Hemopneumothorax

Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDs), FCCPConsultant Cardiothoracic SurgeonAsst. Professor of SurgeryDivision of Cardiothoracic SurgeryKing Abdulaziz University

Definition

• A pneumothorax is a collection of free air in the chest outside the lung that causes the lung to collapse.

incidence

• Spontaneous pneumothorax affects about 9,000 persons each year in the U.S. who have no history of lung disease. This type of pneumothorax is most common in men between the ages of 20 and 40, particularly in tall, thin men. Smoking has been shown to increase the risk for spontaneous pneumothorax

Etiology

• Spontaneous pneumothorax is caused by a rupture of a cyst or a small sac (bleb) on the surface of the lung (apical segment of upper lobe and or superior segment of lower lobe)

• May also occur following an injury to the chest wall such as a fractured rib, any penetrating injury (gun shot or stabbing),

Etiology

• A pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, and infections of the lungs (pnemocysts carinii).

Types of pneumothorax

• A spontaneous pneumothorax, also referred to as a primary pneumothorax, occurs in the absence of a traumatic injury to the chest or a known lung disease

• A secondary (also termed complicated) pneumothorax occurs as a result of an underlying condition

Tension Pneumothorax

• Tension pneumothorax: The accumulation of air under pressure in the pleural space.

• The air enters the pleural cavity and is trapped there during expiration so the air pressure within the thorax mounts higher than atmospheric pressure, compresses the lung, may displace the mediastinum and its structures (including the lung) toward the opposite side, and cause cardiopulmonary impairment (decrease cardiac output)

Clinical Presentation

• Sudden onset chest pain sharp in nature . • Shortness of breath• Tachypnea• Tachycardia• Cyanosis• Decrease or abscent breath sounds

Diagnosis

• Clinical presentation• Chest X-ray

Radiographic Picture

Radiographic Picture

Treatment

• A small pneumothorax without underlying lung disease may resolve on its own.

• A large pneumothorax and a pneumothorax associated with underlying lung disease often require placement of a chest tube to evacuate the air

Thoracostomy Tube

Hemothorax

• Hemothorax refers to a collection of blood within the pleural cavity.

Etiology

• Traumatic – Blunt trauma– Penetrating trauma (including iatrogenic)

• Nontraumatic or spontaneous – Neoplasia (primary or metastatic)– Blood dyscrasias, including complications of

anticoagulation– Pulmonary embolism with infarction– Torn pleural adhesions in association with spontaneous

pneumothorax

Clinical Presentation

• Hemodynamic changes vary depending on the amount of bleeding and the rapidity of blood loss

• Shock (blood loss > 750cc)• A large enough collection causes the patient to

complain of dyspnea

Workup

• Chest radiography – The upright chest radiograph is the ideal primary

diagnostic study in the evaluation of hemothorax - Hemothorax is noted as a meniscus of fluid blunting the costophrenic angle

• CT scan – CT scan is a highly accurate diagnostic study for

pleural fluid or blood

Radiographic Picture

Treatment

• If a hemothorax is equal to or greater than the amount required to obscure the costophrenic sulcus or is found in association with a pneumothorax based on chest radiograph findings, it should be drained by tube thoracostomy

Treatment

• Surgical exploration in cases of traumatic hemothorax should be performed in the following circumstances:

• Greater than 1000 mL of blood is evacuated immediately after tube thoracostomy. This is considered a massive hemothorax.

• Bleeding from the chest continues, defined as 150-200 mL/h for 2-4 hours.

• Persistent blood transfusion is required to maintain hemodynamic stability