PNEUMOTHORAX

[Link] VENNILAVAN R
PG-III
 PNEUMOTHORAX

• DEFINITION:

• Defined as air in the pleural space,that is,air between lung

and chestwall.
 Pneumothorax Classifications
General Terms

Pneumothorax

Closed Open Tension

pneumothorax pneumothorax pneumothorax

The pleural tear Is The pleural tear The pleural tear act
sealed is open as a one way valve
mechanism
 Etiological Classification of pneumothorax
A)Spontaneous pneumothorax
occur without antecedent trauma
1. Primary spontaneous pneumothorax
occur in otherwise healthy individuals.
2. Secondary spontaneous pneumothorax
occur as a complication of underlying lung disease.

B) Traumatic pneumothorax
occur from direct or indirect trauma to the chest.
[Link] pneumothorax
[Link] pneumothorax
-Blunt injuries
- Penetrating injuries
 Epidemiology of pneumothorax
Incidence(/100000 Age group predisposition Recurrence Symptoms
) Male
fema
le
Primary spontaneous 18-28 1.2 – 6 Age 10 -30 years Thin 16 – 52% Symptoms
Rare in >40 years Tall less
Smoking (up to 20x)
Secondary spontaneous 6.3 2 40 – 65 years COPD 39 – 47% Most often
(26/100000) HIV symptomat
( PCP) ic
Traumatic and Any age Procedures unlikely Symptomatic
Iatrogenic Penetrating and
blunt traumas
 Primary spontaneous pneumothorax:

• It occurs in young healthy individuals(20 - 40 years) without

underlying lung disease.

• It is due to rupture of apical sub-pleural bleb.

Predisposing factors:
• Smoking. (airway inflammation)

• Tall, thin male. ( increased distending pressure)

• Familial ( defect in connective tissue)(Marfan,ehlers danlors

etc.)
 THROACOSCOPIC IMAGING OF SUBPLEURAL BLEBS

BLEBS - Pocket of air within the layers of visceral pleura.

< 1 cm & usually apical.
 Secondary Spontaneous Pneumothorax

• Secondary spontaneous pneumothorax

– Occurs with underlying lung disease

• Most common associated disease is COPD

• Also seen during exacerbations of asthma and CF

• Interstitial lung diseases with normal lung volumes

– Sarcoidosis, BOOP

– Depending on extent of disease, pneumothorax can be devastating

• 43% 5-year mortality

 Etiology - Secondary spontaneous pneumothorax

• Airway disease • Interstitial Lung Disease

• COPD • Sarcoidosis
• Idiopathic Pulmonary fibrosis
• Cystic fibrosis
• Langerhans’ cell granulomatosis
• Asthma
• Lymphangioleiomyomatosis
• Infectious lung diseases • Tuberous sclerosis
• Tuberculosis • Connective Tissue disease
• Pneumocysti • Rhumatoid arthritis
s
pneumonia • Ankylosing spondylitis
•Necrotizing pneumonia • Polymyosistis and dermatomyositis
(anaerobic, Gram • Scleroderma
negative, • Marfan’s syndrome
staphylococcus) • Ehlers–Danlos syndrome
• Cancer
• Sarcoma
• Lung cancer
• Catamenial pneumothorax – Pneumothorax related to mensturation
• Postulated to occur in the setting of endometriosis affecting the lung.
IATROGENIC PNEUMOTHORAX
 TRAUMATIC PNEUMOTHORAX

Traumatic pneumothorax
• Penetrating chest trauma
– Common secondary to bullet or knife penetration
– Chest tube is usually adequate to treat.
– May require surgery if bleeding is severe

• Blunt trauma
– Broken ribs puncture lung with air escape into pleura.
– Chest tube is all that is generally required.
 Pathogenesis and mechanisms
• The pressure within the pleural space is negative with
respect to the alveolar pressure during the entire
respiratory cycle.

• This negative pressure results from the inherent

tendency for the lung to collapse (elastic recoil) and the
chest wall to expand.

• Pleural pressure is not uniform.

