Calvin S.H. Ng and Anthony P .C. Yim
Purpose of review
Spontaneous hemopneumothorax can be life threatening,
andisacauseofpatients presentingwithunexplained signs
of significant hypovolemia. The debate relating to patient
hemopneumothorax remains unresolved.
Our experience together with the latest series published
over the last decade on the conservative and surgical
management of spontaneous hemopneumothorax are
presented and discussed.
Surgery should be performed early in the management of
spontaneous hemopneumothorax to reduce morbidity. In
particular, video-assisted thoracic surgery, which is
associated with potentially fewer post-operative
complications and shorter hospital stays compared with
thoracotomy, should be considered in patients with
spontaneous hemopneumothorax who are
spontaneous hemopneumothorax (SHP), spontaneous
pneumothorax, video-assisted thoracic surgery (VATS)
Curr Opin Pulm Med 12:273–277. ? 2006 Lippincott Williams & Wilkins.
Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of
Wales Hospital, Sha Tin, New Territories, Hong Kong
Correspondence to Professor Anthony P.C. Yim, MD, FRCS, FACS, Professor of
Surgery, and Chief, Division of Cardiothoracic Surgery, The Chinese University of
Hong Kong, Prince of Wales Hospital, Sha Tin, NT, Hong Kong
Tel: +852 2632 2629; fax: +852 2637 7974; e-mail: firstname.lastname@example.org
Current Opinion in Pulmonary Medicine 2006, 12:273–277
video-assisted thoracic surgery
? 2006 Lippincott Williams & Wilkins
La ¨ennec in 1828 was credited with the first description of
spontaneous hemopneumothorax (SHP), which was diag-
nosed post mortem. Subsequently, the successful treat-
ment of SHP by thoracentesis was performed by
Whitaker in 1876 . Since then, SHP has become a
1–12% of all spontaneous pneumothoraces [2,3]. The
patients can often deteriorate very quickly due to hemo-
dynamic instability as a result of continued blood loss. In
addition to fluid resuscitation and blood transfusion,
surgical intervention is often required in the manage-
ment of SHP. Tube thoracostomy, aspiration of the
hemothorax, thoracotomy, and decortication after the
initial period of rest have all been used to treat SHP.
More recently, video-assisted thoracic surgery (VATS)
has been used successfully in the management of spon-
tissue trauma and reduced post-operative pain when
compared with traditional thoracotomy approach [4,5].
Furthermore, VATS is increasingly being used for the
management of SHP, with favorable results in terms of
reduced hospital stay and morbidity [3,6].
Presentation and etiology
from thoracic malignancies, primary vascular events,
coagulopathy, spontaneous pneumothorax and a variety
of infectious diseases. SHP is an uncommon but poten-
tially life-threatening clinical situation due to rapid
ventilatory collapse and the large volume of concealed
patients presenting with unexplained signs of significant
Between 80 and 100% of patients with SHP present with
their first episode of pneumothorax, while 10–12%
represent pneumothorax recurrences, and 10% have
had a previous contralateral pneumothorax [2,3,6,7].
Chest roentgenogram remains the most useful investi-
gation in the diagnosis of the condition [3,7] (Fig. 1). In a
large series of SHP patients, 70% of chest radiographs
demonstrated hydropneumothorax, while the remainder
showed some opacity and obscurity of the costophrenic
angle . It should be emphasized, however, that the
admission chest roentgenogram may show only pneu-
mothorax in 10% of SHP patients, with radiological
evidence of hemothorax developing later . There
has been some argument that tube thoracostomy inser-
tion may have been the cause of such cases of
hemothorax; however, bleeding from vascular adhesions
can be usually confirmed later intra-operatively. Failure
of the initial chest roentgenogram to show hemothorax
can be due to the film being taken too early, a supine
rather than an erect/sitting chest film, or the possibility of
delayed hemorrhage from the vascular adhesion band.
Hwong et al.  reported two patients in their series who
had no initial drainage from tube thoracostomy. The first
patient had delayed bleeding from the torn vascular
adhesion, as recorded by the delayed high-drain output.
