A sincere thanks

I’d like to offer my sincere thanks to all of my lovely readers like Jay, Tim, Dann Furia and all the other people who tale the time to share their experiences at Blebs, bullae and spontaneous pneumothorax.

Your personal experiences and advice are valuable contributions and help make this site worthwhile.  It gives the Cirugia de Torax (and other readers) a more rounded and enhanced perspective.  So thanks again – and I love reading each and every comment.

Dann Furia: Spontaneous pneumothorax, bleb disease and the patient’s perspective

the “rapper whose lungs collapse” raps about his life with bleb disease

When I started Cirugia de Torax in April 2011, I wanted bridge the gap between medical specialty societies (and professionals only) websites and the message boards frequented by people suffering from lung disease and thoracic conditions.

I wanted the people with these conditions to be able to read what we are reading; scholarly articles, informative case reports and ground-breaking research.

I also wanted to introduce readers to the ‘heros and cowboys‘ of thoracic surgery – the researchers and surgeons out there who spend long hours (and often sacrifice much of their personal lives) in pursuit of medical and surgical advances for our patients.

The response I have received has been overwhelmingly positive. From the very first post, surgeons were encouraging and generous with their time.  They invited me into their offices and their operating rooms.

Clinica Shaio, Bogota, Colombia
Clinica Shaio, Bogotá, Colombia

Researchers from around the world took the time to answer questions about their articles and explain their work.

Other doctors and health care providers have contacted with their own case reports, questions and experiences.

The patients and their families have been friendly and welcoming.  They have invited me to share their stories with others.

Readers respond:

Almost immediately, readers began contacting me; with questions, comments and stories about their own experiences.  Their questions prompted me to do more reading, more writing and more interviews.

But their stories often touched my heart..  Dann Furia is one of these people.

Meet Dann Furia
Meet Dann Furia

A  Pennsylvania resident in his mid-30’s, Mr. Furia has bleb disease.  Over the years, these blebs have ruptured many times, requiring multiple chest tube placements and thoracic surgery.

Mr. Furia after one of his surgeries
Mr. Furia after one of his surgeries

A musician by trade, Mr. Furia (aka Skip Dawg) has used his considerable talents to share his experiences with bleb disease.

So, here he is – in his own words.

More about Blebs, Bullae and Spontaneous Pneumothorax

a return to one of our most popular topics here at Cirugia de Torax.

This is part of an ongoing discussion at Cirugia de Torax, with periodic updating and additions.

Recommended Reading:

Haynes D, Baumann MH (2011).  Pleural controversy: aetiology of pneumothorax.  Respirology. 2011 May;16(4):604-10. doi: 10.1111/j.1440-1843.2011.01968.x   If you are only going to read one article about primary spontaneous pneumothorax (PSP), this article by researchers at the University of Mississippi is recommended.

Blebs and Bullae: part two

Since there has been a lot of interest in the initial posts on blebs, bullae and blebectomies from around the world, this post has been designed to provide readers with additional resources and information.

One of the most frequent inquiries has been related to pain after thoracic surgery.

Another frequently asked question has been about the etiology or causes of bleb disease, so part of this discussion includes a list of some of the lesser known/ discussed causes of bleb disease.

Pneumothorax without a cause?

Frustrating as it is for many patients, in primary spontaneous pneumothorax (PSP), there may be no known underlying condition or cause.  Much of what we do know, may be just speculation and hypothesis (Dejene, Ahmed, Jack, Anthony 2013).

In other cases, the cause of spontaneous pneumothorax may be detected by underlying lung tissue changes on CT scan.  More rare, or lesser known causes of spontaneous pneumothorax may be more insidious.

Who this affects/ who may need additional testing:  Individuals with ONE isolated spontaneous pneumothorax with no signs of lung disease on CT scan will not need additional testing.  However,  in patients with multiple, bilateral pneumothoraces or strong family history of such conditions, additional testing may be warranted.

However, I caution patients not to attempt to self-diagnose based on these articles, but to use this material to prompt more earnest discussions with their medical providers.


Many, if not all of these conditions will require additional testing such as CT scan, lung biopsy or genetic marker or serum testing.  For systemic conditions or conditions that also affect areas outside the lung (such as the skin lesions in Birt-Hogg-Dube syndrome), pathological and radiological examination of other areas of the body may be required to reach a diagnosis.

