Impact of ventilation strategy on recurrence patterns after pneumothorax surgery: a stratified analysis by lung dystrophy

Introduction

Primary spontaneous pneumothorax (PSP) is a type of pneumothorax without known predisposing factor and it is known to prevail in young, lean and tall male subjects (1). The incidence of PSP is reported to be 17 to 24 per 100,000 person-years in the male population whereas in female, it is much lower with reported rate of 1 to 6.0 per 100,000 person-years (2).

Although PSP is rarely life threatening, the quality of life of the patient could deteriorate due to its high recurrence rate. The recurrence rate is reported to be as high as 54% if treated conservatively (3,4). However, surgical intervention has a much lower recurrence rate than non-surgical management such as closed thoracostomy or oxygen therapy and the rate is reduced to 14% when conducted under video-assisted thoracic surgery (VATS) and 0–7% if conducted under mini-thoracotomy (5,6).

Surgery may be an effective mode of treatment; however, the challenge in treating PSP is identifying patients with a high risk of recurrence. A major factor for the occurrence of PSP is the rupture of blebs/bullae. Identifying the severity and distribution of blebs/bullae is crucial and can be achieved using computed tomography (CT) imaging to aid in clinical decision making (4,7,8). Key findings such as the number, type, and distribution of lung defects were collected for each patient, and scorings were made accordingly. This radiological scoring system we used is entitled Dystrophic Severity Score (DSS) which according to a number of past studies, it has proven to have significant correlation with the risk of PSP recurrence (4,9).

With the aid of DSS, the goal of surgical intervention is to eliminate these pulmonary defects for both the treatment and prevention of PSP recurrence. To achieve meticulous identification and complete resection of such defects, obtaining the best surgical view through a high-quality videoscope and easier manipulation of the lung have become imperative. Thus, PSP surgery using thoracoscopy has gained popularity over the decades despite a slightly higher recurrence rate compared to thoracotomy, and most VATS bullectomies are performed under one-lung ventilation (OLV) during perioperative anesthesia (4,10). OLV has a strong advantage in terms of its superior surgical field of view and lower risk of unintentional lung injury; however, negative effects of OLV have also been reported, such as hypoxemia, acute lung injury due to barotrauma, and tracheobronchial injury (11). In contrary, performing VATS bullectomy under two-lung ventilation (TLV) may hypothetically lessen volumetric stress on both ipsilateral and contralateral lungs, as TLV is usually performed at lower tidal volume (TV) settings. Although the risk of unintentional lung injury during the procedures and limited surgical view are disadvantages of TLV, the lung-protective features of TLV may reduce contralateral recurrence and overall relapse rate of PSP.

This study aimed to investigate how different intraoperative ventilation strategies influence postoperative recurrence patterns in patients with PSP. Specifically, we sought to utilize the preoperative DSS to stratify the risk of both ipsilateral and contralateral recurrence. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-845/rc).

Methods

Study cohort

This study was a retrospective review of medical records of patients under the age of 40 years who underwent VATS bullectomy for PSP at a single tertiary university hospital between January 2017 and December 2022. Patients with traumatic or iatrogenic pneumothorax, secondary pneumothorax associated with underlying lung disease, or those over the age of 40 years were excluded. Clinical data including sex, age, number of pneumothorax episodes, prior treatments, body mass index (BMI), laterality of pneumothorax, and treatment-related details were collected for analysis. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Korea University Anam Hospital (No. 2024AN0079) and individual consent for this retrospective analysis was waived.

Group comparison

Patients were categorized by the type of intraoperative ventilation method used: OLV vs. TLV. Baseline patient characteristics are summarized in Table 1.

PSP diagnosis and management

All study participants underwent preoperative chest CT and plain chest radiography. Patients with minimal lung collapse—defined as a gap of less than 30 mm between the apical chest wall and the apex of the pleural line on plain chest radiograph—were managed with oxygen therapy at a flow rate of 2 to 4 liters per minute. Those with more extensive pneumothorax received chest tube drainage. The decision for surgical resection was made in accordance with the guidelines of the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS) (2,12-14).

CT evaluation and DSS subgroup analysis

Non-contrast chest CTs were taken for PSP patients at 3mm slice thickness. Preoperative chest CT scans were reviewed for the presence of subpleural blebs or bullae (Figure 1), and the DSS was assessed by two thoracic surgeons using the scoring system outlined in Table 2.