• Gradient between the superior ( lowest, most negative)

and inferior (highest, least negative) portions of the lung.
It falls as 0.3 cm H20/ cm vertical distance 15
 Pathogenesis and mechanisms

• When a communication
develops between an
alveolus or airways and
pleural space ,air will
flow into the pleural
space until there is no
longer a pressure
difference or until the
communication is sealed

16
 EFFECTS OF PNEUMOTHORAX
– Negative pressure eliminated
• The chest expands and lung volume decrease
• V/Q decreases
• Anatomical shunt increase
– Positive pressure (in Tension Pneumothorax)
• Compress blood vessels and heart
• decreased cardiac output
• Impaired venous return
• Hypotension
• Shock
– Result in
• A decrease in vital capacity
• A decrease in PaO2
• Total lung capacity, functional residual capacity,and diffusing capacity
are also reduced. 17
 Clinical presentation

• Pleuritic chestpain
• Acute dyspnea

• Symptoms usually resolve within 24 hours, even if thepneumothorax

remains untreated and does not resolve.

• Patients with a small pneumothorax (<15%) may have a normal physical

examination1.
• Tachycardia is the most commonfinding1.
 EXAMINATION

- Tactile fremitus is absent

– The percussion note is hypersonant

– The breath sounds are reduced or absent on the affected side.

– Amphoric breath sound – if BPF present.

– Weak/ absent pulse, hypotension, cyanosis, tracheal deviation,

suggests the possibility of a tension pneumothorax.

 RADIOLOGY

The following numerous imaging modalities have been employed for the diagnosis and
management of pneumothorax:

1. Standard erect PA chest x-ray.(59% sensitive)

2. Supine x-rays.(37% sensitive)

3. Expiratory films. (are not routinely recommended)

4. lateral decubitus x-rays.(most sensitive 88%)

5. Ultrasound scanning-particularly useful in critically ill

6. CT scanning.
 Imaging- Plane chest X-ray film
• Visceral pleural line –
necessary to makea
definitive diagnosis.

• Visceral pleural line

parallels the curvature of
the chest wall (ie. Convex
outwards.

• Usually there is absence of

lung markings peripheral
to pleural line.

21
 Visceral pleural line usually often confused with
Skin fold:

• an abnormal edge with a sharp black ând white interface

laterally, with gradual fading of the density from white to
black medially
• Extend beyond the chest wall.
• Lung markings extend beyond it.
 Right pneumothorax

•Pencil-thin white line

running parallel to chest
wall
•No lung markings lateral
to the line

Blade of right scapula

 Other causes of absent lung markings
• Large emphysematous bullae
• Large lung cysts
• Pulmonary embolism

....but only pneumothorax has a white line parallel to the chest wall
Emphysematous bulla:
• The pleural line with a pneumothorax is usually oriented
in convex fashion toward the lateral chest wall, whereas
the apparent pleural line with a large bulla is usually
concave toward the lateral chest wall.

• Double wall sign on CT is consistent with ruptured bulla

causing pneumothorax.
Emphysematous bulla Vs pneumothorax
 Supine radiographs

• It is much more difficult to establish the diagnosis of

pneumothorax on a supine radiograph(37%
sensitivity)
• The location for collections of air on the supine film
are:
[Link] location(most common)
2. subpulmonary
[Link]
[Link]
Deep costophrenic sulcus
 Double diaphragm sign
subpulmonic pneumothorax
Lucent cardiophrenic sulcus
 Ultrasound
In critically ill patient and traumatic pneumothorax it is superior to
supine chest xray. The sensitivity for US was 98.1% and the specificity
was 99.2%.
Normal lung is characterized
[Link] sliding/ pleural gliding
Respiratory excursions of the visceral pleura can be discerned from the
movement pleural gliding of discrete hypoechoic inhomogeneities
within the high-echo band of the pleural reflection .
[Link] tail artifacts
At the boundary between the pleura and the ventilated lung tissue,
intensive band-like reverberation echoes.

Pneumothorax - Both lung sliding and comet tail artifacts are absent
NORMAL SLIDING
PNEUMOTHORAX
 CT SCAN

CT scanning is recommended :
1.‘gold standard’ in the detection of small (occult)pneumothorax

[Link] estimation

[Link] differentiating a pneumothorax from bullous lung disease.