Less common causes of bleb disease and spontaneous pneumothorax:

Birt-Hogg-Dube syndrome:  this is a genetic condition, (thus often runs in families).  It is “characterised by fibrofolliculomas (skin tumors), renal tumours, pulmonary cysts and pneumothorax” (Furuya M, Nakatani Y. (2013).

This paper by Furuya & Nakatani, Japanese researchers describes more about the clinical and pathological features of this condition.

Furuya M, Nakatani Y. (2013). Birt-Hogg-Dube syndrome: clinicopathological features of the lung.  Clin Pathol. 2013 Mar;66(3):178-86. doi: 10.1136/jclinpath-2012-201200. Epub 2012 Dec 8. Review.

Pulmonary alveolar proteinosis (PAP): this group of disorders is characterized by the build-up of fatty proteins in the lung tissue.  Spontaneous pneumothorax is a rare complication of this rare disease.  (It’s actually rare enough to be categorized as an ‘orphan’ disorder).

Campo I, Mariani F, Rodi G, Paracchini E, Tsana E, Piloni D, Nobili I, Kadija Z, Corsico A, Cerveri I, Chalk C, Trapnell BC, Braschi A, Tinelli C, Luisetti M. (2013). Assessment and management of pulmonary alveolar proteinosis in a reference center.   Orphanet J Rare Dis. 2013 Mar 13;8:40. doi: 10.1186/1750-1172-8-40.  This Italian article discusses findings over twenty years of study, as well as the process of diagnosing / treating this disorder.

Treatment of PAP:

Stoica R, Macri A, Cordoş I, Bolca C. (2012).  Whole lung lavage for pulmonary alveolar proteinosis after surgery for spontaneous pneumothorax.  J Med Life. 2012 Sep 15;5(3):311-5. Epub 2012 Sep 25.  Article has several images of CT, pathology and radiographic findings in this case report.

Bullous lung disease:

Vanishing lung syndrome, (type I bullous disease): In this condition, the appearance of a large bullae on chest radiographs may mimic the appearance of a pneumothorax.  Placement of a chest tube can actually worsen the situation by unintentionally rupturing the intact bullae.  (On a chest X-ray it can be difficult to see a difference between a large intact air ‘bubble’ and a collapsed lung). If these bullae should rupture, the patient will have a pneumothorax.  This condition is usually diagnosed in young men with a smoking history.

Tsao YT, Lee SW. (2012). Vanishing lung syndrome.  CMAJ. 2012 Dec 11;184(18):E977. doi: 10.1503/cmaj.111507. Epub 2012 May 22.  Short Taiwanese case report with radiographic images.

Núñez Delgado Y, Eisman Hidalgo M, Valero González MA.  (2012).  Primary bullous disease of the lung in a young male marijuana smoker. Arch Bronconeumol. 2012 Nov;48(11):428-9. doi: 10.1016/j.arbres.2012.04.024. Epub 2012 Jun 15.  Article also available in Spanish, “Enfermedad primaria bullosa del pulmón en varón joven fumador de cannabis”.  Article discusses how smoking marijuana harms the lungs in additional ways in comparison to tobacco smoking, and leads to the formation of bullous lung disease.

References/ Additional Reading

Gunnarsson SI, Johannesson KB, Gudjonsdottir M, Magnusson B, Jonsson S, Gudbjartsson T. (2012).  Incidence and outcomes of surgical resection for giant pulmonary bullae–a population-based study.  Scand J Surg. 2012;101(3):166-9.  Small Icelandic study of 12 patients and their outcomes after bullectomy.

Hamilton N, Hills MA. (2012).  Medical Image: The Vanishing lung.  NZ Med J. 2012 Sep 21;125(1362):92-4. Case report of very large bullae with radiographs, CT images and discussion of diagnosis and treatment.

Is pneumothorax related to depletion of the Ozone layer?

Abul Y, Karakurt S, Bostanci K, Yuksel M, Eryuksel E, Evman S, Celikel T. (2011).  Spontaneous pneumothorax and ozone levels: is there a relation?  Multidiscip Respir Med. 2011 Feb 28;6(1):16-9. doi: 10.1186/2049-6958-6-1-16.  No clear clinical evidence, but interesting reading.

