pneumothorax - himsr.co.in€¦ · the pneumothorax is large o tactile fremitus is absent o the...
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Pneumothorax
Dr Ummar
1
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WHAT IS PNEUMOTHORAX
•Pneumothorax is defined as presence of air in
the pleural space.
2
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Pathophysiology
3
• Blebs and bullae are also known as emphysema-like
changes (ELCs)
• The probable cause of pneumothorax is rupture of an
apical bleb or bulla
• Because the compliance of blebs or bullae in the apices
is lower compared with that of similar lesions situated in
the lower parts of the lungs
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Pathophysiology
4
• It is often hard to assess whether bullae are the site of leakage, and where the site of rupture of the visceral pleura is
• Smoking causes a 9-fold increase in the relative risk of a pneumothorax in females
• A 22-fold increase in male smokers
• With a dose-response relationship between the number of cigarettes smoked per day and occurrence of PSP
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Mechanism
5
• In normal people, the pressure in pleural space is
negative during the entire respiratory cycle.
• Two opposite forces result in negative pressure in pleural
space(outward pull of the chest wall and elastic recoil of
the lung)
• The negative pressure will be disappeared if any
communication develops .
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• When a communication
develops between an
alveolus or other
intrapulmonary air space
and pleural space, air will
flow into the pleural space
until there is no longer a
pressure difference or the
communication is sealed
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Etiology
Pneumothorax
Spontaneous
Primary Secondary
Traumatic
Iatrogenic
Interventional
procedures.
Positive pressure
ventilation
Non iatrogenic
Penetrating
traumaBlunt trauma.
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Primary spontaneous pneumothorax
• It occurs in young healthy individuals without
underlying lung disease.
• It is due to rupture of apical
sub-pleural bleb or bullae
Predisposing factors:
▪ Smoking.
▪ Tall, thin male.
▪ Airway inflammation (distal)
▪ Structural abnormalities of bronchial tree
▪ Genetic contribution
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Secondary spontaneous pneumothorax
Most common cause.
❖ TB
❖ Asthma
❖ COPD
❖ Suppurative pneumonia
❖Cystic fibrosis
Rare cause
❖ ILD
❖ Eosinophilic granuloma
❖ Sarcoidosis
❖ Lymphangioleiomyomatosis
❖ AIDS.
9
❖ Primary lung carcinoma
❖ Complication of chemotherapy
❖ Connective tissue disease
❖ Scleroderma
❖Marfans syndrome
❖ Histiocytosis- x
❖ Rheumatoid disease
❖ Pulmonary infarct
❖Wegener’s granulomatosis…
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Clinical manifestation
10
Dyspnea
Chest pain ( pleuritic)
Uncommon manifestation
Cough
Hemoptysis
Orthopnea
Cyanosis
Mod tachycardia
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Traumatic pneumothorax
11
Accidental trauma:(non-iatrogenic)
Blunt trauma: with fracture ribs.
Penetrating trauma: stab wound or gun shot injury.
Iatrogenic :Positive pressure ventilation:Alveolar rupture → interstitial emphysema→pneumothorax.(B/L PNX)
Interventional procedures:
Biopsy, thoraco-centesis, CVP line,trachestomy etc..
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Clinical type of PNX
Pneumothorax
Closed
pneumothorax
Open
pneumothorax
Tension
pneumothorax
12
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Closed
pneumothorax
Open
pneumothorax
Tension
pneumothorax
The pleural tear
Is sealed
The pleural tear
is open
The pleural tear
act as a ball &
valve mechanism
The pleural
cavity pressure
is < the
atmospheric
pressure
The pleural
cavity pressure
is = the
atmospheric
pressure
The pleural cavity
pressure is > the
atmospheric
pressure
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Clinical manifestation
14
• Tension pneumothoraxo RAPIDLY PROGRESSIVE DYSPNIA.
o Cyanosis
o Marked tachycardia
o Hypotension
• Patient who suddenly deteriorate clinically,
be suspected in the patient witho Mechanical ventilation (b/l PNX)
o Cardiopulmonary resuscitation
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Physical examination
15
o Depend on size of pneumothorax
o The vital signs usually normal
o Unilateral Chest movements
o The trachea may be shifted toward the contralateral side if
the pneumothorax is large
o Tactile fremitus is absent
o The percussion note is hyperresonant
o The breath sounds are reduced or absent on the affected
side
o The lower edge of the liver may be shifted inferiorly with a
right-side pneumothorax
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Investigations and Diagnosis
16
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Pneumothorax
in erect position
Pneumothorax
in supine position
Air in apicolateral pleural
space
Air in anteromedial pleural
space.
