Spontaneous pneumo question

[ericdiver]

A friend's son, a new-but-avid diver/spearo, about 20 yrs old, recently suffered a primary spontaneous pneumothorax. He had a chest tube for a couple days and is back to normal activities with no problems, but not diving at least yet. This was his first/only episode. Now I am getting this second-hand, but apparently the pulmonary people following him (somewhere in Oregon) are recommending pleurodesis (don't know which specific procedure) and suggesting that he should be able to resume scuba 6 months post-procedure.

Now I had thought that PSP was a permanent contraindication to diving, and a review of the DAN guidelines seems to support this.

But apparently there are professional guidelines out there that imply that a return to diving might be OK after pleurodesis, I found 2 sources although I was only able to access the first paper and read it for myself: but neither is primarily directed at divers as they more general position papers. And the first only refers to diving briefly, as an example of a high-risk activity to which patients might return.

Management of Spontaneous Pneumothorax*

Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986

So, any insight here? I am assuming there is a total lack of actual factual research on recurrent PSP post-pleurodesis in divers, so my friend's son will be his own little case study, but maybe I failed to find some more useful information.

Thanks,
Eric

 

[cutlass]

Two problems with pleurodesis or the more involved pleurectomy (removal of pleura): (1) they have no guarantee of non-recurrence (IIRC pleurodesis has a recurrence rate of about 8% and excluding the risk for the other lung), (2) a recurrence could mean dying. Like so many other decisions, one must weigh desire/need against risk.

Spontaneous pneumothorax isn't an absolute, permanent contraindication to diving but as a practical matter for most of us as recreational divers, it might well be. Read carefully ScubaDoc's article here and you'll note qualifications. Two for example:

This is a life-threatening situation and is one of the main reasons that a history of spontaneous pneumothorax is an absolute contra-indication to diving since most divers and dive boats are not prepared to provide first aid to a diver with pneumothorax.

(underscore is mine and I would add the variables of evacuation and availability of definitive care)
and

The following are absolute contraindications to diving:
---Diving within three months after any type of collapsed lung.
---Spontaneous collapsed lung in beginners.
---Expert divers with recurrent collapsed lung after pleurectomy.

 

[TSandM]

As cutlass observes, pleurodesis isn't perfect, but it would almost certainly reduce the likelihood of a lethal pneumothorax (tension) on the operated side. The other problem is that spontaneous pneumothorax is most often due to abnormalities of the underlying lung, and they are commonly bilateral, and the pleurodesis does not protect the unoperated side at all.

Tension pneumothorax is a surgical emergency and can kill quickly. Someone experiencing a significant pneumothorax at depth will almost certainly convert to tension physiology on ascent; unless someone on the boat knows how to create a chest wall vent of some sort, that patient will have a high risk of dying before getting to medical care.

All diving is a risk assessment. No diving is perfectly safe, and for many situations, the actual risks can't be accurately defined. I think this is one of those cases. The risk of recurrent pneumo is not zero (cutlass has posted some numbers) and the risk of mortality or major injury if there is a recurrence is high. My personal assessment would be that, if I had had a spontaneous pneumo, I'd quit diving, as hard as it would be.

 

[ericdiver]

A belated thanks for the replies, and I note several other recent threads on this subject as well. I'll pass along the info and suggest that CJ (my friend's son) get on scubaboard himself and check this out. He has had pleurodesis about a month ago, not sure if unilateral or bilateral, and I hear he does plan to resume diving after the six months his docs recommended (which is quite different than the recommendations here). So perhaps he will become a test case - anyone doing a prospective study on this?

Thanks again,
Eric

 

[Duke Dive Medicine]

Eric,
I don't think a study like that would get past an institutional review board. As you may have read in the other recent threads, any history of spontaneous pneumothorax is an absolute contraindication to diving. There is a high risk of recurrence in the opposite lung, and as Cutlass has already pointed out, pleurodesis is no guarantee that it won't happen again (about a 10% risk according to one of our fellows who's also a cardiothoracic surgeon, which jibes with Cutlass' figure). From what I've read in your post, we would not give your friend's son medical clearance to dive. If you have any influence with him at all, please try to talk him into seeing a board-certified hyperbaric physician.
Best regards,
DDM