الفهرس 
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Abstract
The pleural cavity, the space between the parietal and visceral pleura, contains a small amount of clear serous fluid.
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions (primary) as well as in those with lung disease (secondary), and many pneumothoraces occur after physical trauma to the chest, blast injury, or as a complication of medical treatment
Management of spontaneous pneumothorax includes observation, supplemental Oxygen, simple aspiration, tube thoracostomy, pleurodesis, medical thoracoscopy, video- Assisted thoracoscopic surgery and open thoracotomy.
Medical thoracoscopy is performed with the patient under local anesthesia, usually combined with conscious sedation. In contrast, video-assisted thoracoscopic surgery (VATS) is performed almost exclusively under general anesthesia with double-lumen endotracheal intubation, which allows single-lung ventilation and the collapse of the lung on the operated side.
Advantage of medical thoracoscopy in the management of spontaneous pneumothorax
• Technique similar to chest tube insertion (Local anaesthesia, no intubation)
• Visualization of adhesions, blebs, bullae, air leaks.
• Guiding the choice of primary treatment (conservative or surgical approach).
• Additional conservative treatment options; coagulation, talc poudrage, fibrin sealant, mechanical pleural abrasion, etc.
On inspection during medical thoracoscopy, the underlying lesions can be directly assessed according to the classification of VANDERSCHUEREN:
Stage I: with an endoscopically normal lung.
Stage II: with pleuropulmonary adhesions.
Stage III: with small bullae and blebs (<2 cm in diameter).
Stage IV: with numerous large bullae (>2cm in diameter).
Pleurodesis is a medical procedure in which the pleural space is artificially obliterated. It involves the adhesion between parietal and visceral pleura.
Pleurodesis is done to prevent recurrence of pneumothorax or pleural effusion. It can be done chemically or surgically.
This study included 32 patients with spontaneous pneumothorax. Medical thoracoscopy using rigid thoracoscope was used for 12 patients as group A to diagnose the underlying cause of spontaneous pneumothorax ,intercostal tube was inserted to 20 patients directly without medical thoracoscopy as group B ,Both groups met the following criteria:
• Diagnosis of spontaneous pneumothorax is established by full history of the patients, clinically, and radiologically.
• Prothrombin activity ≥70%,
• Non-traumatic pneumothorax.
All patients will be subjected to
1. Thorough history taking including age, sex, smoking index, and history of other diseases.
2. Full clinical examination including general examination and local chest examination.
3. Routine laboratory investigation including hemoglobin level, total and differential count of white blood cells, renal and liver function tests, fasting blood glucose level, prothrombin activity and INR.
4. Radiological investigations:
Plain chest x-ray PA view and lateral view (when needed).
CT chest (when needed).
5. Medical thoracoscopy was done for group A patients under conscious sedation with local anesthesia aiming to examine pleural surfaces and obtaining multiple biopsies of the apparently healthy pleurae and of any detected suspicious lesions
6. Intercostal tube was inserted in patients of group B without medical thoracoscopy application and this group will be a control group to determine the role of medical thoracoscopy in the managements of spontaneous pneumothorax.
7. Pleurodesis was done for recurrent or malignant pneumothorax either chemically by using sclerosing agents.
8. Follow up with chest X-ray will be reported for all patients the next day following medical thoracoscopy or intercostal tube insertion, and within one month as follow up for the patients undergoing pleurodesis.
The results of our study were analyzed and the following important points were observed:
• Thoracoscopic findings in group A studied patients, pathological lesions were detected in about (83.3%) of the cases, and multiple bullae were present in 50%, most of these bullae were located apically (83.3%).
• The histopathological diagnosis in group A studied patients. 1 case (9.1%) was diagnosed as malignant deposits and 10cases (90.9%) as non specific pleurisy.
The complications encountered in group A studied patients:
• Post operative chest pain encountered in 12 (100%) patients.
• Local wound infection was encountered in 1 patient (8.3%) and was managed by frequent sterile dressings and local antibiotics, local antiseptic solution and all resolved within 4-5 days. Empyema was encountered in 1patient (8.3%).
• Subcutaneous emphysema was encountered in 9 patients (75%) and resolved 1-2 days after the procedure.
• Persistent air leak more than 7 days was encountered in 3 patients (25%).
The complications encountered in group B studied patients:
• Post operative chest pain encountered in 20 patients (100%).
• Subcutaneous emphysema was encountered in 14 patients (70%).