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Pneumothorax
Erect
Small pneumothorax
Apical lucency
Visceral pleural line
Large pneumothorax
Apical lucency (>2cm in width)
Visceral pleural line
Tension pneumothorax
Lung collapse
Mediastinal shift
Low flat diaphragm
Supine
Deep Costophrenic
sulcus
Lucent Cardiophrenic
sulcus
Sharp
Mediastinal contour
Double diaphragm
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Quantification of the size
Thesimplemethodtoestimatethesiz e
S
2424
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Quantification of the size
The simple method to estimate the sizeSmall, a visible rim of < 2 cm between the lung margin and the chest wall
Large, a visible rim of ≥2 cm between the lung margin and chest wall
Light indexMeasure transverse
Diameters of lung and
Compare it with diameter
hemithorax
25 25
Lung (L)
Hemithorax (HT)
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Estimation of pneumothorax volume
⚫ Light equation pneumothorax%=(1-L3/HT3) 100
⚫ Kircher equation
pneumothorax%
Thorax area-lung area
Thorax area
⚫ Collins equation
4.2+[4.7(A+B+C)]
100
Hemithorax (HT)
Lung (L)
21
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⚫ A pneumothorax of 2 cm on the PA chest radiograph occupies about 49% of the hemithorax volume
⚫ Lung is 8 cm, hemithorax is 10 cm in diameter
⚫ EquationVolume of pneumothorax = (HT3 – L3) ÷ HT3
= (103 – 83) ÷ 103
= (1000 – 512) ÷1000
= 0.49
Plane chest X-ray film
22
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Small pneumothorax
29
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Small pneumothorax
30
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LARGE PNEUMOTHORAX````````
31
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Visceral pleural line
33
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Tension pneumothorax
36
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37
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39
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Deep costophrenic sulcus
40
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Lucent cardiophrenic sulcus
41
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Sharp mediastinal contour
42
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Double diaphragm sign
subpulmonic pneumothorax
43
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CT scanning
44
➢ It is recommended in difficult cases such aspatients in whom the lungs are obscured byoverlying surgical emphysema
➢ To differentiate a pneumothorax from suspected bulla in complex cystic lung disease
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CT can diagnose easily
pneumothroax
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CT can diagnose easily
pneumothroax
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CT scanning
4747
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CT scanningSmall
pneumothorax
Subcutaneous emphysema
4748
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U/S in pneumothorax
• Ultrasound found to be more sensitive than CXR in
diagnosis of pneumothorax.
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U/S signs of pneumothorax
• Loss of lung sliding.
• Loss of comet tails.
• loss of seashore sign (M mode).
• Stratosphere sign or bar code sign(M mode).
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MANAGMENT
61
➢ Goalso To promote lung expansion
o To eliminate the pathogenesis/cause
o To decrease pneumothorax recurrence➢ Treatment options according to
o Classification of pneumothoraxo Pathogenesis
o The extension of lung collapse
o Severity of diseaseo Complication and concomitant underlying
diseases
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63
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O2 TREATMENT-- PSP or SSP
68
Inhalation of high concentration of {10 l/m} oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen
This should increase the pressure gradient between the pleural capillaries and the pleural cavity
Thereby increasing absorption of air from the pleural cavity
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The rate of resolution/reabsorption of spontaneous pneumothorax is
1.25 – 1.8% of volume of hemithorax every 24 hours (ABOUT 50 DAYSTO TAKE if 40% pnx)
The addition of high flow oxygen therapy has been shown to result in a 4-fold increase in the rate of pneumothorax reabsorption during the periods of oxygen supplementation
69
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Simple aspiration
70
Simple aspiration is recommended as first linetreatment for all PSP requiring intervention
Simple aspiration is less likely to succeed in
secondary pneumothoraces and in this situation,
is only recommended as an initial treatment in
small (<2 cm) pneumothoraces in minimally
breathless patients under the age of 50 years
Patients should be admitted to hospital and
observed for at least 24 hours before discharge.
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Repeated aspiration is reasonable for
primary pneumothorax when the first
aspiration has been unsuccessful
A volume of < 2.5 L has been aspirated on
the first attempt
The aspiration can be done by needle or
catheter
71
Catheter aspiration
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Intercostal tube drainage• INDICATIONS
o Tension pneumothorax
o Severe dyspnea
o Large/complete pneumothorax
o Intermittent positive pressure ventilation pneumothorax
o Recurrent pneumothorax
o Bilateral pneumothorax
o Presence of pleural fluid
o Simple aspiration or catheter aspiration drainage is unsuccessful in controlling
symptoms
72
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A common site of chest tube insertion is in the
2nd ICS in mid-clavicular line.