Figure 1 Representative preoperative chest CT images demonstrating the DSS. (A) Axial CT image of a patient with a single ipsilateral bleb, corresponding to a DSS of 3. (B) Axial CT image showing multiple bilateral bullae, consistent with a DSS of 6. Red arrows indicate the presence of bleb (A) and bullae (B). CT, computed tomography; DSS, Dystrophic Severity Score.

Patients were divided into three DSS subgroups: score <4, score =5, and score =6. Comparative analysis among these subgroups was conducted to evaluate the association between the extent of lung dystrophy and the risk of pneumothorax recurrence.

Ventilator setting and surgical procedure

In our hospital, the thoracic surgery ventilator protocol recommends setting the TV between 6 and 10 mL/kg. Nonetheless, when performing OLV, the TV is usually adjusted to roughly 60–80% of the level applied during TLV. For PSP surgery carried out under TLV conditions, the TV setting was set lower than that for standard TLV procedures, if adequate oxygenation was sustained. Peak airway pressure (PAP) for both OLV and TVL was kept under 30 cmH₂O throughout the surgery. These details are listed in Table 1.

Thoracoscopic surgery was performed on all patients. The choice of ventilation method was determined by the operating surgeon’s preference. Linear staplers were used for all lung resections, and an intraoperative air leak test was conducted for every patient. Lung parenchymal reinforcement was added for patients exhibiting extensive subpleural blebs or emphysematous parenchyma.

Follow-up

All patients in the study cohort had at least one outpatient follow-up visit after discharge. Radiological evaluations and telephone interviews were conducted over a minimum follow-up period of one year to assess for recurrence of ipsilateral pneumothorax or the development of contralateral pneumothorax.

Statistical analysis

All data were recorded using Microsoft Excel (Microsoft Corp., Bellevue, WA, USA). Baseline characteristics are presented as mean ± standard deviation (SD) or median with interquartile range (IQR) for continuous variables, and as number (percentage) for categorical variables. The mean with SD was used for normally distributed data without significant outliers, whereas the median with IQR was applied to variables with skewed distributions or notable outliers.

Categorical variables were analyzed using the Chi-squared test or Fisher’s exact test, as appropriate, while continuous variables were assessed using the Mann-Whitney U test.

The primary endpoints were pneumothorax recurrence on either side and 1-year RFS. The 1-year RFS was estimated using the Kaplan-Meier method, and a P value of <0.05 was considered statistically significant.

Statistical analysis was performed using RexPro (http://rexsoft.org/, version 3.6.3, RexSoft Inc., Seoul, Republic of Korea), an Excel plug-in based on R Statistical Software (version 3.6.1; R Foundation for Statistical Computing, Vienna, Austria) and statistical analysis was performed using Python (https://www.python.org/, Version 3.10.12, Python Software Foundation, Wilmington, DE, USA) employing libraries such as StatsModels, SciPy, Pandas, NumPy and Scikit-learn for statistical modeling and analysis.

Results

A total of 180 patients were diagnosed with PSP and underwent VATS during the study period. Of these, 145 patients received surgery under OLV, while 35 underwent surgery under TLV. Clinical demographics of the enrolled patients are summarized in Table 1, and recurrence patterns for both groups are illustrated in Figure 2. Baseline characteristics were generally comparable between the two groups.

Figure 2 Number of recurrences (N=180). Bar graph illustrating subsequent recurrence patterns stratified by ventilation method. Patients were grouped according to OLV vs. TLV, and recurrence rates are presented for ipsilateral, contralateral, and overall recurrence. OLV, one-lung ventilation; TLV, two-lung ventilation.

Significant differences were observed in anesthesia induction time (25 vs. 20 min, P<0.001), operation time (45 vs. 30 min, P<0.001), TV (450 vs. 380 mL, P<0.001), PAP (18 vs. 10 cmH₂O, P<0.001), duration of hospital stay (6 vs. 5 days, P=0.003), and the application of lung parenchymal reinforcement following lung resection (75.2% vs. 100%, P=0.002).

The time interval to recurrence was significantly shorter in the TLV group (74 vs. 257 days, P=0.003). Overall, 19.4% of patients experienced recurrence on either the ipsilateral or contralateral side. Ipsilateral recurrence was higher in the TLV group (14.3% vs. 8.3%), whereas contralateral recurrence was lower (5.7% vs. 11.0%).

