Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required. @ERSpublications A European Task Force reviews scientific evidence and suggests future research for primary spontaneous pneumothorax

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Surgery alone or in combination with other strategies gives the best hope for lung survival in patients with resectable nonsmall-cell lung cancer [1]. Most patients with lung cancer are current smokers or exsmokers and often have associated chronic obstructive pulmonary disease (COPD) [2] and other comorbidity factors that increase the risk of postoperative complications and death. Pulmonary function tests (PFT) and split pulmonary function, as determined by quantitative macroaggregate lung scanning, are useful in identifying patients with impaired lung function who are at risk of postoperative complications [3]. To what extent further functional testing contributes to more accurate prediction of postoperative morbidity and mortality is unclear.Some authors have recommended exercise testing as a useful tool in the assessment of operative risk in thoracotomy candidates [4,5]. Impaired exercise capacity, as assessed by a low oxygen uptake (V 'O 2 ), has been proposed as a predictor of a poor postoperative outcome [4], but the usefulness of V 'O 2 imeasurements in patients with severely impaired pulmonary function at increased risk remains controversial. While some authors have shown that the V 'O 2 value is useful in the prediction of surgical outcome in high-risk candidates [6-9], others have not confirmed such results [10,11].Furthermore, since pulmonary hypertension is a poor prognostic factor in COPD [12] and a decreased arterial O 2 saturation on exertion has been proposed as a predictor of postoperative complications [13,14], it was hypothesized that among COPD patients who are at a high-risk for resectional lung surgery, those who develop gas exchange and/or haemodynamic abnormalities during exercise may be at greatest risk of morbidity and mortality after surgery. Accordingly, the present study was intended to evaluate the potential role of both gas exchange and pulmonary haemodynamic measurements during exercise in the prediction of early post-thoracotomy morbidity and mortality in patients with a high-risk for surgery as assessed by conventional PFT and lung scanning. Invasive exercise testing in the evaluation of patients at high-risk for lung resection. J. Ribas, O. Díaz, J.A. Barberà, M. Mateu, E. Canalís, L. Jover, J. Roca, R. Rodriguez-Roisin. ©ERS Journals Ltd 1998.ABSTRACT: The aim of this study was to investigate whether invasive exercise testing with gas exchange and pulmonary haemodynamic measurements could contribute to the preoperative assessment of patients with lung cancer at a high-risk for lung resection.Sixty-five patients scheduled for thoracotomy (aged 66±8 yrs (mean±SD), 64 males, forced expiratory volume in one second (FEV1) 54±13% predicted) were studied prospectively. High risk was defined on the basis of predicted postpneumonectomy (PPN) FEV1 and/or carbon monoxide diffusing capacity of the lung (DL,CO) <40% pred. Arterial blood gas measurements were performed in all patients at rest and during exercise. In 46 patients, pulmonary haemodynamic measurements were also performed at re...

The pattern and clinical implications of bronchial bacterial colonization have been widely investigated in patients with chronic lung disease, particularly chronic obstructive pulmonary disease. The main aim of this study was to determine the frequency and risk factors for bronchial colonization in lung cancer patients who have undergone surgical resection.Forty-one patients with resectable lung cancer (22 (54%) active smokers, 52¡23 pack-yrs) with a mean forced expiratory volume in one second of 80 ¡ 16% predicted, were studied with bilateral protected specimen brush and lung tissue biopsy during the surgical procedure. Quantitative bacterial culture, susceptibility tests and histological examination of samples were performed.Bronchial colonization with o1 potential pathogenic micro-organism was found in 17 of 41 (41%) patients. The most frequent strains isolated were: Haemophilus influenzae (35%), Streptococcus pneumoniae (13%) and Pseudomonas spp. (9%). The risk factors for bronchial colonization were central location of the tumour (odds ratio (OR)=9.2, confidence interval (CI) 95%=2.1-39.6, p=0.003) and increased body mass index (OR=1.6, CI 95%=1.2-2.2, p=0.005). The frequency of postoperative infectious pulmonary complications was low (five cases (12%)) and no relationship was observed with bronchial colonization.Patients with resectable lung carcinoma had a high rate of bronchial colonization (41%), mainly with potential pathogenic microorganisms. The independent risk factors for colonization in these patients were central location of the tumour and a high body mass index.

The prognostic value of p53 and c-erbB-2 immunostaining and preoperative serum levels of CEA and CA125 was investigated in a prospective multicentric study including 465 consecutive non-small cell lung cancer (NSCLC) patients with resectable tumors. Four end-points were used: lung cancer death, first relapse (either locoregional or metastasis), locoregional recurrence and metastasis development. Standard statistical survival methods (Kaplan-Meier and Cox regression) were used. The specificity of the prognostic effect across different types of tumors was also explored, as had been planned in advance. Our results showed, once again, that pathological T and N classifications continue to be the strongest predictors regarding either relapse or mortality. Three of the studied markers seemed to add further useful information, however, but in a more specific context. For example, increased CEA concentration defined a higher risk population among adenocarcinomas but not among people with squamous tumors; and p53 overexpression implied a worse prognosis mainly in patients with well differentiated tumors. The analysis of type of relapse proved to be very informative. Thus, CA125 level was associated with a worse prognosis mainly related with metastasis development. Another interesting result was the influence of smoking, which showed a clear dose-response relationship with the probability of metastasis. For future studies, we recommend the inclusion of different endpoints, namely considering the relationship of markers with the type of relapse involved in lungcancer recurrence. They can add useful information regarding the complex nature of prognosis. Prognosis for non-small cell lung cancer (NSCLC) has remained disappointing over the last decades, even in localized stages that are amenable to curative surgery. 1 Recurrence rates among patients with resectable NSCLC are substantial, 2-4 and only around 50% of them will be alive after 5 years. 5 The clinical or pathologic TNM staging (T, primary tumor; N, regional lymph nodes; M, distant metastasis) does not always provide a satisfactory explanation for differences in relapse and survival. It is of major importance, however, to be able to anticipate a bad prognosis to prescribe an active chemotherapy or radiotherapy adjuvant program. 6,7 In this context, a large number of articles have been published proposing the incorporation of different prognostic markers in clinical practice, 8 but the interpretation and integration of their results is hampered by methodological problems. Many studies included a low number of patients, and very few examined more than 1 or 2 markers. Furthermore, the majority are retrospective cohorts, where the quality of the follow-up is uncertain and the possibility of a selection bias cannot be ruled out. 9 Prognostic studies try to identify one or more variables that might be useful to classify a heterogeneous population into smaller subgroups with more predictable outcomes. This classification will serve to apply therapy more efficiently, avoiding...

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