Pneumothorax
Objectives: Definition of Pneumothorax
Classifications Etiology Clinical features
Sign & Symptoms Complications Investigations
Treatment2
Pneumothorax
Definition: Air in pleural space, between the lung and the chest wall First coined as pneumothorax simple by Itard in 1803
Pneumothoraxcollection of air within the pleural space transforms the potential space into a real one may lead to various degrees of respiratory compromise
with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario impairs respiratory function decreases venous return to the right-side of the heart
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PneumothoraxClassificationSpontaneous PneumothoraxPrimary Secondary
Traumatic PneumothoraxIatrogenic Non IatrogenicOpenClosed
Types of Spontaneous Pneumothorax Primary spontaneous pneumothorax in healthy persons with no apparent underlying lung abnormalities or underlying conditions Secondary spontaneous pneumothorax
Clinically apparent underlying lung disease
Types of Traumatic Pneumothorax
Traumatic PneumothoraxOpenChest wall is penetrated : outside air enters pleural space
ClosedChest wall is intact Ex. Fractured rib
Etiology: Simple spontaneous: rupture of subpleural blebs at the lung apex, This most commonly occurs in healthy, tall males between the ages of 20 to 40. - Secondary spontaneous:
These occur as a result of trauma or pre-existing pulmonary disease (eg TB, malignancy, emphysema, insterstitial fibrosis).widespread emphysema is the most common cause of secondary pneumothorax.
Risk Factors: Sex: male more than female Age: 20 40 years most likely Smoking Lung disease: specially emphysema A history of pneumothorax
Effect of smoking on PSP recurrence riskBense et. al. Chest 1987; 92:1009
No. of cigarettes/day
Relative Risk (men)
Relative Risk (women)
1-1213-22 >22
721 102
414 68
PneumothoraxTraumatic Ptx
Parenchymal Injury vs. Tracheobronchial vs. EsophagealBlunt or Penetrating
Iatrogenic central lines / thoracentesis / biopsy endotracheal tube placement (esp. dual-lumen tubes !) endoscopy / dilational techniques
Barotrauma Ventilation / blast injury / Boerhaves syndrome
Operative
Pathogenesis of PSP90% of cases at thoracoscopy or thoracotomy 80% of cases on CT showed subpleural blebs or bullae
Etiology of bullous changes in healthy: airway inflammation from smoking lifetime risk in smoking men 12% vs. 0.1% non-smokers tall stature-subpleural blebs in apex
Pathogenesis of PSP (contd) Other causes
Marfans syndrome Homocystinuria
Catamenial pneumothorax in thoracic endometriosis Familial spontaneous pneumothorax: autosomal dorminant, recessive, polygenic and X-linked recessive inheritance
PneumothoraxPrimary Spontaneous Ptxa disease of younger individuals (15 - 35 yrs of age)males > females tall, slim body habitus cigarette smoking implicated usual cause: parenchymal blebs apex of the upper lobe superior segment of the lower lobe
Genetic mutation and PSPGene for Familial cancer syndromechromosome17p11.2 Birt-Hogg-Dube syndrome: benign skin tumors and renal cancer: high PSP incidence-23% in one study Other mutations of FLCN-bullous lung disease and spontaneous pneumothorax only Autosomal dorminant inheritance of bullous lung disease with 100% penetrance in a Finnish family
Clinical Presentation
Primary spontaneous pneumothorax Usually occurs at rest Peak age is early 20s; rare after 40 Sudden onset of dyspnea and pleuritic chest pain Severity of sx related to size of pneumothorax
Secondary spontaneous pneumothorax More severe sx for same size of pneumothorax
Physical Findings
Decreased chest excursions Decreased breath sounds Hyperresonant percussion Subcutaneous emphysema
Pleural line on chest radiograph
Clinical Manifestations1. Hyperresonance, diminished breath sound 2. Asymmetric chest expansion 3. Trachial deviation away from affected side 4. Mild to moderate discomfort dyspnea & chest
5. In tention pneumothorax one of air hunger, agitation, hypotension, and cyanosis
Sign & Symptoms:
DyspneaSOB if little amount of pleuritic air Rapid heart rate Rapid breathing Couph Pleuretic chest pain Sudden onset
Signs:Inspection: - movement of the affected side - bulging of the affected side ( tension pneumothorax)
Palpation:
- movement (affected side) -Mediastinal shift opposite side - TVF (affected side)
Percussion: Hyperresonance or tympanatic note (affected side)
Ausculation: -Air entry (affected side) - Vocal resonance (affected side) - Amphoric breathing may be heard - Coin test may be positive in tension pneumothorax
Complications Spontaneous Pnemothorax: Recurrence Persist air leak
Tension Pneumothorax: Hypoxemia Cardiac arrest Respiratory failure Shock
DDx MI
PE Pneumonia Asthma
Pleural effusion Aortic dissection Pericarditis
Aortic aneurysm rupture
Invistigations
CXR Ultrasound CT
Investigations:C.X.R.:-Lung separated from chest wall by a homogenous jet-black zone ,best seen over apex. Best seen in films taken during expiration. -Lung lies close to the mediastinum and may show the underlying disease. -In tension pneumothorax : Copula of diaphragm may be depressed and flattened. Mediastinum shifted to opposite side.