Table 3 presents the preoperative chest CT findings of both ipsilateral and contralateral lung parenchyma, along with the distribution of DSS subgroups. All 180 patients demonstrated ipsilateral blebs or bullae, and the overall distribution of DSS scores was comparable between the two ventilation groups. However, contralateral lung dystrophy was more frequently observed in TLV group (82.9% vs. 69.7%, P>0.99). DSS subgroup analysis revealed a relatively even distribution among patients in the OLV group. In contrast, 80% of patients in TLV group had a DSS score of 5 or higher, suggesting a higher degree of parenchymal abnormality in this group compared to the OLV group.

Additional group comparisons were conducted between the non-recurrent cohort and the ipsilateral and contralateral recurrence groups. Comparative analyses of baseline characteristics across these groups are presented in Tables S1,S2. TV (430 vs. 500 mL, P=0.004) and PAP (15 vs. 18 cmH₂O, P=0.003) were both significantly higher in contralateral recurrence group compared to non-recurrent group. RFS and subgroup analyses based on DSS for each ventilation group are illustrated in Figures 3,4. The estimated 1-year RFS rates were 84.2% for the OLV and 75.7% for the TLV (Figure 3, P=0.25). Subgroup analysis by DSS (Figure 4) demonstrated an inverse correlation between DSS and RFS in both ventilation groups. Although the trend did not reach statistical significance in the OLV (Figure 4A, P=0.45), a significant decline in RFS with increasing DSS was observed in TLV (Figure 4B, P=0.03).

Figure 3 RFS by ventilator groups: OLV vs. TLV. Overall RFS according to the type of ventilator used for surgery. OLV, one-lung ventilation; RFS, recurrence-free survival; TLV, two-lung ventilation.

Figure 4 RFS stratified by DSS for OLV and TLV groups. (A) Kaplan-Meier curve showing RFS in the OLV group, stratified according to DSS. (B) Kaplan-Meier curve showing RFS in the TLV group, stratified according to DSS. DSS, Dystrophic Severity Score; OLV, one-lung ventilation; RFS, recurrence-free survival; TLV, two-lung ventilation.

The differential impact of DSS on ipsilateral vs. contralateral recurrence is illustrated in Table 4 and Figure 5. At 1-year, ipsilateral RFS rates were 96.1%, 94.2%, and 90.0% for DSS groups 4, 5, and 6, respectively (P=0.52), whereas contralateral RFS rates were 96.1%, 92.8%, and 90.0% (P=0.02).

Figure 5 Ipsilateral and contralateral RFS by DSS group. DSS, Dystrophic Severity Score; RFS, recurrence-free survival.

Discussion

The clinical course of pneumothorax recurrence is still not fully understood and continues to represent the most common complication following pneumothorax treatment. Although rarely life-threatening, pneumothorax often necessitates repeated hospital admissions, imposing a considerable burden on patients and healthcare systems. Surgical resection has been shown to be more effective in reducing recurrence rates; however, the optimal management strategy for an initial episode of PSP remains a subject of debate. This is largely due to the difficulty in accurately identifying patients at high risk for recurrence.

Previous studies have identified pulmonary blebs and bullae as key contributors to the pathogenesis of pneumothorax (1-3,15). Consequently, the identification of these structural abnormalities prior to treatment initiation is critical for the effective management PSP.

While plain chest radiography is widely used as the initial diagnostic tool due to its high sensitivity for detecting pneumothorax itself, its sensitivity for identifying blebs or bullae is notably low, with detection rates reported as low as 15%. In contrast, chest CT offers significantly greater diagnostic accuracy, with detection rates for blebs and bullae reaching up to 88%, enabling more comprehensive assessment of underlying pulmonary pathology not visible on standard radiographs (8). Accurate detection is also important for reduction of contralateral pneumothorax. Previous studies revealed that over 50% of PSP patients had contralateral blebs/bullae at the time of diagnosis, and up to 70.2% eventually developed contralateral pneumothorax (16-19). Notably, a study conducted by Huang et al. in 2007 reported a 100% contralateral recurrence rate among patients with contralateral blebs or bullae identified on preoperative chest CT scans. Based on these findings, the authors proposed prophylactic VATS on the contralateral lung for patients with identifiable risk factors for pneumothorax recurrence (20).

Although such recurrence may reflect the natural course of pre-existing vulnerable parenchymal tissue in patients with PSP, surgeons often face a dilemma regarding whether to pursue invasive intervention on the asymptomatic contralateral lung with identified blebs or bullae. This challenge is further complicated by the ongoing debate over the appropriateness of surgical intervention during the first episode of ipsilateral pneumothorax, as well as uncertainty regarding whether ipsilateral lung surgery increases the risk of future contralateral pneumothorax (15,21).