In the other patient, the position of the tube thoracost-
omy was relatively apical, causing a slight delay in the
‘initial’ drainage of hemothorax. The presence of signifi-
cant dyspnea and lower levels of blood hemoglobin are
indicators of SHP rather than spontaneous pneumothorax
[8?]. Measuring the hemoglobin level of the pleural fluid
may also be a useful tool to help differentiate between
SHP and blood-stained effusion. Computed tomography
can be considered in cases where the diagnosis of SHP is
in doubt , or to exclude neoplasia in hemodynamically
stable patients prior to elective surgery. Past experience
has shown that 13–46% of patients with SHP will
develop hypovolemic shock (systolic blood pressure
? 90 mmHg) [2,3,6,7,10??], and blood transfusion may
be necessary in 64–100% of these patients [3,6].
vessel in an area of torn vascular adhesion between the
twolayersofthepleurae[2,3,6,10??](Fig.2),rupture of a
vascular bulla or lung parenchyma at the apex of the
lungs [2,6,7,10??] (Fig. 3), or the presence of an aberrant
vessel that is usually thin-walled and does not contract
adequately dueto the lack ofmuscular fibres
[2,3,6,7,10??,11]. Interestingly, more recent pathological
studies have shown vessel degeneration and sclerosis, as
well as intima-media fibrosis, to be the likely causes of
apex and subclavian vessels, and also in the aorta,
superior vena cava and pericardium. Normal hemostasis
by vasoconstriction and clot formation may be impeded
by lung movement, changes in pleural pressure during
respiration and the absence of a surrounding tamponade
effect. In our experience, the source of bleeding can be
identified intra-operatively in 53% of SHP patients;
bleeding occurs most commonly from a torn vascular
adhesion band from the apical parietal pleura, which
Diseases of the pleura
Figure 1 Representative chest roentgenogram of spontaneous
hemopneumothorax before surgical intervention
Figure 2 Multiple bullae with highly vascular wall at the apex of
left upper lobe
Figure 3 Remnant of a vascular adhesion (arrow) following
hemostasis by electrocautery near the apex of the chest wall
accounts for three-quarter of cases. In comparison,
authors of other series were able to identify a source
of bleeding in 50–100% of their cases [2,6,7,10??], and
around half of the identified bleeding was from an
aberrant vessel [6,10??].
Males are between 8 and 30 times more likely to develop
SHP than females [2,3,7,10??,12]. The reason for the
relative infrequency of SHP in females is not clear but
is well documented, and only a handful of cases have
been reported in the English literature [6,10??,12,13]. Fry
et al.  suggested that there is an increased bleeding
tendency in males due to their additional strength and
vigor, but this theory fails to explain why SHP occurs
while the patients are at rest. SHP has also been reported
to be associated with other conditions, such as congenital
cystic adenomatoid malformation , Ehlers–Danlos
syndrome , sarcoidosis , systemic lupus erythe-
matosis  and cystic lung metastasis . Rarely, SHP
may be the presenting feature of hemophilia .
Management of spontaneous
Mortality from SHP remained relatively high until the
open surgical management of SHP became a realistic
option in the late 1940s onwards [20,21]. The debate
relating to patient selection and timing of surgery in SHP
patients remains unresolved. The initial management of
SHP patients should be tube thoracostomy and resuscita-
tion. Several centres have advocated a conservative
approach with tube thoracostomy, as for uncomplicated
pneumothorax, which they report can be successfully
adopted in most cases of SHP. In contrast, others advo-
of patients where bleeding subsides within 24 h and the
patients remain hemodynamically stable [7,10??,22,23].It
should be borne in mind that the presence of a blocked or
poorly positioned chest drain can result in underestima-
tion of the severity of the situation; in addition, many
SHP patients are young, and will tolerate significant
hypovolemia before developing hemodynamic decom-
pensation. Furthermore, in one series where patients
were managed conservatively, many were discharged
with residual hemothorax, although only a minority of
them later developed empyema or trapped lung
Our experience has shown that all SHP patients will
benefit from surgical intervention as an emergency or
non-emergency procedure during their hospital stay if
optimum results are to be achieved. Emergency surgery
is indicated if the patient has hemodynamic instability or
[3,10??]. The need for non-emergency surgery for SHP
arises when complications relating to the SHP occur, or if
there is persistent air leak with pneumothorax [2,3,7]
(Table 1). Furthermore, a potential pitfall of conservative
accumulation of fluid in the pleural cavity and lung
restriction [2,3]. Several series showed that between 14
Another consideration in favor of surgery is the young
age of SHP patients, which places them in the low-risk
category for anesthetic. In addition, the benefits of per-
forming surgery while patients are stable before the onset
of decompensated hemodynamics should not be under-
estimated. Several series have also noted that patients
who were initially managed conservatively but sub-
sequently required surgery, therefore resulting in a pro-
longed hospital stay, reported a poor quality of life [2,7].