An alternative site now commonly used is
midaxillary line of 4th and 5th intercostal
space for cosmetic reason and also for when
pleural effusion.
Intercostal tube drainage
7373
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Trocar tube thoracostomy
Insertion of trocar into the pleural space.
74
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Trocar tube thoracostomy
Insertion of the chest tube through the
trocar
75
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Observation of drainage
77
No bubble released
◦ The lung re-expansion
◦ The chest tube is obstructed by secretion or blood clot
◦ The chest tube shift to chest wall, the hole of the chest
tube is located in the chest wall
If the lung re expanded, removing the chest tube 24
hours after re expansion.
Otherwise, the chest tube will be inserted again or
regulated the position.
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Complications of intercostal tubedrainage
78
Penetration of major organs
◦ Lung, stomach, spleen, liver, heart and great vessels
◦ It occurs more commonly when a sharp metal trocar is inappropriately applied
Pleural infection
◦ Empyema, the rate of 1%
Surgical emphysema
◦ Subcutaneous emphysema
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Chemical pleurodesis
79
Goals
◦ To prevent pneumothorax recurrence
◦ To produce inflammation of pleura and adhesions
Indications
◦ Persist air leak and repeated pneumothorax
◦ Bilateral pneumothorax
◦ Complicated with bullae
◦ Lung dysfunction, not tolerate to operation
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Chemical pleurodesis
Sclerosing agents
◦ Tetracycline
◦ Doxycycline
◦ Talc
◦ Erythromycin
◦ 10% povidine iodine
The instillation of sclerosing agents into the pleural
space lead to an aseptic inflammation with dense
adhesions.
80
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Chemical pleurodesis
81
Methods
◦ Via chest tube or by surgical mean
◦ Administration of intrapleural local anaesthesia, 200 – 300 mg
lidocaine intrapleurally injection
◦ Agents diluted by 60 – 100 ml saline
◦ Injected to pleural space
◦ Clamp the tube 4hours
◦ Drainage again
◦ Observed by chest X-ray film, if air of pleural space is absorbed,
remove the chest tube
◦ If pneumothorax still exist, repeated pleurodesis.
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Chemical pleurodesis
82
82
Side effect
◦ Chest pain
◦ Fever
◦ Dyspnea
◦ Acute respiratory distress syndrome
◦ Acute respiratory failure
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Surgical treatment
83
Indications
◦ No response to medical treatment
◦ Persistant air leak
◦ Hemopneumothorax
◦ Bilateral pneumothoraces
◦ Recurrent pneumothorax
◦ Tension pneumothorax failed to drainage
◦ Thickened pleura making lung unable to reexpand
◦ Multiple blebs or bullae
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Complications of pneumothorax
Recurrence of spontaneous pneumothorax
Tension pneumothorax
Hydropneumothorax
Encysted pneumothorax
Failure of expansion of the collapsed lung
Re-expansion pulmonary edema
Broncho-pleural fistula
Pneumomediastinum
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Recurrence of spontaneous
pneumothorax
• 50% on the same side.
•15% on the contralateral side.
More common in
• secondary spontaneous pneumothorax.
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Tension pneumothorax
• It is life threatening condition.
• The pleural pressure is more than the atmospheric pressure.
Radiological manifestations of large pneumothorax
• Mediastinal shift,
• Flattening of the hemidiaphragm &
• Lung collapse.
Associated with clinical manifestations of rapidly progressive breathlessness and circulatory collapse (tachycardia, hypotension & sweating).
It is more common with
• Positive pressure ventilation &
• Traumatic pneumothorax.
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Tension pneumothorax
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Hydropneumothorax
• Due to rupture of pleural adhesions.
• Bronchopleural fistula.
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Encysted pneumothorax• Due to pleural adhesions.
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Failure of re-expansion of the
collapsed lung
• Due to pleural adhesions.
• Or tracheobronchial injury.
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93
Mediastinal and subcutaneous emphysema
◦ Alveoli rupture, the air enter into pulmonary
interstitial, and then goes into mediastinal and
subcutaneous tissues.
◦ After aspiration or intercostal chest tube insertion, the
air enters the subcutaneous by the needle hole or
incision – surgical emphysema
◦ Physical exam – crepitus is present.
Subcutaneous
emphysema
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95
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