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Fernández-Caramés, Miguel González-López, Carlos J. Escudero and Luis Castedo",authors:[{id:"20183",title:"Dr.",name:"Luis",middleName:null,surname:"Castedo",fullName:"Luis Castedo",slug:"luis-castedo"},{id:"21733",title:"Prof.",name:"Miguel",middleName:null,surname:"González-López",fullName:"Miguel González-López",slug:"miguel-gonzalez-lopez"},{id:"42447",title:"Mr",name:"Tiago M.",middleName:null,surname:"Fernandez-Carames",fullName:"Tiago M. Fernandez-Carames",slug:"tiago-m.-fernandez-carames"},{id:"53470",title:"Dr.",name:"Carlos J.",middleName:null,surname:"Escudero",fullName:"Carlos J. Escudero",slug:"carlos-j.-escudero"}]},{id:"20131",title:"Position Location Technique in Wireless Sensor Network Using Rapid Prototyping Algorithm",slug:"position-location-technique-in-wireless-sensor-network-using-rapid-prototyping-algorithm",signatures:"Touati Youcef, Aoudia Hania, Ali-Cherif Arab and Mohamed Demri",authors:[{id:"42120",title:"Dr.",name:"Touati",middleName:null,surname:"Youcef",fullName:"Touati Youcef",slug:"touati-youcef"},{id:"134926",title:"Prof.",name:"Arab",middleName:null,surname:"Ali Cherif",fullName:"Arab Ali Cherif",slug:"arab-ali-cherif"},{id:"136709",title:"Prof.",name:"Aoudia",middleName:null,surname:"Hania",fullName:"Aoudia Hania",slug:"aoudia-hania"},{id:"136971",title:"Dr.",name:"David",middleName:null,surname:"Papo",fullName:"David Papo",slug:"david-papo"}]},{id:"20132",title:"Application of RP and Manufacturing to Water-Saving Emitters",slug:"application-of-rp-and-manufacturing-to-water-saving-emitters",signatures:"Zhengying Wei",authors:[{id:"47614",title:"Prof.",name:"Zhengying",middleName:null,surname:"Wei",fullName:"Zhengying Wei",slug:"zhengying-wei"}]},{id:"20133",title:"The Use of the Rapid Prototyping Method for the Manufacture and Examination of Gear Wheels",slug:"the-use-of-the-rapid-prototyping-method-for-the-manufacture-and-examination-of-gear-wheels",signatures:"Grzegorz Budzik",authors:[{id:"7725",title:"Dr. Eng.",name:"Grzegorz",middleName:null,surname:"Budzik",fullName:"Grzegorz Budzik",slug:"grzegorz-budzik"}]}]}],publishedBooks:[{type:"book",id:"307",title:"Rapid Prototyping Technology",subtitle:"Principles and Functional Requirements",isOpenForSubmission:!1,hash:"aa39f8a56e606bbc2935e87620674425",slug:"rapid-prototyping-technology-principles-and-functional-requirements",bookSignature:"Muhammad Enamul Hoque",coverURL:"https://cdn.intechopen.com/books/images_new/307.jpg",editedByType:"Edited by",editors:[{id:"39279",title:"Prof.",name:"Md Enamul",surname:"Hoque",slug:"md-enamul-hoque",fullName:"Md Enamul Hoque"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"930",title:"Advanced Applications of Rapid Prototyping Technology in Modern Engineering",subtitle:null,isOpenForSubmission:!1,hash:"3775beff84516a387ab64fe05390fbea",slug:"advanced-applications-of-rapid-prototyping-technology-in-modern-engineering",bookSignature:"Muhammad Enamul Hoque",coverURL:"https://cdn.intechopen.com/books/images_new/930.jpg",editedByType:"Edited by",editors:[{id:"39279",title:"Prof.",name:"Md Enamul",surname:"Hoque",slug:"md-enamul-hoque",fullName:"Md Enamul Hoque"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7249",title:"3D Printing",subtitle:null,isOpenForSubmission:!1,hash:"bd92f056fb3bb4793bf7f07413747568",slug:"3d-printing",bookSignature:"Dragan Cvetković",coverURL:"https://cdn.intechopen.com/books/images_new/7249.jpg",editedByType:"Edited by",editors:[{id:"101330",title:"Dr.",name:"Dragan",surname:"Cvetković",slug:"dragan-cvetkovic",fullName:"Dragan Cvetković"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8374",title:"New Innovations in Engineering Education and Naval Engineering",subtitle:null,isOpenForSubmission:!1,hash:"4019cba8abf5c1688f512dd73a1e79aa",slug:"new-innovations-in-engineering-education-and-naval-engineering",bookSignature:"Nur Md. Sayeed Hassan and Sérgio António Neves Lousada",coverURL:"https://cdn.intechopen.com/books/images_new/8374.jpg",editedByType:"Edited by",editors:[{id:"143363",title:"Dr.",name:"Nur Md. Sayeed",surname:"Hassan",slug:"nur-md.-sayeed-hassan",fullName:"Nur Md. Sayeed Hassan"}],equalEditorOne:{id:"248645",title:"Dr.",name:"Sérgio",surname:"Lousada",slug:"sergio-lousada",fullName:"Sérgio Lousada"},equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],publishedBooksByAuthor:[{type:"book",id:"307",title:"Rapid Prototyping Technology",subtitle:"Principles and Functional Requirements",isOpenForSubmission:!1,hash:"aa39f8a56e606bbc2935e87620674425",slug:"rapid-prototyping-technology-principles-and-functional-requirements",bookSignature:"Muhammad Enamul Hoque",coverURL:"https://cdn.intechopen.com/books/images_new/307.jpg",editedByType:"Edited by",editors:[{id:"39279",title:"Prof.",name:"Md Enamul",surname:"Hoque",slug:"md-enamul-hoque",fullName:"Md Enamul Hoque"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5379",title:"Computer-aided Technologies",subtitle:"Applications in Engineering and Medicine",isOpenForSubmission:!1,hash:"f33a3bdb537f32114b4c1ca6ed3be8dd",slug:"computer-aided-technologies-applications-in-engineering-and-medicine",bookSignature:"Razvan Udroiu",coverURL:"https://cdn.intechopen.com/books/images_new/5379.jpg",editedByType:"Edited by",editors:[{id:"13146",title:"Prof.",name:"Razvan",surname:"Udroiu",slug:"razvan-udroiu",fullName:"Razvan Udroiu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7489",title:"Product Lifecycle Management",subtitle:"Terminology and Applications",isOpenForSubmission:!1,hash:"4cd1c0770949d5fe717936f01c4a1c61",slug:"product-lifecycle-management-terminology-and-applications",bookSignature:"Razvan Udroiu and Paul Bere",coverURL:"https://cdn.intechopen.com/books/images_new/7489.jpg",editedByType:"Edited by",editors:[{id:"13146",title:"Prof.",name:"Razvan",surname:"Udroiu",slug:"razvan-udroiu",fullName:"Razvan Udroiu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},onlineFirst:{chapter:{type:"chapter",id:"82740",title:"Secondary Pneumothorax from a Surgical Perspective",doi:"10.5772/intechopen.105414",slug:"secondary-pneumothorax-from-a-surgical-perspective",body:'Pneumothorax (PNX) is an abnormal collection of air in the pleural space. It is defined as primary spontaneous pneumothorax (PSP) or secondary, based on age, causes, and the requirement of different management [1].