Once the decision has been made to undergo surgery, the
patient should be optimized with adequate fluid resusci-
tation and transfusion if necessary. SHP patients who
require blood transfusion typically have drainage of more
than 1200 ml, and represent between 10 and 20% of cases
[2,3,7]. Patients with underlying conditions, such as clot-
ting abnormalities in hemophiliacs, should be treated
appropriately prior to surgery . Recently, autologous
blood transfusion from blood salvaged from the pleural
space by cell-saving device systems has been used suc-
cessfully in SHP patients undergoing emergent surgery,
thereby avoiding the risks associated with allogeneic
Management of spontaneous
hemopneumothorax: video-assisted thoracic
surgery versus open surgery
The advent of VATS has caused a paradigm shift in the
way many thoracic conditions are managed, and this
technique is now considered the gold standard in the
treatment of spontaneous pneumothorax [4,5]. When
compared with the conventional thoracotomy operation,
VATS for spontaneous pneumothorax and major lung
resection is known to have quicker access time, less
access trauma, reduced post-operative pain, attenuated
post-operative immunosuppression, and faster recovery
with shorter post-operative hospital stay [4,5,25,26].
Spontaneous hemopneumothorax Ng and Yim 275
Table 1 Delayed indication(s) for surgery due to spontaneous
Sudden high output
Persistent output with drop in hemoglobin
Failure of lung to re-expand
Persistent air leak
In the context of SHP, early surgery in the form of VATS
can help to reduce the incidence of delayed surgical
exploration and decortication. In particular, VATS offers
the added advantages of a better view of the pleural
cavity, and more precise identification of bleeding via the
magnified lens and hence direct hemostasis. Further-
more, evacuation of clotted blood from pleural cavity,
sealing the area of air leak with endoscopic stapler and
mechanical pleurodesis, as well as placement of the
drainage tube under direct thoracoscopic vision, can all
be performed by VATS with minimal access trauma
[3,4,5,10??]. In addition, the smaller wounds of VATS
 can lead to significantly less blood loss, which is
particularly important in SHP patients who may already
be coagulopathic . The results from our experience
and that of others support the practice of VATS in the
management of SHP, with potential advantages of
shorter post-operative stay and fewer complications for
the patient compared with open surgery [3,6] (Table 2).
Thus, VATS is increasingly considered as a better
alternative to the open approach for SHP [3,6]. Even
among advocates of access by open thoracotomy, many
surgeons are now recommending early surgery to reduce
hospital stay and improved cost-effectiveness [2,7].
Nevertheless, VATS is generally contra-indicated in
SHP patients with hemodynamic instability unless there
is prompt and complete response to fluid replacement
therapy [2,3,10??]. In cases of shock or where major
bleeding is encountered, thoracotomy remains the access
of choice. Some centers also recommend thoracotomy for
more chronic cases where adhesions may be present;
however, we have not encountered major difficulties
performing adhesiolysis with VATS .
In conclusion, SHP is potentially a life-threatening con-
dition, and should be considered as a cause in patients
presenting with unexplained signs of significant hypovo-
lemia, particularly in young male patients. Early surgery
may help reduce the incidence of delayed surgical
exploration and decortication. Furthermore, in experi-
enced centers, surgery for SHP in the form of VATS
should be considered for patients who are hemodynami-
cally stable. Larger prospective trials are warranted in
the management of SHP.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
Additional references related to this topic can also be found in the Current
World Literature section in this issue (pp. 280–281).
of special interest
of outstanding interest
Whittaker JT. Case of hemopneumothorax, relieved by aspiration. Clinic
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Tatebe S, Kanazawa H, Yamazaki Y, et al. Spontaneous hemopneumothorax.
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Diseases of the pleura
Table 2 Results of surgery for spontaneous hemopneumothorax
M : F
R : L
MIBD by TT
Mean post-op hospital
stay (days) (range)
Hsu et al. [10??]
25 : 2
Hwong et al. 
30 : 0
17 : 13
4 VATS 3 Thor
21 VATS 2 Thor
Thor: 2 chest
airleak VATS: 1
VATS 3.9 Thor 7.5
Kakaris et al. 
63 : 8
1 : 1
(100 – 2200)
Wu et al. 
24 : 0
Tatebe et al. 
10 : 0
4 : 6
4 Thor 1 VATS
The recurrence rate was 0% in all studies. Abbreviations: M : F, male : female; MIBD, mean initial blood drainage; NA, not available; R : L, right : left; SP, spontaneous pneumothorax; SHP, spontaneous
hemopneumothorax; Thor, thoracotomy; TT, tube thoracostomy; VATS, video-assisted thoracic surgery.
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