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Posttraumatic Pneumatocele
Vol. 201, No. 2, August 2005
need to maintain an awareness of the possibility of this complication and be familiar with its secondary presentations and treatment. The second comment regards our proposed treatment algorithm. Although patients without symptoms directly attributable to pneumatocele formation should demonstrate resolution after the treatment of the inciting pathology, secondary presentation can be sudden and severe and include rupture with pneumothorax formation, sudden expansion with hemodynamic compromise (a phenomenon known as “tension pneumatocele”), and secondary infection. The presence of any of these complications mandates treatment. Although pneumothorax may be treated with conventional tube thoracostomy (and should be in an emergency situation), all of these clinical scenarios have been effectively treated with image-guided transthoracic aspiration and drainage techniques with CT scan being preferred by most. Our preference for complicated pneumatocele would be for CT-guided catheter drainage as first-line therapy but we stress that operative therapy should be considered early in the event of failed treatment. In contrast to the results achieved by Barbick and colleagues, the subject of my report failed attempted drainage and required urgent thoracotomy with complete resolution of symptoms after open drainage and debridement. In addition to index of suspicion for diagnosis, vigilance is required to assess for completeness of nonoperative management. REFERENCES 1. Barbick B, Cothren CC, Zimmerman MA, et al. Posttraumatic pneumatocele. J Am Coll Surg 2005;200:306–307. 2. Beck JM. Pleural diseases in patients with acquired immune deficiency syndrome. Clin Chest Med 1988;19:341–349. 3. DiBardino DJ, Espada R, Seu P, Goss JA. Management of complicated pneumatocele. J Thorac Cardiovasc Surg 2003; 126:859–861.
Posttraumatic Pneumatocele Gil Hauer Santos, MD New York, NY I read with curiosity the article on posttraumatic pneumatocele by Barbick and colleagues1 in the February issue of the Journal of the American College of Surgeons. In
Letters
319
this article, the authors presented a case of traumatic pulmonary parenchyma disruption resulting from a motor vehicle accident. Five references were presented in their article, and in all of them, the lung injury is referred to as a “traumatic pulmonary pseudocyst.” In our article, “Traumatic Pulmonary Pseudocysts,” published in April 1979 in The Annals of Thoracic Surgery,2 a discussion was included concerning the different nomenclatures used to that date when referring to this clinical entity. As we reported, the term pneumatocele was applied only to a specific and distinct pathology, initially proposed by Zarfl in 1932,3 to describe air-filled cavities appearing in the lung during the course of pneumonia in children. Since then, pneumatocele has continued to be used in that context. As far as the term cyst is concerned, this word should not be applied to traumatic cavities, because by definition, a cyst is an epithelial-lined cavity. So the proper terminology to be applied to pulmonary traumatic cavities should continue to be traumatic pulmonary pseudocysts, which, in itself, indicates the anatomic and etiologic nature of the lesion. The term pneumatocele should not be applied to this pathology. REFERENCES 1. Barbick B, Cothren CC, Zimmerman MA, Moore EE. Posttraumatic pneumatocele. J Am Coll Surg 2005;200:306–307. 2. Santos GH, Mahendra T. Traumatic pulmonary pseudocysts. Ann Thor Surg 1979;27:359–362. 3. Zarfl M. Zur Kenntnis der geschwulstformigen luftausammlungen (Pneumatocel) im Brustraum. Z Kinderh 1932;54:92.
Reply C Clay Cothren, MD Ernest E Moore, MD, FACS Denver, CO We appreciate the interest our article “Posttraumatic Pneumatocele” has generated.1 Although our article was about a multiple-injury patient, we agree with Dr DiBardino that pneumatoceles can occur in a wide range of medical and surgical patients. As such, diagnostic diligence, early intervention, and vigilance for clinical improvement are mandated in patients with complicated pneumatoceles,
need to maintain an awareness of the possibility of this complication and be familiar with its secondary presentations and treatment. The second comment regards our proposed treatment algorithm. Although patients without symptoms directly attributable to pneumatocele formation should demonstrate resolution after the treatment of the inciting pathology, secondary presentation can be sudden and severe and include rupture with pneumothorax formation, sudden expansion with hemodynamic compromise (a phenomenon known as “tension pneumatocele”), and secondary infection. The presence of any of these complications mandates treatment. Although pneumothorax may be treated with conventional tube thoracostomy (and should be in an emergency situation), all of these clinical scenarios have been effectively treated with image-guided transthoracic aspiration and drainage techniques with CT scan being preferred by most. Our preference for complicated pneumatocele would be for CT-guided catheter drainage as first-line therapy but we stress that operative therapy should be considered early in the event of failed treatment. In contrast to the results achieved by Barbick and colleagues, the subject of my report failed attempted drainage and required urgent thoracotomy with complete resolution of symptoms after open drainage and debridement. In addition to index of suspicion for diagnosis, vigilance is required to assess for completeness of nonoperative management. REFERENCES 1. Barbick B, Cothren CC, Zimmerman MA, et al. Posttraumatic pneumatocele. J Am Coll Surg 2005;200:306–307. 2. Beck JM. Pleural diseases in patients with acquired immune deficiency syndrome. Clin Chest Med 1988;19:341–349. 3. DiBardino DJ, Espada R, Seu P, Goss JA. Management of complicated pneumatocele. J Thorac Cardiovasc Surg 2003; 126:859–861.
Posttraumatic Pneumatocele Gil Hauer Santos, MD New York, NY I read with curiosity the article on posttraumatic pneumatocele by Barbick and colleagues1 in the February issue of the Journal of the American College of Surgeons. In
Letters
319
this article, the authors presented a case of traumatic pulmonary parenchyma disruption resulting from a motor vehicle accident. Five references were presented in their article, and in all of them, the lung injury is referred to as a “traumatic pulmonary pseudocyst.” In our article, “Traumatic Pulmonary Pseudocysts,” published in April 1979 in The Annals of Thoracic Surgery,2 a discussion was included concerning the different nomenclatures used to that date when referring to this clinical entity. As we reported, the term pneumatocele was applied only to a specific and distinct pathology, initially proposed by Zarfl in 1932,3 to describe air-filled cavities appearing in the lung during the course of pneumonia in children. Since then, pneumatocele has continued to be used in that context. As far as the term cyst is concerned, this word should not be applied to traumatic cavities, because by definition, a cyst is an epithelial-lined cavity. So the proper terminology to be applied to pulmonary traumatic cavities should continue to be traumatic pulmonary pseudocysts, which, in itself, indicates the anatomic and etiologic nature of the lesion. The term pneumatocele should not be applied to this pathology. REFERENCES 1. Barbick B, Cothren CC, Zimmerman MA, Moore EE. Posttraumatic pneumatocele. J Am Coll Surg 2005;200:306–307. 2. Santos GH, Mahendra T. Traumatic pulmonary pseudocysts. Ann Thor Surg 1979;27:359–362. 3. Zarfl M. Zur Kenntnis der geschwulstformigen luftausammlungen (Pneumatocel) im Brustraum. Z Kinderh 1932;54:92.
Reply C Clay Cothren, MD Ernest E Moore, MD, FACS Denver, CO We appreciate the interest our article “Posttraumatic Pneumatocele” has generated.1 Although our article was about a multiple-injury patient, we agree with Dr DiBardino that pneumatoceles can occur in a wide range of medical and surgical patients. As such, diagnostic diligence, early intervention, and vigilance for clinical improvement are mandated in patients with complicated pneumatoceles,