[Link] aberrant tube placement is suspected .

[Link] the plain chest radiograph is obscured by surgical

emphysema .

[Link] lung pathology like malignancy.

OCCULT PNEUMOTHORAX
MALPOSITIONED CHEST TUBE
 ECG CHANGES IN PNEUMOTHORAX
• Abnormal axis deviation and reduction of amplitude is much
more common in patients with the left sided compared with
right-sided pneumothorax

• QRS morphology (most commonly right bundle branch block)

and T waves (inversion)appear more often in patients with
the right-sided pneumothorax.

Ted Feldman, Craig T et [Link] changes in [Link] 1984:86(1)

 Quantification of the size

• The size of a pneumothorax, in terms of volume, is difficult to assess

accurately from a chest radiograph.

• The simple method to estimate the size

– Small, a visible rim of < 2 cm between the lung margin and the
chest wall(at the level of hilum)

– Large, a visible rim of ≥2 cm between the lung margin and chest

wall.
43
1. Apex – cupola
distance(ACCP) - 2001
• a ≥ 3cms small
• a < 3cms large

[Link] distance
at hilum (BTS) -2010
• b ≥ 2cms small
• b < 2cms large
 Size
• [Link] index:
lung is viewed as a sphere within a
sphere. Using this model it is
possible to estimate the size of the
pneumothorax using the following
equations:
• DL = average diameter of lung
DH = average diameter of
hemithora
• % PTX = (1 - DL 3/DH3) X 100

[Link] method

10% pneumothorax for every

cm of intrapleural distance
 TREATMENT

• CONSERVATIVE

• ACTIVE
• The clinical evaluation is more important than the size of the
pneumothorax in determining the management strategy.

• Therefore presence of breathlessness irrespective of size requires

active management.
 CONSERVATIVE

• OBSERVATION

• SUPPLEMENTAL OXYGEN
 OBSERVATION
• Observation along is advised for small(<2 cm), closed asymptomatic spontaneous
pneumothorax.

• Patients with small PSP and minimal symptoms do not require hospital admission
and asked to review after 2 to 4 weeks.

• However, it should be stressed before discharge that they he should return

directly to hospital in the event of developing breathlessness.

• Most patients in this group who fail this treatment have secondary pneumothorax
49
 Observation - SSP

• Observation alone is only recommend in patients with small

SSP of less than 1 cm depth in asymptomatic patients.

• However,Hospitalisation is recommended in these cases.

• All other cases will require active intervention ( aspiration or

chest drain insertion)

50
 SUPPLEMENTAL OXYGEN

• Inhalation of high concentration of 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.

51
• If patient is hospitalised,then it is recommended to provide supplementaion
oxygenation whether it is primary or secondary spontaneous.
• Supplemental oxygen:- (Grade Brecommendation)

• Spontaneous rate of reabsorption 1.25% to 1.8% (50-75 mL) of the total

volume/24 hours
• Supplemental oxygen increases the rate of absorption by a factor of41
• It reduces partial pressure of nitrogen in the pleural capillaries. And enhancesthe
reabsorption of air in the pleural cavity.

[Link] Medical Journal, 1971, 4, 86-8 T. [Link]

Oxygen therapy for spontaneous pneumothorax1

• The calculated time for full re-expansionwith

daily oxygen therapy ranged from 3 -8 days,
with a mean of 5days.

[Link] Medical Journal, 1971, 4, 86-8 [Link]

 Active management

• SIMPLE MANUAL ASPIRATION

• TUBE THORACOSTOMY

• SURGERY
 Simple aspiration
• Simple aspiration is recommended as first line treatment 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 with secondary pneumothoraces treated successfully with simple

aspiration should be admitted to hospital and observed for at least 24 hours
before discharge 55
 Simple Aspiration

• Size>2cm and/or Breathless –

1.Aspirate16-18G cannula

After no more air can be aspirated at 2.5 l, the stopcock is closed and the catheter is
secured to the chest wall. After 4 hours of observation, a chest radiograph should be
obtained.