What about dramatic changes in intra-thoracic pressure?

Dejene S, Ahmed F, Jack K, Anthony A. (2013). Pneumothorax, music and balloons: A case series. Ann Thorac Med. 2013 Jul;8(3):176-8. doi: 10.4103/1817-1737.114283.

Beydilli H, Cullu N, Kalemci S, Deveer M, Ozer S. (2013).  A case of primary spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema following cough.  Tuberk Toraks. 2013 Jun;61(2):164-5.  Subcutanous emphysema is not lung disease, it is the presence of air beneath the skin and subcutanous tissues. (To the examining clinician, it feels like ‘rice crispies’ beneath the skin.) SQ emphysema may result from air leaking from the lung, or from thoracic procedures where air becomes trapped (ie. chest tube insertion).

Bourne CL. (2013). The perils of sneezing: Bilateral spontaneous pneumothorax. J Emerg Trauma Shock. 2013 Apr;6(2):138-9. doi: 10.4103/0974-2700.110796.

Can medications cause pneumothorax?

This has actually be discussed for years among thoracic surgeons.  In one of my older textbooks, amphetamines including Adderall were implicated in the development of spontanous pneumothorax in otherwise healthy young men, but in subsequent editions, this reference was removed,presumably due to a lack of large published studies to demonstrate this.   Case reports have reported several chemotherapy induced pneumothoraces but the Pfizer-sponsered study by Hauben & Hung is one of the first to take a methodical look at this phenomenon.

Hauben M, Hung EY. (2013).  Pneumothorax as an adverse drug event: an exploratory aggregate analysis of the US FDA AERS database including a confounding by indication analysis inspired by Cornfield’s condition. Int J Med Sci. 2013 Jun 13;10(8):965-73. doi: 10.7150/ijms.5377. 2013.

Note:  As many readers are aware, I am a nurse in thoracic surgery, not pulmonology, so much of the diagnosis of the cause of blebs and bullae are outside of my area of expertise.  However, I hope that this post serves as a resource for patients in pursuing discussions with their clinicians after spontaneous pneumothorax, particular in cases of repeated pneumothorax or unknown etiology. 

Pulmonologists, pathologists and thoracic surgeons are invited to provide additional comments.

Post operative pain after thoracic surgery

What kind of pain should patients expect after thoracic surgery, and how long will it last? Also, is this normal? When should I call my doctor?

Like all posts here at Cirugia de Torax, this should serve as a guide for talking to your healthcare provider, and is not a substitute for medical advice.

Quite a few people have written in with questions about post-operative pain after thoracic surgery procedures so we will try to address those questions here.

1.  What is a normal amount of pain after these procedures?

While no two people will experience pain the same, there are some general guidelines to consider.  But to talk about this issue – we will need to refer to a basic pain scale which rates pain from 0 (no pain) to 10 – (excruciating, writhing pain, worst possible imaginable).

Unfortunately, for the majority of people who have thoracic surgery, there will be some pain and discomfort.

Pain depends on the procedure

In general, the intensity and duration of pain after thoracic procedures is related to the surgical approach – or the type of surgical incision used.

open thoracotomy,empyema, advanced with extensive purulence
This open incision (with rib spreading) will hurt more..
Photo: advanced empyema requiring open thoracotomy for decortication
Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)
Pain will be much less with a single incision VATS surgery (now with chest tube) and specimen removed (photo courtesy of Dr. Chen)

Patients with larger incisions like a sternotomy, thoracotomy or clamshell incision will have more pain, for a longer period of time than patients that have minimally invasive procedures like VATS because there is more trauma to the surrounding tissues.  People with larger incisions (from ‘open surgeries’) are also more likely to develop neuralgia symptoms as they recover.

.  (I will post pictures of the various incisions once I return home to my collection of surgical images).

Many patients will require narcotics or strong analgesics for the first few days but most surgeons will try to transition patients to anti-inflammatories after surgery.

Post-operative surgical pain is often related to inflammation and surgical manipulation of the chest wall, particularly in procedures such as pleurodesis, decortication or pleurectomy.  For many patients this pain will diminish gradually over time – but lasts about 4 to 6 weeks.