Multiple studies involving both adult and adolescent patients with pneumothorax have reported surgery to be the most effective treatment modality across age groups (10,17). However, these investigations have largely focused on the affected ipsilateral pleura, leaving the impact on the unaffected contralateral side less well understood.

Notably, previous data demonstrated that in patients with contralateral blebs or bullae identified at the time of pneumothorax diagnosis, recurrence rates following unilateral and bilateral VATS were 14.6% and 2.9%, respectively, indicating a significant disparity in outcomes (22). Another related study reported no instances of pneumothorax recurrence following simultaneous bilateral VATS in patients initially presenting with ipsilateral PSP, whereas those who underwent unilateral surgery experienced a contralateral recurrence rate of 17.14% (19). Similar findings were observed by Hofmann et al. [2018] in a retrospective study of 135 PSP patients, comparing treatment outcomes between conservative management (chest tube insertion) and VATS across both pleural sides. In that study, chest tube treatment showed a 4:1 ratio of ipsilateral to contralateral recurrence, while VATS showed a 1:1 ratio (23).

Interestingly, while VATS was associated with a reduction in the absolute number of recurrences, the risk of contralateral recurrence remained relatively high. The underlying mechanism for this phenomenon remains unclear; however, one proposed hypothesis is increased mechanical stress on the contralateral pleura due to positive pressure ventilation during OLV. This may result in overdistension of pre-existing blebs or bullae, leading to parenchymal injury and the development or rupture of new lesions.

As mentioned previously, ventilator setting for thoracic surgery for the TV was set between 6 and 10 mL/kg and this TV range was reduced to 60–80% when performing OLV. Interestingly this study found that the TV was lower during TLV (450 vs. 380 mL, P<0.001) and this outcome is likely due to the deliberate application of reduced TVs in TLV, aiming to optimize the surgical field and improve the precision of stapler placement and firing within the target lung tissue during resection procedures.

The primary distinguishing feature of our study lies in the utilization of two different ventilation strategies during VATS, allowing us to explore the potential association between increased recurrence and ventilatory stress on the lung parenchyma. As shown in Table 1 and Figure 2, patients in the TLV group were managed with lower TV compared to the OLV group (380 vs. 450 mL, P<0.001), lower PAP (10 vs. 18 cmH₂O, P<0.001) and exhibited a lower overall rate of contralateral recurrence (5.7% vs. 11%, P=0.41). These findings are consistent with the hypothesis that increased positive pressure ventilation may contribute to contralateral recurrence. Our study also revealed a higher ipsilateral recurrence rate in the TLV group compared to the OLV group (14.3% vs. 8.3%, P=0.41), despite all patients in the TLV receiving parenchymal reinforcement following resection. This paradoxical outcome may be attributed to the limited surgical field and restricted pleural space encountered when ventilation is maintained during the procedure. Preserved lung inflation may hinder optimal handling of the lung tissue and thorough inspection of the pleural cavity. Furthermore, continued ventilation during stapling may increase mechanical tension along the stapler line, as the device is applied to actively ventilating parenchyma. This mechanical stress could predispose the surrounding tissue to new bulla formation or compromise staple line integrity, ultimately increasing the susceptibility to future ipsilateral recurrence.

Although pulmonary structural abnormalities, such as blebs and bullae, are recognized as major predictors for the development of pneumothorax, their presence does not invariably indicate recurrence in all patients. In the absence of a standardized risk assessment tool for pneumothorax recurrence, several studies have sought to guide clinical decision-making and reduce recurrence rates by categorizing pulmonary defects—based on their number, size, and location—using high-resolution computed tomography (HRCT) (4,8). HRCT has been employed to evaluate and grade the severity of these defects, leading to the development of the DSS, which stratifies patients based on the extent of parenchymal abnormalities (Table 2 and Figure 1) (9). This scoring system has demonstrated significant correlation with outcomes in both conservatively and surgically managed patients.

Recent studies have highlighted the clinical utility of DSS in stratifying patients with PSP. For example, Casali et al. reported a significant association between higher DSS and increased ipsilateral recurrence following conservative treatment (4). Additionally, other studies have supported the feasibility of using DSS in first-episode PSP patients, suggesting that early surgical intervention may be warranted in individuals presenting with multiple lung defects (9,18).