A PSP usually occurs following the rupture of subvisceral pleural blebs and its cause is unknown. Most frequently, patients are males, healthy teenagers or young adults, and smokers [2].
Instead, a spontaneous secondary pneumothorax (SPS) is often associated with a known lung disease and the main cause is a chronic obstructive pulmonary disease (COPD). Other causes are, for instance, idiopathic fibrosis, acquired immunodeficiency syndrome (AIDS), and neoplastic disease. Secondary pneumothorax (SP) could also occur after a chest trauma (post-traumatic pneumothorax) or after invasive procedures (iatrogenic). A specific subgroup is represented by the catamenial pneumothorax, as discussed further on.
The annual incidence of SPS is in general 26 cases per 100.000 and it is more common in men with a 3:1 ratio. It is mainly observed in patients aged 50–60 years old [3, 4].
In general, symptoms include chest pain and shortness of breath, but symptoms could differ according to the cause of pneumothorax [5].
In the following chapter, all the aspects related to a secondary pneumothorax are described.
The annual incidence of an SP is approximately 6.3 cases per 100.000 in men and 2 cases per 100.000 in women, every year [3].
A SP may occur:
in the presence of pre-existing lung diseases, like COPD, infections (e.g., tuberculosis, necrotizing pneumonia, and pneumocystis carinii), inflammatory disease (e.g., rheumatoid arthritis, polymyositis and dermatomyositis, and systemic sclerosis);
in the presence of neoplastic disease (e.g., primary lung cancer, sarcoma metastases, and malignant pleural mesothelioma);
as a consequence of a chest trauma;
as a complication of medical or surgical procedures (iatrogenic pneumothorax); or
concomitant to other pre-existing pathologies (e.g., catamenial pneumothorax) [6].
Moreover, compared to a primary pneumothorax, SP afflicts patients with a known history of lung disease. For such reasons, an SP:
is less tolerated by patients because of a co-existing lung disease;
is generally characterized by the presence of a persistent air leak that does not tend to resolve spontaneously, requiring an active intervention; and
oxygen could be required to promote air reabsorption, especially in the case of subcutaneous emphysema.
Generally, the management of such patients is complex and the treatment requires a chest tube insertion, prolonged hospitalization, and consideration for a surgical procedure to induce pleurodesis.
The main cause of SP is COPD, with an incidence of 26 cases per 100.000 patients per year [7]; COPD is one of the three main causes of death in the world and one of the main causes of chronic disease [8].
Based on computed tomography (CT) images, COPD may be divided into:
emphysema- and airway-dominant COPD: SP generally occurs as a consequence of bullae disruptions (Figure 1);
nonemphysematous COPD.
Emphysema dominant COPD.
According to the GOLD guideline [9], COPD severity depends on pulmonary function, evaluated by means of a spirometry. The risk of an SP is higher in patients affected by severe COPD. Patients with FEV1 < 1 L and/or a FEV1/FVC < 40% are deemed at high-risk [10], with a common observance of severe hypoxemia associated with hypercapnia in case of pneumothorax [8].
The development of a secondary pneumothorax in COPD patients is a parameter of high mortality and, in fact, it has been demonstrated that each SP event increases fourfold the chances of death in such patients [11].
When a pneumothorax occurs in a COPD patient with a low respiratory function, it is common to observe severe hypoxemia caused by a lower ventilation-perfusion (V/Q) rate, which is capable to determine an incremented shunt that is directly proportional to the PNX size. Compensatory hypercapnia is often associated [8].
For such reasons, an SP onset in COPD patients is generally associated with a rapidly progressive dyspnea and pleuritic chest pain where a prompt management is mandatory.
Generally, COPD patients present with hyperinflated lungs and abnormal lung auscultation. A reduced or absent vesicular murmur associated with symptoms such as shortness of breath, low saturation, and hyperventilation should easily guide to diagnose a PNX.
A chest X-ray is mandatory to assess the presence of a PNX, which usually appears as a complete collapse of the lung. Seldomly, a subcutaneous emphysema may occur, concealing the PNX at the chest X-ray (Figure 2).
Massive subcutaneous emphysema. Red arrow to indicate the small size SP.
Generally, at chest X-ray, bullous lesions have a concave appearance while a pneumothorax has a concave profile (Figure 3).
The different appearance between an SP and bullae. Image a: a secondary pneumothorax in a COPD patient. At the chest X-ray, a pneumothorax has a concave profile. Image b: bulls lesion has a concave appearance.
In COPD patients, however, a CT scan is useful to better analyze the pneumothorax size and the severity of the lung disease. Moreover, The CT scan can help in distinguishing a big bulla from a true PNX. This may not be an easy task; however, if a bulla is detected, a chest tube is not always indicated, or if it is, it should be carefully placed under CT guidance, in order to avoid an iatrogenic rupture of the bulla determining a complex PNX, which potentially requires a surgical treatment.
It is important to remember that due to the underlying pathology and the low functional reserve, these patients could become suddenly critical in case of a PNX and should therefore be treated accordingly. For the same reason, even if the PNX is correctly treated by means of a chest drain, these patients still remain at a higher risk of death. Death causes are, in fact, associated with the onset of an acute or late respiratory failure [12, 13], or with a higher risk of developing sepsis as a consequence of pneumonia or empyema due to the pneumothorax management (i.e., chest tube and/or pleurodesis) [14].
Any noxa capable to affect the integrity of the visceral pleura and reduce the lung elasticity could be a cause of a secondary pneumothorax and therefore, a secondary pneumothorax may be diagnosed in the process of:
Infection: tuberculosis, necrotizing pneumonia, and
Interstitial diseases: cystic fibrosis, acute severe asthma. Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, and fibrosing lung disease of unknown etiology. The rates of pneumothorax range from 2 to 20% in patients with IPF, becoming the second cause of SP after chronic obstructive pulmonary disease (COPD) [15].