Wide intercostal spaces
Imaging Plain Radiographs Upright PA on inspiration Detect other pathologies: pneumonia, cardiac, etc.
Partially collapsed lung Tension Pneumothorax Trachea and mediastinum deviate contralaterally
Ipsilateral depressed hemidiaphragm
Chest CT Not routine Only to assess the need for surgery (thoracotomy)
PNEUMOTHORAX DIAGNOSIS: standard procedure is making chest x ray posteroanterior projection. Should upright position, may miss a pneumothorax in semisupine portable anteroposterior view. Lateral decubitus view if patient cant be upright. The percentage of collapse is underestimated. Artifact skin fold. CT, cost effective.
Pneumothorax General Management
First: evacuate the air Second: address the underlying source Third: promote pleural symphysis
Choice of Treatment Options Size of pneumothorax Symptoms Clinical stability: 60-90%, can speak whole sentences in between breaths Recurrence risk, underlying conditions Patient occupation
Size of PneumothoraxSmall < 2cm between lung margin and chest wall (BTS) < 3 cm apex-to-cupola distance (ACCP) < 15% of the hemithorax (UpToDate) Large > 2 cm between lung margin and chest wall (BTS) > 3cm apex-to-cupola distance (ACCP) > 15% of hemithorax (UpToDate)
Treatment Recommendations based on Size Small < 15% SP and stable patients: observation and supplemental oxygen to facilitate absorption of pleural air Large >15% Initial simple aspiration of the pleural space Tube thoracostomy if persistent airleak and no lung reexpansion
Tube Thoracostomy Indications PSP that fails aspiration treatment Recurrent spontaneous pneumothorax Presents with hemopneumothorax
Small chest tube in most (5.5 or 7.0 French) Clamp chest tube when no bubbles emanate from a patent tube in 12 hours Remove after 24 hours if no clinical or xray evidence of recurrence
Pleurodesis Procedures Chemical pleurodesis Intrapleural instillation of sclerosing agents
Tetracycline, doxycycline, talc, premedicate with midazolam and an opiate Open or surgical pleurodesis
thoracoscopy vs. a limited or full thoracotomy Indications: lung remains unexpanded after 3 days of chest tube, bronchopleural fistula, recurrence after chemical pleurodesis, bullae resection, patient occupation
Tx
Postgrad Med 2005;118(6) (online
Surgical indication:i. Failure of closure of the tear after 48 hours of continous drainage ii. Intrapleural haemorrhage
iii. Bronchopleural fistulaiv. History of pneumothorax in the opposite side
PNEUMOTHORAX Spontaneous rupture of esophagus present as ptx without gastrointestinal symptoms. Ptx accompanying pleural fluid, atelectasis. spontaneous pneumothorax with COPD especially with bullae formation is troublesome, tolerate poorly even small degree of collapse. Catamenial pneumothorax, occurred first three days of menses, nonovulatory states such as pregnancy and oral contraceptive use were not associated with pneumothorax.