While our findings are consistent with those of previous studies, they further elucidate the impact of different ventilation strategies on RFS in patients stratified by DSS. A positive correlation between recurrence and DSS was observed across both ventilation groups (Figure 3, P=0.25); however, this trend became more pronounced when RFS was analyzed separately for ipsilateral and contralateral recurrences.

The differential impact of DSS on ipsilateral vs. contralateral recurrence is illustrated in Table 4 and Figure 5. At 1-year, ipsilateral RFS rates were 96.1%, 94.2%, and 90.0% for DSS groups 4, 5, and 6, respectively (P=0.522), whereas contralateral RFS rates were 96.1%, 92.8%, and 90.0% (P=0.02). These findings indicate that higher DSS is significantly associated with poorer contralateral RFS.

Furthermore, when stratified by ventilation mode, DSS demonstrated differential effects on RFS. In the OLV group, the association between DSS and ipsilateral RFS remained modest and non-significant (Figure 4A; P=0.45). In contrast, DSS was strongly predictive of contralateral recurrence in patients managed with TLV (Figure 4B; P=0.03). Notably, patients in the DSS 6 who received TLV experienced worse outcomes.

These findings indicate a strong, negative association between high DSS and contralateral RFS, particularly in patients managed with TLV and warrants a cautious approach in selecting ventilation strategy for these high-risk subgroups as well as emphasizing the importance of preoperative evaluation. The standard approach of OLV may not carry the same risk. This is potentially because it provides surgeons with better access to inspect and reinforce the pleural surface, an advantage that is particularly crucial in cases requiring multiple resections. Nevertheless, further investigation is required to definitively establish OLV as the preferable ventilation strategy for patients with DSS 6. Taken together, these highlight the role of DSS not only as a prognostic tool for recurrence but also as a practical preoperative stratification method to inform optimal ventilation method and surgical planning in PSP patients.

One notable limitation of the DSS observed during our study period is the challenge of accurately assessing small pulmonary lesions, even for experienced thoracic surgeons. This difficulty introduces potential interobserver variability that may affect the consistency and reliability of DSS-based stratification. The issue was particularly evident in patients with apical scarring or pleural adhesions, which may not reflect the true severity of underlying lung dystrophy and therefore may not be adequately represented in the DSS. This limitation has also been highlighted in previous studies, with reported rates of PSP cases lacking visible blebs or bullae on CT ranging from 6.5% to 37%, underscoring the variability in radiologic interpretation (8,9,24). To preserve the validity of DSS as a reliable pretreatment assessment tool, it is essential to establish standardized interpretation criteria and encourage close collaboration between radiologists and thoracic surgeons when evaluating CT findings.

This study has other limitations. First, it was a retrospective analysis conducted at a single center, which may limit the generalizability of the findings. Although the study included a relatively large sample size (n=180), only 18 cases of contralateral recurrence were observed, limiting the statistical power for subgroup analyses. In addition, potential interobserver bias may have influenced the interpretation of preoperative CT scans, as the imaging was reviewed solely by two thoracic surgeons. Selection bias may also have affected the results, as the choice of ventilation strategy was based on the individual surgeon’s preference rather than a standardized protocol.

Despite these limitations, our study has notable strengths. It is one of the few studies to evaluate contralateral recurrence patterns in the context of intraoperative ventilation strategies, stratified by the severity of lung parenchymal dystrophy. The results support the hypothesis that pneumothorax recurrence may be influenced by ventilation-related lung stress, particularly barotrauma, and highlight the relevance of the DSS in guiding surgical decision-making.

Conclusions

In summary, this study revealed that RFS in PSP patients is significantly influenced by both the preoperative DSS and the intraoperative ventilation strategy. Furthermore, our results particularly highlight that DSS is a robust predictor of contralateral recurrence, enabling surgeons to anticipate this specific patient risk profile.

Based on these findings, we suggest that a more tailored approach to ventilation, guided by preoperative DSS, could be a beneficial strategy for reducing recurrence. While our study’s retrospective nature necessitates caution, considering a patient’s DSS for the choice of optimal ventilation strategy may lead to more promising surgical outcome. Although further prospective and multicenter studies are necessary to validate these findings, our results provide meaningful insights into optimizing surgical approaches in PSP, potentially reducing recurrence and improving long-term patient quality of life.

Acknowledgments

We sincerely express our appreciation and gratitude to Ms. Donghee Son, a statistician formerly affiliated with Konkuk University Hospital for her valuable support and counseling that made our research possible.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-845/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-845/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-845/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-845/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Korea University Anam Hospital (No. 2024AN0079) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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