Inflammatory or connective-related diseases: such as rheumatoid arthritis, polymyositis, dermatomyositis, systemic sclerosis, Marfan’s syndrome, and Ehlers-Danlos syndrome.
Pneumothorax caused by tubercular infection.
Acquired immunodeficiency syndrome (AIDS) could be another cause of SP, likely related to an increased risk of developing cystic lesions in the sub-pleural space [16].
As in the case of primary pneumothorax, the treatment goals should aim at:
evacuating the pleural cavity from the air to restore the normal intrapleural negative pressure;
obtaining lung re-expansion and pleural apposition;
reducing the risk of recurrence.
According to the BTS guidelines, a secondary pneumothorax that occurred in a known diseased lung requires the insertion of a small-bore chest tube to drain the air in the pleural space [17].
Pneumothorax aspiration, which finds a treatment indication in the primary spontaneous pneumothorax, has a high-risk of failure, but it may be taken into account in the case of symptomatic patients with a small pneumothorax. A persistent air leak can be managed conservatively obtaining a complete resolution [17].
A talc slurry pleurodesis could be a nonsurgical therapeutic management option to be considered for persistent air leak in patients deemed unfit for surgery. According to the American College of Chest Physicians (ACCP) consensus, a talc slurry pleurodesis through the chest tube is indicated to avoid recurrence after the first episode [14].
By contrast, the BTS guidelines suggest pleurodesis in case of a recurrent SP or in case of a persistent air leak, which in COPD patients may resolve in a long time compared to non-COPD patients [18]. Surgery is an option in SP, but COPD patients may not be deemed fit enough for surgery because of their clinical status. A prerequisite for talc pleurodesis is a complete or major re-expansion of the lung. In case of partially expanded or nonexpandable lungs, other options should be advocated, such as permanent drains connected to a Heimlich valve. Furthermore, prior to proceeding to talc pleurodesis, the increased risk of a pulmonary restrictive dysfunction secondary to talc insufflation should be well pondered and discussed interdisciplinary.
Contrarily to the ACCP guidelines that suggest medical thoracoscopy or VATS as the first choice to perform talc pleurodesis, because of their lower morbidity, the BTS guidelines consider an open approach (thoracotomy) as the procedure of choice, limiting VATS procedures to unfit patients [17].
Furthermore, in nonsurgical patients with a persistent air leak a talc slurry via chest tube should be taken into consideration.
The 2021 GOLD guidelines consider as the main surgical option in high-grade COPD [9]:
lung volume reduction surgery (LVRS);
bullectomy/blebectomy, which are associated with an improvement of dyspnea and lung function;
lung transplantation: in very high-risk patients, with progressive COPD. Inclusion criteria are exacerbations associated with hypercapnia (pCO2 ≥ 50 mmHg), pulmonary hypertension, FEV1 < 20%, and/or a diffusing capacity for carbon monoxide (Dlco <20%) [9].
LVRS can improve survival in severe lung emphysema, mainly in the upper lobes localized emphysema, and low-ability exercise patients [17]. The National Emphysema Treatment Trial (NETT) identified four groups of patients [19] on the basis of their postoperative exercise tolerance and their emphysema pattern at the CT scan (Table 1).
Emphysema at CT scan | Pre-operative exercise capacity | LVRS risk of death | Survival | Post-operative exercise tolerance | Symptoms control |
---|---|---|---|---|---|
Upper lobe-predominant emphysema | Low | Lower than medical therapy | Improved | Improved within 3 years from surgery | Improved |
High | Not improved | Improved (years 1–3) | Improved (years 1–4) | ||
Non-upper lobe-predominant emphysema | Low | No effects | Not improved | No effects | |
High | Increased | Not improved | No effects | No effects |
Results in the four groups studied in the NETT trial.
The NETT demonstrated that the effects of LVRS are durable and that it is strongly recommended in upper lobe-predominant emphysema with low exercise capacity and should be considered for palliation in patients with upper lobe emphysema and high exercise capacity (Figure 5).
Results of NETT. Image D: Upper lobe–predominant emphysema with low exercise capacity group. The surgical group has a lower probability of death than the medical group.
Predominantly, the following endobronchial procedures find an indication in reducing the end-expiratory lung volume and to improve exercise tolerance:
endobronchial lung volume reduction with one-way valves (BLVR);
endobronchial coils filling;
thermal ablation.
Endobronchial valves are placed in segmental or lobar bronchi through rigid bronchoscopy, allowing peripheral lung deflation, lung volume reduction, and improvement of symptoms with an accepted mortality rate equal to 5–10% [20]. The valve mechanism does not permit air to go through the segmental or lobar bronchus during the inspiration but, instead, it allows it passage during the expiratory phase. The valves are available in multiple diameters, ranging from 4 to 8.5 mm.
In general, two main devices are available:
the “aspiration umbrella”, which is an implantable Intra-Bronchial Valve (IBV) that can be positioned via flexible bronchoscopy, leaving the umbrella shape adherent to the airway wall and limiting the airflow distally;
the Emphasis Bronchial Valve (EBV), which is able to prevent air entering in the lung during inspiration but allows outflow of air and secretion. A flexible aspiration valve is present in the endobronchial valve structure from which exhaled air and secretions can be cleared out or aspirated because of the unidirectional valve.
Both devices are inserted in the operating theater with the patient sedated and in spontaneous assisted (jet-) ventilation [21].
The VENT trial (Endobronchial Valve for Emphysema Palliation Trial) [22] is a two-arm, randomized, controlled, multi-center trial that showed a 4.3% FEV1 increase in the EBV group compared to the 2.5% in the control medical group.
However, the study shows that complications following the procedure may counterbalance the advantages of the procedure itself. In fact, on the one hand, patients may obtain an improvement in their respiratory function, and on the other hand, it may be associated with hemoptysis, pneumothorax with persistent air leak, and COPD exacerbations, which may occur more frequently in advanced, hyper-inflated emphysema patients. Moreover, as evidenced in the VENT trial, the 2-yrs mortality rate in the EBV group was 2.8% compared to no deaths in the control group, but the difference wasn’t statistically significant (p = 0.19).
Although rare findings, the main causes of SP from malignant diseases are primary cancers of the lung and pleura (e.g., mesothelioma) followed by infiltrative/metastatic pleural diseases, such as in the case of germ cell tumors, breast cancer, or osteogenic and soft tissue sarcomas metastasis [21, 22, 23].
The occurrence of an SP as the first manifestation of a lung cancer ranges between 0.03% and 0.05% and usually allows to detect the unknown presence of a lung tumor or metastasis [24] without affecting the prognosis [25, 26].