If adequate expansion persists, the catheter be can removed and the patient
discharged. Patients should return in 24 to 72 hours for a follow-up chest radiograph.
The Heimlich valve is a one-way, rubber flutter valve.
The proximal end attaches to the chest tube .
The distal end connects to a suction device or is left open to
the atmosphere.
It allows outpatient treatment of a pneumothorax.
 Intercostal tube drainage
• INDICATIONS

1. Dyspnea

[Link] lung collapse

[Link] or tension pneumothorax

[Link] Pneumothorax

[Link] pneumothorax

[Link] aspiration is unsuccessful in controlling symptoms

59
 Size of tube
• There is no evidence that large tubes (20–24 F) are any better than
small tubes (10–14 F) in the management of pneumothorax.

• If the decision is made to insert a chest drain, small (10–14 F)

systems should be used initially .

• It may become necessary to replace a small chest tube with a larger

one if there is a persistent air leak.
 The site of chest tube insertion
• The ‘triangle of safety’.
• Anteriorly - the lateral edge of
pectoralis major
• Laterally -the lateral edge of
latissimus dorsi
• inferiorly -the line of the fifth
intercostal space
• superiorly - the base of the axilla.

• This position minimises the risk to

underlying structures (eg, internal
mammary artery) and avoids
damage to muscle and soft tissue
resulting in unsightly scarring.
 The preferred position for standard drain insertion is on the bed,slightly rotated,
with the arm on the side of the lesion behind the patient’s head (figure A) An
alternative is for the patient to sit upright leaning over an adjacent table with a
pillow under the arms (figure B). or in the lateral decubitus position (figure C).

The preferred position for standard drain insertion is on the bed,slightly rotated, with the
arm on the side of the lesion behind the patient’s head (figure A) An alternative is for the
patient to sit upright leaning over an adjacent table with a pillow under the arms (figure
 Observation of drainage
• No bubbling

– The lung reexpansion

– 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.

• The chest tube should remain in place for 24 hrs after the lung
reexpands and air leak ceases.

• If the lung reexpansion,the tube is clamped(remains controversial)

and is removed after 24 hours if the lung remains expanded. 63
 Complications of intercostal tube drainage

[Link]

[Link] infection

[Link] infection

– Empyema, the rate of 1%

[Link] emphysema

5. Visceral puncture and serious bleeding, which are rare.

[Link] are also reports of damage to intercostal nerves

during insertion.

[Link] Pulmonary Edema 64

 Chemical pleurodesis

• Chemical pleurodesis can control difficult or recurrent

pneumothorax but should only be attempted if the patient is either

unwilling or unable to undergo surgery.

• Medical pleurodesis for pneumothorax should be performed by a

respiratory specialist.
 Chemical Pleurodesis

 Substance used :
- Tetracycline(RECOMMENDED)
- Slurry Talc

 Persistent Air leak

- Autologus blood patch.

- Fibrin Glue
 Indications for surgical advice

1. Second ipsilateral pneumothorax.

2. First contralateral pneumothorax.

3. Synchronous bilateral spontaneous pneumothorax.

4. Persistent air leak (despite 5 to7 days of chest tube drainage)

[Link] of lung re-expansion.

[Link] haemothorax.

7. Professions at risk (eg, pilots, divers).

8. Pregnancy
 Surgical strategies
• In cases of persistent air leak or failure of the lung to reexpand an early (3
(PSP)- 5 (SSP)days) thoracic surgical opinion should be sought.

Open thoracotomy and pleurectomy

OR

Video-assisted thoracoscopic surgery (VATS)

 Surgical strategies

Two objectives in the surgical management of apneumothorax.

• The first widely accepted objective is resection of blebs or the suture

of apical perforations to treat the underlying defect .

• The second objective is to create a pleural symphysis to prevent

recurrences.
 Open thoracotomy

Pleural abrasion .

Parietal pleurectomy for recurrent pneumothorax.

Both of these techniques are designed

• To obliterate the pleural space by creating symphysis between the

two pleural layers .

• Between the visceral pleura and subpleural plane, in the case of

parietal pleurectomy .
 Open thoracotomy yields the lowest postoperative recurrence results.

