung.

 But, age is not specifically related to a collapsed lung except for the tendency for this growth spurt to happen in young people that get tall very quickly. Then, of course, young would kind of be a an age tendency. There are no gender differences, however. These things happen equally amongst men and women. And so yeah, we haven't seen that yet.

Scott Webb: Right. All the risk factors that you're going through, it seems like this would happen more than it probably does, or that we should be talking about it more than we actually are, but we are today. So how do you treat this?

Mary Maish, MD, MPH: Yeah, this is actually super common and it's interesting because I'll have young kids come into my emergency room or even into my office after having been initially treated for one in the emergency room, talking about how once they had it, now they know all these kids that have had it, or even young adults, the same thing.

So it's, really actually super common in parts of my career. Some places where I've worked, I'll treat two and three patients a week with this condition. And the initial way that we treat it is to put in a small tube. We slip a small tube into the chest, so between the balloon and the box, between the lung and the chest wall to evacuate that air.

Because the pressure inside the chest is negative pressure. It's, it has to be sucked out in order for the lung to expand. And so we initially put a little tube in, we connect that tube to external suction, and then that suction allows that lung to re-expand. But the next steps in terms of how to treat it really have to do with what the underlying cause is. So in a case where it's happened spontaneously to somebody young that has grown too fast, we can offer the option to observe to see if it happens again. Or we can do something called a pleurodesis, which is where we introduce either some talc, which is just like Baby powder, but not exactly baby powder, but similar to that, or sometimes other sorts of chemicals that will cause an inflammation of the lining of the lung, which makes it sticky. And then that stickiness will then allow the balloon to stick to the edges of the box and that lung will stay inflated so that if they have another growth spurt or even another blunt trauma force in the football field, the lung would not collapse.

We have traditionally waited, for that second episode to occur before going ahead and fixing it. That was sort of the gold standard many years ago. But now we're moving more aggressively towards treating it because so many of these young people come back with a second episode and it's quite painful and really traumatic for young people to have to go through it once, let alone twice.

We often offer surgery for it, right away. So that's the first line of treatment. If you have a bleb, then it gets escalated to the second line of treatment, which is going to the operating room to remove the bleb and also do that pleurodesis or the sticking portion of the operation. So those blebs are removed surgically using a special kind of staples that we have in the operating room, which allow us to excise or remove the bleb and keep the rest of the lung tissue there that's healthy. So that's the next level. And then finally, if we have patients that have other reasons for why they might have their spontaneous pneumothorax, so let's say for instance, they broke some ribs. Sometimes we have to do a rib fixation so that that rib can't go and poke the lung again. If they have a tumor, in the lung or on the chest wall, then we would go and remove that tumor in order to prevent that from happening again.

Host: Yeah, just trying to follow along here. And I wanted to ask you, I guess the, the natural follow up is, you know, what do we do to prevent this from happening in the future? But as you're saying, especially with young people, if they play football and they love football, they're going to keep playing and it may happen again. But in general, what's your recommendations to avoid, you know, spontaneous pneumothorax?

Mary Maish, MD, MPH: Right. So, to avoid spontaneous pneumothoraces, in trauma patients, the best thing is to wear some kind of a vest that can deploy air. So an air vest. And it's not uncommon now for people to wear them for horseback riding and even for bike riding. So they are pretty thin and they inflate like an airbag as soon as there's any traumatic impact, and this really reduces the blunt force to the chest wall, but also helps to prevent rib fractures, which can then subsequently cause a spontaneous hemothorax. In young kids that are growing, I think the most important thing is just to be aware of it, so that if it does happen, especially parents, it can be quite unsettling for parents to know that, you know, no one's going to die from this problem.

have time to get to the emergency room, it'll be treated timely. Young kids are very resilient and can manage to have a collapse lung without having any other than just some discomfort. They can do very well. The most obvious thing that you can do to prevent these things from happening is if you are a substance abuser to stop smoking, whatever it's that you're smoking. Because these obviously lead considerably to a collapsed lung.

Host: Yeah. Just want to give you a chance here at the end Doctor, final thoughts, takeaways? I think I've got it. You know, that if there are things that we're doing to ourselves that cause this, we should stop doing those things if we can. But in general, what do you want folks to know?

Mary Maish, MD, MPH: The take homes for the spontaneous pneumothorax is, if you have chest pain and shortness of breath that happen in combination, think about the possibility that maybe you have a spontaneous pneumothorax or your child might have one, and get to an emergency room in a timely fashion, but keep yourself calm.

It is a rare scene where anybody would actually die from a spontaneous pneumothorax. So stay calm and know that your body's very resilient and you're likely to do just fine. But do get yourself to an emergency room, you know, in a timely fashion. The other thing is to remember that these things happen all the time.

And after you have one, you'll know other people that do too. It's not an uncommon thing. But make sure that you find a surgeon who has experienced treating these and has options for you because it's not a one size fits all treatment program. And you definitely need to find somebody who has a lot of experience treating it so that the right treatment can be, found for your particular condition.

Host: Right. Well, that's perfect. I know we're going to speak again soon. I appreciate your time today. This is very educational. Good to educate folks, obviously. Great advice from an expert. Thanks so much.

Mary Maish, MD, MPH: You're welcome.

Host: And to learn more, visit franciscanhealth.org and search lung health. And if you found this podcast helpful, please share it on your social channels, and be sure to check out the full podcast library for additional topics of interest. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.