In spite of the fact that blebs and bullae are frequently found in patients with primary spontaneous pneumothorax, they seldom seem to be the actual cause of the pneumothorax. Inflammatory changes in the distal airways play an important role in the occurrence of the pneumothorax during transpulmonary pressure changes.The value of the routine use of additional expiratory chest radiographs in diagnosing pneumothoraces has been doubted in previous studies. In this review, the diagnostic yield from additional expiratory chest radiographs is analysed. The role of previous pneumothoraces at presentation and the presence of blebs and bullae are discussed in predicting future recurrences and choosing appropriate treatment for optimal cost-effectiveness. Recommendations are made regarding treatment of primary and secondary spontaneous pneumothorax. Eur Respir J 1997; 10: 1372-1379 Pneumothorax is defined as the presence of air in the pleural cavity [1]. As early as 1819, LAENNEC [2] described the symptoms and signs of a patient with a pneumothorax. Although most pneumothoraces were then caused by tuberculosis, he also found pneumothoraces during autopsies of patients with apparently healthy lungs; he named these "pneumothorax simple". Aetiology and pathogenesisToday, pneumothoraces are divided into spontaneous pneumothorax, occurring without a preceding event, and traumatic pneumothorax, due to direct or indirect trauma. Iatrogenic pneumothoraces, resulting from diagnostic or therapeutic medical procedures, are also categorized as traumatic pneumothoraces.Spontaneous pneumothoraces are divided into primary and secondary spontaneous pneumothoraces. Secondary spontaneous pneumothoraces are associated with underlying pulmonary pathology, usually chronic obstructive pulmonary disease (COPD). Acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii infections appear to play an increasing role in the aetiology of secondary spontaneous pneumothoraces [3].No underlying pulmonary disease is present in patients with primary spontaneous pneumothorax. However, blebs and bullae seem to play a role in the pathogenesis, since they are frequently found during thoracoscopy, thoracotomy or sternotomy (table 1). Thoracoscopic studies have shown the presence of blebs and bullae in 48-79% of patients with unilateral primary spontaneous pneumo-thorax [4][5][6][7][8]. With the development of video-assisted techniques, the recognition of blebs and bullae during thoracoscopy has improved. In more than 76% of patients,

Review of histopathological and clinical data showed that 153 patients at one hospital developed a second primary lung cancer during 1980-6, 10% of all those with lung carcinoma. There were 64 synchronous tumours (interval less than one year) and 89 metachronous tumours (interval over one year). The average interval between metachronous tumours was 6-1 years. The criteria for diagnosing a second primary lung cancer were any of the following: (1) different histological type; (2) different lobe; (3) interval between the two tumours of at least three years. The incidence of second primary tumours increases with survival, and close follow up is required for their early detection.

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From 1979 to 1993, 79 patients underwent pulmonary resection for lung cancer and a concomitant cardiac operation using extracorporeal circulation. There were 75 men and 4 women with a mean age of 65 years (range 52-77). Cardiac procedures consisted of coronary artery bypass grafting (CABG) in 69 patients (three redos), aortic valve replacement in 7 (2 combined with CABG), mitral valve repair in 1 (combined with CABG) and other in 2. In CABG cases the mean number of distal anastomoses was 4.0. Pulmonary resection included bilateral lobectomy in 1 patient, sleeve lobectomy in 3, pneumonectomy in 6, bilobectomy in 5, lobectomy in 60 and segmental resection in 4. Postoperatively 52 patients were stage I (65.8%), 18 stage II (22.8%) and 9 stage III a. Histology was squamous cell carcinoma in 48 patients (61%) and adenocarcinoma in 24 patients (30%). The hospital mortality was 6.3% (n = 5). Re-exploration for bleeding was necessary in seven patients. Follow-up was complete for all patients. The estimated mean survival for all patients (including hospital deaths) was 58 months. Two- and five-year survival rates were 62% and 42% with 45 and 22 patients, respectively, under surveillance. Lung cancer accounted for 64% of the late deaths. We conclude that pulmonary resection for lung cancer in patients undergoing a concomitant cardiac operation can be performed safely with low operative morbidity and mortality and good long-term survival.