By contrast, a review published in 2010 analyzed data available in the literature concerning pneumothorax secondary to sarcoma, highlighting increased mortality in such patients compared to those without such complications [26].
Several hypotheses have been taken into account to explain the pathogenesis of pneumothorax secondary to malignant disease, which include (i) an alteration of the pleural surface following tumoral pleural infiltration; (ii) rupture of a necrotic tumoral nodule; and (iii) necrosis of subpleural metastases [27].
Moreover, adjuvant or neoadjuvant chemotherapy and/or radiotherapy treatments may alter the lung parenchymal structure. In these cases, the high-risk of infection associated with a reduced functional repair mechanism could enhance the risk of pleural alterations, possibly leading to a secondary pneumothorax. Also, a tumoral invasion of the small airways could be responsible for a distal alveolar space dilatation determining air-trapping, which may lead to rupture and pneumothorax.
The clinical presentation depends on the patients’ performance status according to their functional status and disease stage. Usually, clinical signs and symptoms are chest pain and shortness of breath.
A chest X-ray is mandatory to assess the presence of a pneumothorax, which usually appears as a complete collapse of the normal areas of the lung. A CT scan is useful to better analyze the pneumothorax size and to investigate a possible progression of disease.
Pneumothorax can be the first sign of neoplastic disease, especially when it assumes a recurrent nature in high-risk patients (heavy smokers, COPD), who will therefore undergo further investigations, which will lead to eventually diagnose the tumor.
Diagnosis and management of a secondary pneumothorax concomitant to a pulmonary neoplastic disease are the same for a pneumothorax happening in a pre-existing neoplastic condition. A chest tube is recommended according to its size and the clinical features of patients.
In case of a persistent air leak or in a recurrent pneumothorax, surgery is an option in order to investigate the causes and proceed to talc pleurodesis in case of nonoperable tumors or unfit for surgery patients. If surgery is contemplated, the surgeon may proceed to obtain a diagnosis in case this was not achieved previously, by means of pleural biopsy/wedge resection/lymph node sampling. Cases of recurrent pneumothorax as the first sign of pleural mesothelioma or sarcoma metastasis have been reported, identifying the thoracoscopic bullectomy as the key to the best diagnosis and treatment [28, 29].
Thoracic trauma is the third leading cause of death following abdominal injury and head trauma in polytrauma patients [30]. Management of chest trauma patients is complex and requires an interdisciplinary team with experience in anesthesia, critical care, and surgical disciplines, especially neurosurgery, trauma surgery, abdominal surgery, and thoracic surgery.
Blunt and penetrating chest traumas can be the cause of pneumothorax and trauma should be taken into account when discussing secondary pneumothoraces.
Thoracic trauma can be differentiated into blunt or penetrating.
Penetrating injuries, such as blade wounds and firearm injuries, are disruptive to tissue integrity. Gunshot and stabbing account for 10% and 9.5% of penetrating chest injuries, making these the most common etiology of penetrating trauma.
A blunt trauma (Figure 6) is a nonpenetrating injury of the chest. Blunt thoracic injuries are more common than penetrating injuries [30].
Pneumothorax after a barotrauma.
Blunt injuries can cause damage to organs and structures without disrupting the integrity of the tissue. Falls from a great height, motor vehicle accidents, and occupational accidents are the main mechanisms of blunt injuries [31, 32, 33].
Depending on the mechanism of injury (e.g., acceleration-deceleration and direct impacts on the chest) an SP may be detected and should be treated and investigated on the cause of its onset (rib fractures, tracheal/bronchial or esophageal disruptions, lung contusion, and lung laceration).
Particular attention is reserved for a tension pneumothorax, in which air enters the pleural space at each inspiration, while the air in the pleural space cannot escape from the pleural space due to the one-way valve mechanism. The continuous accumulation of air in the pleural space determines a lung collapse, hypoxia, tachypnea, and tachycardia, a mediastinal shift with compression of the contralateral lung and the superior vena cava (SVC), leading to respiratory distress and rapidly to respiratory failure with cardiovascular collapse.
Management of patients following major trauma should follow the standardized protocol of emergency and resuscitation advanced trauma life support guidelines (ATLS), and a primary survey of the airway, breathing, circulation, disability, and exposure (ABCDE approach) should be performed.
Particular attention is required in a tension pneumothorax because, if a prompt intervention is not carried out, can rapidly lead to death [34]. Immediate evacuation through a chest tube is mandatory as recommended by the ATLS [35].
In general, a chest tube has to be positioned in a post-traumatic pneumothorax, in order to stabilize the patient.
Once the patient is stabilized, radiological investigations, such as chest X-ray and chest CT scan are mandatory to identify the cause of pneumothorax and eventually determine the need for further treatments (surgery).
At the same time, minor blunt traumas may be cause of small pneumothoraces, which may not require a chest tube and can be treated conservatively with high flow oxygen, pain control, and repeated CXR [36].
Penetrating injuries are disruptive to tissue integrity, with direct communication between the pleural space and the external environment and they can be acutely life-threatening.
It is mandatory to know the mechanism of injury as the management may vary. For example, stab versus gunshot injury to the chest can result in different patterns of injury.
Depending on the penetrating trauma, immediate surgery may be deemed necessary and a chest tube is required to stabilize the patient for surgery (e.g., during patient transportation from the trauma site to the hospital). Frequently, when a post-traumatic pneumothorax is present it can be associated with a hemothorax [37].
Iatrogenic pneumothorax is a possible complication of several invasive procedures, such as a central venous line insertion (0.5–5%), thoracentesis (1, 5–7%), and CT-guided lung biopsy (1–6%); at times they can be associated with hemothorax (1% of all procedures) [38, 39].
In some cases, it may occur as a complication following bronchoscopic positioning of unidirectional valves in emphysematous patients [21].
The term “catamenial” derives from two Greek words meaning “pertaining to” and “monthly.”
Catamenial pneumothorax is defined as a recurrent accumulation of air in the pleural cavity in reproductive-age women.
A catamenial pneumothorax (CP) arises within 48–72 h from menstruation. It occurs in 3–6% of spontaneous pneumothoraces and most frequently involves the right side [40].
This kind of pneumothorax is, mainly, included in two syndromes:
the thoracic endometriosis syndrome (TES), which is associated with hemothorax and lung nodules. It is a rare clinical disease that sometimes is secondary to the presence of endometrial gland tissue in the lungs, pleura, diaphragm, and tracheobronchial tree [41]. TES has been reported for the first time in 1953, in a case report of a young woman that developed hemothorax. In 1958, Mauerer described recurrent pneumothoraces in association with menstruation and pelvic endometriosis [42].
the porous diaphragmatic syndrome: cases of CP without any evidence of endometrial implants, but secondary to the presence of diaphragmatic defects [43]. In rare cases, in fact, diaphragm fenestrations over the tendinous portion may be visualized during surgery and appear as orifices in the muscle, becoming the cause of pneumothorax.