PNEUMOTHORAX Lung cancer with pneumothorax only 0.03 to 0.05%. Lymphangioleiomyomatosis seen in young women. Acquired pneumothorax is most often iatrogenic, chest tube dysfunction. Barotraumas pneumothorax is patient receving positive-pressure ventilation--treated by intervention rather than observation, indication for tube thoracostomy.
PNEUMOTHORAX
Small fluid collections frequently encountered if pneumothorax over 24 hours. The fluid always clear. Large effusion often bloody and suggest a torn vascular adhesion, may require immediate operation to control bleeding.
PNEUMOTHORAX
Important to exclude a giant bullae in differential diagnosis because the tube drainage if such bullae is unrewarding. Patient with pneumothorax should not be encouraged to travel by air.
PNEUMOTHORAX 1.5% of the air is reabsorbed over each 24 hours. Tube thoracostomy for pneumothorax over 30% or for patient with heart disease or COPD. Tube place at anterior and mid-axillary line, less muscle tissue has to be traversed. Anterior tube through second intercostal space, provide excellent apical air clearance but avoided in women.
PNEUMOTHORAXVarious agents for induce pleural symphysis: siver nitrate, talc, hypertonic glucose, urea, oil, nitrogen mustard, various antibiotics. Intrapleural tetracycline instillation could reduce the incidence of recurrence but difficulty to obtain. Talc should be reserved for malignant effusion, not benign pneumothorax.
PNEUMOTHORAXOpen operation by limited lateral or axillary incision with bleb excision and pleural abrasion or limited apical pleurectomy--- excellent result, low recurrence.
Video-assisted thoracic surgery VATS.The recurrence rate is more high in VATS than other minithoracotomy.
PNEUMOTHORAXComplete parietal pleurectomy should be reserved for open treatment failure, for postpneumonectomy patient with first pneumothorax and for old patient usually with COPD. Bilateral pneumothorax could be treated for bilateral via median sternotomy.
PNEUMOTHORAX
Goal of surgical treatment is to find the offending bleb, remove it, encourage adhesion formation but not too dense an adhesion.If no bleb is found, the apex of the upper lobe should be staple off.
PNEUMOTHORAX Surgical treatment of AIDS patient: usually persistent air leak. Thoracoscope approach with fibrin glue derivative. YAG laser, Heimlich valves. Persistent air leak who is poor operative risk,could be treated by using closed by pneumoperitoneum. Conclusion: If surgical treatment is going to be necessary the sooner it is performed, the sooner that patient can resume a routine life style.
Tension Pneumothorax
Tension PneumothoraxBall-valve mechanism Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration
Tension PTHX= air in the pleural space, which pressure exceeds the atmospheric pressure throughout expiration (inspiration).
CAUSES any type of PTHX:1. 2. 3. 4. 5. with mechanical ventilation / NIPPV during cardiopulmonary resuscitation in divers in air travel in spontaneously breathing person at constant pressures (airway, environment)
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improper chest tube handling
Tension PTHX
mediastinal shift hyperinflation
collapsed lung
low hemidiaphragm
2. Tension PTHXPathophysiology: impaired venous return and decreased cardiac output V/Q mismatch - profound hypoxia
Clinical manifestations: sudden deterioration dyspnoe, cyanosis, tachicardia, profuse sweating hypotension, low O2 saturation, distended neck veins subcutaneous emphysema, unilateral hyperinflation respiratory acidosis, hypoxemia sudden increse in plateau and peak pressures (volume type vent.) sudden drop of tidal volumes (pressure type vent.)
2. Tension PTHXTH: medical emergency clinical diagnosis do not wait for CXR 100% O2 observation, auscultation, percussion needle & syringe with saline 2nd anterior ICS
bubbles? replace with large - bore needle prepare for tube thoracostomy
Risk of RecurrenceRange 25 - >50%; 54% within first 4 years in one studyRisk factors for recurrence in PSP smoking tall stature female gender low body weight
Risk factors for recurrence in SSP age over 60 years pulmonary fibrosis emphysema