This pain is often better managed with over the counter medications such as ibuprofen than with stronger narcotics.  That’s because the medication helps to relieve the inflammation in addition to relieving pain.  Anti-inflammatory medications also avoid the risks of oversedation, drowsiness and severe constipation that often comes with narcotics.

Use with caution

However, even though these medications are available without a prescription be sure to talk to your local pharmacist about dosing because these medications can damage the kidneys.  Also, be sure to keep hydrated while taking this medications.

People with high blood pressure should be particularly cautious when taking over the counter anti-inflammatories because many of these medications have drug interactions with blood pressure medications.

2.  “I had surgery three weeks ago, and I recently developed a burning sensation near the incision”

Neuralgias after surgery

For many patients, the development of a neuralgia is a temporary effect and is part of the healing process.  However, it can be quite disturbing if patients are unprepared.  Neuralgic pain is often described as a burning or stinging sensation that extends across the chest wall from the initial incision area.  Patients also describe it as a ‘pins and needles’ sensation or “like when your foot falls asleep”.  This usually develops a few weeks after surgery as the nerves heal from the surgery itself.

It the discomfort is unmanageable, or persists beyond a few weeks, a return visit to your surgeon is warranted.  He/She can prescribe medications like gabapentin which will soothe the irritated nerves and lessen the sensations.  However, these medications may take some time to reach full effect.

Range of motion and exercise after surgery

Exercise limitations are related to the type of incision.

Sternotomy incisions/ sternotomy precautions

If you have a sternotomy incision – (an incision through the breast bone at the center of your chest), this incision requires strict precautions to prevent re-injury to the area.  Since the sternal bone was cut, patients are usually restricted from lifting anything greater than 10 pounds for 6 to 12 weeks, and to avoid pushing, pulling or placing stress on the incision.  Patients are also restricted from driving until bone healing is well underway.  (Be sure to attend a rehab program or physical therapy program to learn the proper way to exercise during this time period).

Patients will also need to take care to prevent a surgical skin infection or something more serious like mediastinitis.  The includes prohibitions against tub bathing/ soaking, swimming or over- aggressive cleaning of the incision with harsh abrasives like hydrogen peroxide or anti-bacterial soaps.  These chemicals actually do more harm than good in most cases by destroying the newly healing tissue.  A good rule of thumb to remember (unless your doctor says otherwise): No creams or lotions to your incisions until the scabs fall off.

Post-thoracotomy incisions

With a large thoracotomy incision, most patients will be restricted from lifting any items greater than 10 pounds on the surgery side for around two weeks.  However, unlike sternotomy patients – we want you to use and exercise that arm daily – otherwise patients have a risk of developing a ‘disuse’ syndrome.  One of the common exercises after a thoracotomy is called the spider crawl. This exercise helps the muscles to heal and prevent long-term disability or problems.  The physiotherapist at your local hospital should have a list of several others that they can teach you to practice at home.

The spider crawl

In this example, the patient had a left thoracotomy:

1. Stand with your surgical side within arm’s length of the wall.

start with your hand at waist level
start with your hand at waist level

Now, use your hand to “walk” up the wall, similar to a spider crawling.

'walking' the hand up the wall
‘walking’ the hand up the wall

Continue to walk your hand up the wall until your arm is fully extended.

continue until arm fully extended
continue until arm fully extended

Perform this exercise (or similar ones) for several minutes 5-6 times a day.  As you can see – it is fast and easy to do.


For patients with minimally invasive procedures – there are very few exercise restrictions, except no heavy lifting for 2 to 3 weeks (this is not the time to help your neighbor move his television.)

General incision care guidelines are similar to that for sternotomy patients – no soaking or bathing (showering is usually okay), no creams or lotions and no anti-bacterial soaps/ hydrogen peroxide/ harsh cleaners.

Whats NOT normal – when it’s time to call your surgeon

– dramatic increase in pain not associated with activity (i.e. lifting or reaching).  If your pain has been a “4” for several days and suddenly increases to an “8”

– If the quality of the pain changes – ie. if it was a dull ache and becomes a stabbing pain.