The cancer antigen 125 (CA-125), a gynecological serum marker, has assumed a role in the diagnostic work-up for TES. In fact, high levels of CA-125 have been associated with recurrent SP with evidence of thoracic endometriosis, such as focal thoracic endometrial implants, during VATS procedures. On the contrary, patients without thoracoscopic evidence of endometrial disease have normal CA-125 serum level [44].
The presence of a CP is not always related to pelvic endometriosis.
In a prospective study, 32 women had a CP diagnosis, but only 2 had pelvic endometriosis associated [41].
The occurrence of PSP in women of childbearing age is not unusual and there appears to be an increased risk of recurrence during pregnancy and during parturition with potential risks to the mother and fetus.
A more recent case series and literature review have recommended the use of more modern conservative management methods for which favorable outcomes have now been experienced [17, 45]. Pneumothorax in pregnancy can be managed by simple observation, if the mother is not symptomatic, there is no fetal distress and the pneumothorax is small (<2 cm). Otherwise, aspiration can be performed, chest drain insertion being reserved for those with a persistent air leak or a greater pneumothorax.
To avoid spontaneous delivery or cesarean section, both of which have been associated with an increased risk of recurrence, the safest approach will usually be that of elective assisted delivery at or near term. Less maternal effort is required with forceps delivery, which is therefore preferable. Because of the risk of recurrence in subsequent pregnancies, a minimally invasive VATS surgical procedure should be considered few weeks from delivery. Successful pregnancies and spontaneous deliveries without pneumothorax recurrence have been reported after a VATS procedure [17, 45].
In contrast to the benign clinical course of a PSP, SP is associated with pre-existing underlying lung disease, trauma, or invasive procedures and can be a life-threatening event. Patients with pre-existing lung disease tolerate a pneumothorax less well, and the distinction between PSP and SSP should be made at the time of diagnosis to guide appropriate management. The consequences of a pneumothorax in patients with a pre-existing lung disease are significantly greater, and the management is potentially more complex than in PSP patients. Furthermore, SP is correlated to a higher morbidity and mortality compared to PSP. Differently from a PSP, where the management is well defined by different international guidelines, SP treatment may vary because of the clinical conditions, previous episodes, severity and duration of symptoms, and the presence of an underlying pulmonary disease. Its treatment will therefore vary accordingly, from observation to needle aspiration or thoracostomy tube drainage with or without pleurodesis and potentially escalating to an open thoracotomy or VATS procedures, as described in this chapter. In case of surgery in high-risk patients (e.g., COPD patients, frail patients), the risk of proceeding to surgery with the aim of resolving the underlying cause and securing the lung with adequate pleurodesis should be well pondered both from the surgical and anesthesiological point of view based onto the patients’ clinical status and consent.
IntechOpen - where academia and industry create content with global impact
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\\n\\nCo-founded by Alex Lazinica and Vedran Kordic: “We are passionate about the advancement of science. As Ph.D. researchers in Vienna, we found it difficult to access the scholarly research we needed. We created IntechOpen with the specific aim of putting the academic needs of the global research community before the business interests of publishers. Our Team is now a global one and includes highly-renowned scientists and publishers, as well as experts in disseminating your research.”
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\\n\\nSara Uhac, COO
\\n\\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
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\\n\\nAdrian Assad De Marco joined the company as a Director in 2017. With his extensive experience in management, acquired while working for regional and global leaders, he took over direction and control of all the company's publishing processes. Adrian holds a degree in Economy and Management from the University of Zagreb, School of Economics, Croatia. A former sportsman, he continually strives to develop his skills through professional courses and specializations such as NLP (Neuro-linguistic programming).
\\n\\nDr Alex Lazinica
\\n\\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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\n\nCo-founded by Alex Lazinica and Vedran Kordic: “We are passionate about the advancement of science. As Ph.D. researchers in Vienna, we found it difficult to access the scholarly research we needed. We created IntechOpen with the specific aim of putting the academic needs of the global research community before the business interests of publishers. Our Team is now a global one and includes highly-renowned scientists and publishers, as well as experts in disseminating your research.”
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\n\nSara Uhac, COO
\n\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
\n\nAdrian Assad De Marco
\n\nAdrian Assad De Marco joined the company as a Director in 2017. With his extensive experience in management, acquired while working for regional and global leaders, he took over direction and control of all the company's publishing processes. Adrian holds a degree in Economy and Management from the University of Zagreb, School of Economics, Croatia. A former sportsman, he continually strives to develop his skills through professional courses and specializations such as NLP (Neuro-linguistic programming).
\n\nDr Alex Lazinica
\n\nAlex Lazinica is co-founder and Board member of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his Ph.D. in Robotics at the Vienna University of Technology. There, he worked as a robotics researcher with the university's Intelligent Manufacturing Systems Group, as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and, most importantly, co-founded and built the International Journal of Advanced Robotic Systems, the world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career since it proved to be the pathway to the foundation of IntechOpen with its focus on addressing academic researchers’ needs. Alex personifies many of IntechOpen´s key values, including the commitment to developing mutual trust, openness, and a spirit of entrepreneurialism. Today, his focus is on defining the growth and development strategy for the company.
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Subtle changes that occur over time in periodontal tissues that are below the detection limit of visual examination or periodontal probing can be found and tracked accurately over time using 3D imaging, fluorescence spectroscopy, and optical coherence tomography. During debridement of teeth and dental implants, the effective removal of subgingival microbial biofilms and dental calculus deposits can be enhanced using magnifying loupes and operating microscopes and by novel methods based on the interactions of light with bacterial deposits, such as differential reflectometry and light-induced fluorescence. While such techniques can also be used using initial case assessment, their primary purpose is for checking debridement procedures, since the point when bacterial deposits are no longer present represents an endpoint for treatment. The concept of real-time feedback has been developed, using fluorescence readings to control the removal of deposits. Overall, optical methods can support traditional periodontal diagnosis and improve treatment planning and clinical periodontal care.",book:{id:"7244",slug:"periodontology-and-dental-implantology",title:"Periodontology and Dental Implantology",fullTitle:"Periodontology and Dental Implantology"},signatures:"Fardad Shakibaie and Laurence Walsh",authors:[{id:"179467",title:"Prof.",name:"Laurence",middleName:null,surname:"Walsh",slug:"laurence-walsh",fullName:"Laurence Walsh"},{id:"235443",title:"Dr.",name:"Fardad",middleName:null,surname:"Shakibaie",slug:"fardad-shakibaie",fullName:"Fardad Shakibaie"}]},{id:"24363",title:"Biomechanics of Tooth-Movement: Current Look at Orthodontic Fundamental",slug:"biomechanics-of-tooth-movement-current-look-at-orthodontic-fundamental",totalDownloads:26816,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"277",slug:"principles-in-contemporary-orthodontics",title:"Principles in Contemporary Orthodontics",fullTitle:"Principles in Contemporary Orthodontics"},signatures:"Joanna Antoszewska and Nazan Küçükkeles",authors:[{id:"50158",title:"Prof.",name:"Joanna",middleName:null,surname:"Antoszewska",slug:"joanna-antoszewska",fullName:"Joanna Antoszewska"}]},{id:"71271",title:"Flap Techniques in Dentoalveolar Surgery",slug:"flap-techniques-in-dentoalveolar-surgery",totalDownloads:2628,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Most dentoalveolar procedures involve the reflection of mucosal flaps. 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Yet the common flap’s principles are fundamental for all types of flaps regardless of their application, namely, it should provide wide exposure, clear vision, good access, and assure rich vascularity and good final aesthetic outcome.",book:{id:"9387",slug:"oral-diseases",title:"Oral Diseases",fullTitle:"Oral Diseases"},signatures:"Randa Abdulmoein AlFotawi",authors:[{id:"308701",title:"Dr.",name:"Randa",middleName:"Abdulmoein",surname:"Alfotawi",slug:"randa-alfotawi",fullName:"Randa Alfotawi"}]},{id:"65088",title:"Evaluation and Management of Mandibular Fracture",slug:"evaluation-and-management-of-mandibular-fracture",totalDownloads:2903,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The mandibular bone is an important component of the facial bone, which has a unique role in digestive system, speech, and facial esthetics. For these important functions of mandibular bone, it is vital that surgeons should not only treat function but also consider the esthetics together. Mandibular fractures are among the most common traumatic injuries of the maxillofacial region. Even though treatment modalities are well established and being practiced for a long time, untreated and postoperative complications still decrease the patient’s quality of life. This chapter aims to describe the cause, clinical presentations, diagnoses, and current treatment methods on the basis of resent literature.",book:{id:"7572",slug:"trauma-in-dentistry",title:"Trauma in Dentistry",fullTitle:"Trauma in Dentistry"},signatures:"Guhan Dergin, Yusuf Emes and Buket Aybar",authors:[{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin"},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes"},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar"}]},{id:"56461",title:"Permanent Maxillary and Mandibular Incisors",slug:"permanent-maxillary-and-mandibular-incisors",totalDownloads:2715,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"The permanent incisors are the front teeth that erupt between 6 and 8 years of age. They are eight in number, four upper and four lower, two centrals and two laterals. They have sharp biting surfaces designed for shearing and cutting of food materials into small chewable pieces. They are the teeth most visible to the others during eating, smiling and talking, and thus, they have high aesthetic value for the individuals. The unique characteristics, arch position, function, development and chronological age of each tooth will be highlighted. In addition, the different aspects with their geometric outlines, outlines and surface anatomy of these teeth will be described. A brief explanation about the pulp cavity, tooth socket and normal occlusion for each tooth will be included.",book:{id:"5814",slug:"dental-anatomy",title:"Dental Anatomy",fullTitle:"Dental Anatomy"},signatures:"Mohammed E. Grawish, Lamyaa M. Grawish and Hala M. Grawish",authors:[{id:"82989",title:"Prof.",name:"Mohammed",middleName:"E",surname:"Grawish",slug:"mohammed-grawish",fullName:"Mohammed Grawish"}]}],onlineFirstChaptersFilter:{topicId:"174",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80964",title:"Upper Airway Expansion in Disabled Children",slug:"upper-airway-expansion-in-disabled-children",totalDownloads:44,totalDimensionsCites:0,doi:"10.5772/intechopen.102830",abstract:"Breathing is essential for life in all of its stages. Cellular, mitochondrial respiration requires an adequate supply of oxygen, provided by the air we breathe, after airway conduction, treatment by the lungs, and transport to tissues. At different stages of life, pediatric dentists and orthodontists can intervene in the upper airway, expanding it, which helps with ventilation. The greater airway space, if used, contributes in different ways to the child’s development and the recovery of respiratory problems and should always be present as a weapon that physicians and the population should know. The value of the techniques becomes even more important when applied to children and young people with disabilities who can significantly improve their development and performance. Rapid Maxillary Expansion and Extraoral Traction Appliances are two important pediatric resources to treat these children. Clinical practice of the authors, is discussed, emphasizing the importance of early intervention and the need for multi and interdisciplinary collaboration in the follow-up of disabled people.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"David Andrade, Joana Andrade, Maria-João Palha, Cristina Areias, Paula Macedo, Ana Norton, Miguel Palha, Lurdes Morais, Dóris Rocha Ruiz and Sônia Groisman"},{id:"80963",title:"Pain Perception in Patients Treated with Ligating/Self-Ligating Brackets versus Patients Treated with Aligners",slug:"pain-perception-in-patients-treated-with-ligating-self-ligating-brackets-versus-patients-treated-wit",totalDownloads:33,totalDimensionsCites:0,doi:"10.5772/intechopen.102796",abstract:"This study compared the perception of pain experienced by patients undergoing orthodontic treatment with conventional, self-ligating brackets and aligners, and investigated the impact that pain had on their daily lives. 