– any breathlessness, shortness of breath or difficulty breathing

– Any increase in redness, or swelling around your incisions.  Incisions may be pink and swollen for the first 2-3 days, but any increase after that warrants a ‘wound check’ by your surgeon

– Any fresh bleeding – bright red blood.  A small amount of drainage (from chest tube sites) that is light pink, clear or yellow in nature may be normal for the first few days.

– Drainage from the other sites (not chest tube sites) such as your primary incision is not normal and may be a sign of a developing infection.

– Fever, particularly fever greater than 101.5 – may be a sign of an infection.

– If you are diabetic, and your blood sugars become elevated at home, this may also be a sign of infection. (Elevation in the first few days is normal, and is often treated with insulin – particularly if you are in the hospital.

– Pain that persists beyond 3 months may be a sign of nerve damage (and you will need additional medications / therapies).

Mailbag: Cancer Treatment Centers of America & Lung Cancer

Cirugia de Torax answers one of the most frequently received email inquiries regarding lung cancer treatment and the Cancer Treatment Centers of America.

Update:  in March of 2014 (almost three years after our original post), the Cancer Treatment Centers of America announced the addition of a thoracic surgeon, Dr. Johnathan Kiev to their staff at the midwestern campus in Zion, Illinois.  

Here at Cirugia de Torax.org, we receive quite a bit of email about lung cancer, and lung cancer treatment.  A significant portion of this email concerns questions regarding the efficacy and treatments available at the Cancer Treatment Centers of America – a commercial, for-profit chain of hospital facilities that advertise ‘holistic’ and specialized cancer treatment.

The company currently has four hospitals, spread across the United States (Philadelphia, PA, Arizona, Oklahoma and Illinois with additional facilities scheduled to open in 2012.)

This organization is particularly well-known due to a series of television advertisements with various actors making statements such as “when I woke up from surgery, my surgeon said I had cancer.  He had no compassion” etc, etc.  These commercials tend to be emotionally exploitative (in my opinion), but I thought I would investigate some of the treatments offered for thoracic cancers due to the volume of inquiries.

However, when perusing the information available on-line, including surgeon profiles – it was readily apparent that despite offering a wide range of therapies and information targeted at patients with lung / esophageal/ and other thoracic cancers – there are no board-certified or specialty trained thoracic surgeons currently working for this organization.  The majority of surgeons listed are general surgeons, with a few head and neck surgeons.  In fact, there are only 2 general surgeons at each facility (as well as a plastic surgeon at each facility – listed under ‘breast surgeon’.)

This hospital chain – doesn’t offer thoracic surgical procedures despite advertising heavily for these patients. (Some of the terminology used on their website is vague – but lobectomies, lung resections, esophagectomies are not specifically mentioned.) The website alludes to this fact – in one small section – stating that ‘we’ll give you treatments when others can’t” or at least the assumption that the centers are only treating advanced (late stage) lung cancers is expressed.  But on another section of the site, they advertise diagnostic modalities for diagnose lung cancer – so it’s not the most open/ easily understood website from the patient perspective.

So – to answer previous inquiries, “What about the Cancer Treatment Centers of America?  Is that a good place to go for lung cancer?”

Short answer:  No. (or at least not yet.)

Detailed answer:  As we’ve discussed before, the best long-term outcomes for lung cancer are obtained via surgery.  The first stop after a lung cancer diagnosis should be to see a thoracic surgeon.  After a discussion of your particular circumstances (stages, burden of disease etc.) your thoracic surgeon will be better able to determine whether surgery is an option.  Until this determination has been made, all other therapies/ holistic treatments/ supplements/ etc. should be considered secondary.  These are not the best first-line treatments for someone with surgically manageable disease.

Only after this determination – should/ could patients consider receiving additional or adjuvant treatments in facilities such as the organization mentioned above.

please note – Cirugia de Torax.org does not dispense or provide medical advice, and does not answer individualized/ specific medical or surgical questions.  Questions should be general in nature.  Replies are for basic consumer education, and none of the information provided on this site should be considered in lieu of a medical consultation with a board certified health care provider. 

Additional information –

1. Commercial – a particularly vague ‘cancer’ commercial emphasising holistic / ‘alternative’ treatments.  As a nurse, this specific commercial is rather offensive to me.

2. Cancer treatment center of america – website