346 consecutive patients were included in the study: 115 patients treated with conventional brackets, 112 Patients treated with self-ligating brackets, and 119 patients treated with aligners. The quantitative aspect of pain was assessed using the Visual Analogue Scale, while the qualitative aspect of pain was evaluated using the Moroccan Short Form of McGILL Pain questionnaire. In all three groups experienced pain after activation tended to decrease in the following week. This pain was greater in patients with conventional braces and less in patients with aligners. Using the M-SF-MPQ to describe the qualitative aspect of the pain revealed that the “cramping مزير,” “aching تيألم ” aspect was most accentuated in the 3 groups. Medication intake was correlated with the intensity of pain experienced in all 3 systems. As for the impact of pain on daily activities, patients in groups of conventional and self-ligating braces showed more pain than those in the aligners group. Overall, aligners were less painful than conventional and self-ligating appliances. Patients did not suffer from an alteration in their quality of life due to orthodontic treatment.",book:{id:"10780",title:"Current Trends in Orthodontics",coverURL:"https://cdn.intechopen.com/books/images_new/10780.jpg"},signatures:"Farid Bourzgui, Rania Fastani, Salwa Khairat, Samir Diouny, Mohamed El Had, Zineb Serhier and Mohamed Bennani Othmani"},{id:"80839",title:"Herbs and Oral Health",slug:"herbs-and-oral-health",totalDownloads:69,totalDimensionsCites:0,doi:"10.5772/intechopen.103715",abstract:"Herbal medicine has long been used to prevent and control disease, and it can minimize the potential side effects of chemical products. However, side effects from herbs do exist. Most of the challenges with herbal medicine revolves around inadequate information about the effect of herbs in the oral cavity, the mechanism of action, and potential side effects. There are several herbs described in this chapter have anti-inflammatory, anti-bacterial, anti-viral, anti-fungal in oral micro-organisms. It includes aloe vera, ginger, clove, cinnamon, garlic, neem, miswak, turmeric, tulsi, green tea, chamomile, fenugreek, anise plant, peppermint, bloodroot, caraway, eucalyptus, phyllanthus emblica, black seed, myrrh, rosemary, sage, and thyme; some may act as an alternative management option to current treatments for oral conditions such as caries prevention, gingivitis, periodontitis, oral burn, ulcers and inflammation, after extraction, dry mouth, pain reduction, anesthesia, intracanal medications, ill-fitting dentures, peri-implant mucositis and peri-implantitis. It can be used in several forms such as mouthwashes, toothpastes, topical agents or local drug delivery devices. However, more research is needed to understand their mechanisms and potential side effects.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Zuhair S. Natto"},{id:"80441",title:"Periodontitis and Heart Disease: Current Perspectives on the Associative Relationships and Preventive Impact",slug:"periodontitis-and-heart-disease-current-perspectives-on-the-associative-relationships-and-preventive",totalDownloads:66,totalDimensionsCites:0,doi:"10.5772/intechopen.102669",abstract:"Due to the important advancement and the accumulation of new evidence on the periodontitis-cardiovascular disease (CVD) relationship as well as the major medical, economic and social burden caused by both diseases this chapter aims to review existing epidemiological and pathogenetic links related to this topic. Also, this chapter aims to highlight the impact of the periodontitis-CVD relationships on clinical practice and on the preventive approaches targeting to decrease the impact of periodontitis on CVD. Periodontitis is an infectious disease eliciting local and general inflammation, which leads to periodontal destruction and systemic involvement. Several pathways could explain the link between periodontitis and CVD such as bacteraemia, chronic persistent systemic inflammation and oxidative stress. The first step in the treatment of periodontitis addresses the elimination of microbial components, which lead to a decrease in local and systemic inflammation. Periodontal therapy seems to positively impact CVD. Specialists should inform patients with CVD on the negative impact of periodontitis on their systemic status and refer patients to the periodontist for an extensive examination as routine management of CVD. Some possible risks of periodontal therapy should be considered in patients undergoing antithrombotic medication.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Alexandra Roman, Andrada Soancă, Bogdan Caloian, Alexandru Bucur, Gabriela Valentina Caracostea, Andreia Paraschiva Preda, Dora Maria Popescu, Iulia Cristina Micu, Petra Șurlin, Andreea Ciurea, Diana Oneț, Mircea Viorel Ciurea, Dragoș Alexandru Țermure and Marius Negucioiu"},{id:"79498",title:"Oral Aspects and Dental Management of Special Needs Patient",slug:"oral-aspects-and-dental-management-of-special-needs-patient",totalDownloads:112,totalDimensionsCites:0,doi:"10.5772/intechopen.101067",abstract:"Individuals with special needs are the most underserved regarding healthcare needs in almost all populations. Special needs patients with intellectual disability have muscle coordination disorder, impaired oral motor function, drooling, weak muscles that cause chewing and swallowing problems. Also, soft diet consumption makes this population more prone to dental disease. They have more caries, missing teeth, orthodontic and periodontal problems. Besides more difficulties obtaining professional dental care than other segments of the population. Though many countries developed community-based systems to improve oral health for people with special needs, providing good oral health mainly depends on the effort of the families. Therefore the education of the caregiver about oral hygiene provision is also critical for the special needs patient to enjoy a lifetime of oral health the same as other members of the society.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Pinar Kiymet Karataban"},{id:"79699",title:"Metabolomics Distinction of Cigarette Smokers from Non-Smokers Using Non-Stationary Benchtop Nuclear Magnetic Resonance (NMR) Analysis of Human Saliva",slug:"metabolomics-distinction-of-cigarette-smokers-from-non-smokers-using-non-stationary-benchtop-nuclear",totalDownloads:56,totalDimensionsCites:0,doi:"10.5772/intechopen.101414",abstract:"Implementations of high-field nuclear magnetic resonance (NMR) facilities into metabolomics studies are unfortunately restricted by their large dimensions, high costings, and specialist technical staff requirements. Therefore, here the application and practical advantages offered by low-field (60 MHz), compact NMR spectrometers for probing the metabolic profiles of human saliva was explored, as was their value in salivary metabolomics studies. Saliva samples were collected from cigarette smoking (n = 11) and non-smoking (n = 31) human participants. 1H NMR spectra were acquired on both low-field (60 MHz) and medium-field (400 MHz) spectrometers. Metabolomics analyses were employed to evaluate the consistencies of salivary metabolite levels determined, and their abilities to distinguish between smokers and non-smokers. Low-field 1H NMR analysis detected up to 15, albeit permitted the reliable quantification of 5, potentially key diagnostic biomolecules simultaneously (LLOQ values 250–400 μmol/L), although these were limited to those with the most prominent resonances. Such low-field profiles were also found to be suitable for salivary metabolomics investigations, which confirmed the successful discrimination between smoking and non-smoking participant sample donors. Differences observed between these groups were largely ascribable to upregulated salivary levels of methanol, and its metabolite formate, in the smoking group, but higher smoking-mediated concentrations of acetate, propionate and glycine may arise from a diminished salivary flow-rate in these participants. In conclusion, determination of salivary biomolecules using low-field, benchtop 1H NMR analysis techniques were found to be valuable for bioanalytical and metabolomics investigations. Future perspectives for the applications of this non-stationary NMR technique, for example for the on-site ‘point-of-care’ testing of saliva samples for diagnostic oral disease screening purposes at dental surgeries and community pharmacies, are considered.",book:{id:"10827",title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg"},signatures:"Benita C. 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The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:"2753-6580",scope:"\r\n\tThis topic aims to provide a comprehensive overview of the latest trends in Oral Health based on recent scientific evidence. 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",coverUrl:"https://cdn.intechopen.com/series_topics/covers/1.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11397,editor:{id:"173955",title:"Prof.",name:"Sandra",middleName:null,surname:"Marinho",slug:"sandra-marinho",fullName:"Sandra Marinho",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRGYMQA4/Profile_Picture_2022-06-01T13:22:41.png",biography:"Dr. Sandra A. Marinho is an Associate Professor and Brazilian researcher at the State University of Paraíba (Universidade Estadual da Paraíba- UEPB), Campus VIII, located in Araruna, state of Paraíba since 2011. She holds a degree in Dentistry from the Federal University of Alfenas (UNIFAL), while her specialization and professional improvement in Stomatology took place at Hospital Heliopolis (São Paulo, SP). Her qualifications are: a specialist in Dental Imaging and Radiology, Master in Dentistry (Periodontics) from the University of São Paulo (FORP-USP, Ribeirão Preto, SP), and Doctor (Ph.D.) in Dentistry (Stomatology Clinic) from Hospital São Lucas of the Pontifical Catholic University of Rio Grande do Sul (HSL-PUCRS, Porto Alegre, RS). She held a postdoctoral internship at the Federal University from Jequitinhonha and Mucuri Valleys (UFVJM, Diamantina, MG). She is currently a member of the Brazilian Society for Dental Research (SBPqO) and the Brazilian Society of Stomatology and Pathology (SOBEP). Dr. Marinho's experience in Dentistry mainly covers the following subjects: oral diagnosis, oral radiology; oral medicine; lesions and oral infections; oral pathology, laser therapy and epidemiological studies.",institutionString:null,institution:{name:"State University of Paraíba",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,series:{id:"3",title:"Dentistry",doi:"10.5772/intechopen.71199",issn:"2631-6218"},editorialBoard:[{id:"267724",title:"Prof.",name:"Febronia",middleName:null,surname:"Kahabuka",slug:"febronia-kahabuka",fullName:"Febronia Kahabuka",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZpJQAW/Profile_Picture_2022-06-27T12:00:42.JPG",institutionString:"Muhimbili University of Health and Allied Sciences, Tanzania",institution:{name:"Muhimbili University of Health and Allied Sciences",institutionURL:null,country:{name:"Tanzania"}}},{id:"70530",title:"Dr.",name:"Márcio",middleName:"Campos",surname:"Oliveira",slug:"marcio-oliveira",fullName:"Márcio Oliveira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRm0AQAS/Profile_Picture_2022-08-01T12:34:46.jpg",institutionString:null,institution:{name:"State University of Feira de Santana",institutionURL:null,country:{name:"Brazil"}}}]},onlineFirstChapters:{paginationCount:25,paginationItems:[{id:"82654",title:"Atraumatic Restorative Treatment: More than a Minimally Invasive Approach?",doi:"10.5772/intechopen.105623",signatures:"Manal A. Ablal",slug:"atraumatic-restorative-treatment-more-than-a-minimally-invasive-approach",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Caries - The Selection of Restoration Methods and Restorative Materials",coverURL:"https://cdn.intechopen.com/books/images_new/11565.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"82735",title:"The Influence of Salivary pH on the Prevalence of Dental Caries",doi:"10.5772/intechopen.106154",signatures:"Laura-Cristina Rusu, Alexandra Roi, Ciprian-Ioan Roi, Codruta Victoria Tigmeanu and Lavinia Cosmina Ardelean",slug:"the-influence-of-salivary-ph-on-the-prevalence-of-dental-caries",totalDownloads:12,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Caries - The Selection of Restoration Methods and Restorative Materials",coverURL:"https://cdn.intechopen.com/books/images_new/11565.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"82357",title:"Caries Management Aided by Fluorescence-Based Devices",doi:"10.5772/intechopen.105567",signatures:"Atena Galuscan, Daniela Jumanca and Aurora Doris Fratila",slug:"caries-management-aided-by-fluorescence-based-devices",totalDownloads:6,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Caries - The Selection of Restoration Methods and Restorative Materials",coverURL:"https://cdn.intechopen.com/books/images_new/11565.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"81894",title:"Diet and Nutrition and Their Relationship with Early Childhood Dental Caries",doi:"10.5772/intechopen.105123",signatures:"Luanna Gonçalves Ferreira, Giuliana de Campos Chaves Lamarque and Francisco Wanderley Garcia Paula-Silva",slug:"diet-and-nutrition-and-their-relationship-with-early-childhood-dental-caries",totalDownloads:20,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Caries - The Selection of Restoration Methods and Restorative Materials",coverURL:"https://cdn.intechopen.com/books/images_new/11565.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"80964",title:"Upper Airway Expansion in Disabled Children",doi:"10.5772/intechopen.102830",signatures:"David Andrade, Joana Andrade, Maria-João Palha, Cristina Areias, Paula Macedo, Ana Norton, Miguel Palha, Lurdes Morais, Dóris Rocha Ruiz and Sônia Groisman",slug:"upper-airway-expansion-in-disabled-children",totalDownloads:44,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"80839",title:"Herbs and Oral Health",doi:"10.5772/intechopen.103715",signatures:"Zuhair S. Natto",slug:"herbs-and-oral-health",totalDownloads:69,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"80441",title:"Periodontitis and Heart Disease: Current Perspectives on the Associative Relationships and Preventive Impact",doi:"10.5772/intechopen.102669",signatures:"Alexandra Roman, Andrada Soancă, Bogdan Caloian, Alexandru Bucur, Gabriela Valentina Caracostea, Andreia Paraschiva Preda, Dora Maria Popescu, Iulia Cristina Micu, Petra Șurlin, Andreea Ciurea, Diana Oneț, Mircea Viorel Ciurea, Dragoș Alexandru Țermure and Marius Negucioiu",slug:"periodontitis-and-heart-disease-current-perspectives-on-the-associative-relationships-and-preventive",totalDownloads:66,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"79498",title:"Oral Aspects and Dental Management of Special Needs Patient",doi:"10.5772/intechopen.101067",signatures:"Pinar Kiymet Karataban",slug:"oral-aspects-and-dental-management-of-special-needs-patient",totalDownloads:112,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Pinar",surname:"Karataban"}],book:{title:"Oral Health Care - An Important Issue of the Modern Society",coverURL:"https://cdn.intechopen.com/books/images_new/10827.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"79699",title:"Metabolomics Distinction of Cigarette Smokers from Non-Smokers Using Non-Stationary Benchtop Nuclear Magnetic Resonance (NMR) Analysis of Human Saliva",doi:"10.5772/intechopen.101414",signatures:"Benita C. 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