Bulla ligation/excision, thoracotomy with pleural abrasion, and either

apical or total parietal pleurectomy all have failure rates under 0.5%.

Open thoracotomy is generally performed using

• Single lung ventilation .

• A limited posterolateral thoracotomy allowing parietal pleurectomy,

excision, or stapling of bullae or pleural abrasion.
Video assisted thoracoscopic surgery (VATS)

Bullectomy,pleurectomy,pleural abrasion, and surgical

pleurodesis have all been shown to have reasonable success
rates when carried out thoracoscopically .

Recurrence rates of pneumothorax after VATS are 5 –10%which

are higher than the 1% rates reported after open procedures .
VATS
 Pleural Abrasion

Metallic scrubber before mechanical pleural abrasion.

Before abrasion, the parietal pleura looks normal .

The parietal pleura is reddened and bleeds slightly .

 VATS offers significant advantages over open thoracotomy
:

• A shorter post operative hospital stay .

• Significantly less post operative pain .

• Better pulmonary gas exchange in the post operative

period .
 IATROGENIC PNEUMOTHORAX

• The treatment is similar to Spontaneous pneumothorax.

• Only difference is Recurrence,iatrogenic pneumothorax do not recur so no need to

try for pleurodesis.
 Treatment of Iatrogenic Pneumothorax
• If the patient has no symptoms and the pneumothorax occupies less than
40% of the hemithorax, the patient can be managed with observation and
supplemental oxygen .

• If the patient is symptomatic, if the pneumothorax occupies more than 40% of

the hemithorax, or if the pneumothorax continues to enlarge, however, one
should consider removing the intrapleural air.

• In general, most iatrogenic pneumothoraces should first be treated with

aspiration
 TRAUMATIC PNEUMOTHORAX

• Often require treatment with chest drain

• Management of occult pneumothorax

No lung edge seen on chest x-ray

Often picked up on CT chest

• Require intervention (drain) if intubation is required or patient

symptomatic

• Can be treated with observation and oxygen

 Recurrence Rate
Recurrence:
• PSP- The rate of recurrence is approximately 40 percent (range23 to 52percent).

Recurrence usually occurs within 1 to 2 years after the first episode(75% on the same side,10%
on the opposite side).

• Secondary Spontaneous Pneumothorax has a higher recurrence rate than Primary.

• The size or treatment of the original pneumothorax does not contribute for recurrence.
Re-expansion only Recurrence rate
Wait and see 30-50%
Aspiration 30-50%
Chest tube drainage 30-50%
Recurrence prevention
Pulmonary intervention:
Talc slurry 8%
Thoracoscopy/talc poudrage 5%
Surgical intervention
Open thoracotomy/pleurectomy 1%
VATS/pleurectomy 5%
1The estimated recurrence rate increases after every episode of spontaneous pneumothorax.2The recurrence rate
after talc slurry pleurodesis has not been well-assessed.

Management of Pneumothorax-Update with Emphasis on Interventional and

Minimally Invasive Procedures
 DISCHARGE ADVICE

• Return if sympytoms increase.

• No flying until completeresolutio
• Avoid sports until completeresolution No scubadiving
– Unless cleared to doso

– Undergone bilateral surgical pleurectomy, has normal lung function and chest
CT
• Stop smoking
– Increased risk of recurrence
 Air travel advice – BTS(September 2011)1

1. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations
British Thoracic Society Air Travel Working GroupSeptember 2011 Volume 66 Supplement 1
 Recommendation on diving-BTS 2003 guideline1
• Barotrauma: is caused by compression or expansion of gasfilled spaces
during descent or ascent,respectively
• Expansion of the lungs during ascent may cause lung rupture
leadingto pneumothorax, pneumomediastinum, and arterial gas
embolism.
Lung bullae or cysts increase risk of barotrauma and are contraindications todiving.1
Previous spontaneous pneumothorax is a contraindication unless treated by bilateral surgical
thoracotomy and pleurectomy and associated with normal lung function and thoracicCTscan
performed after surgery.1

Previous traumatic pneumothorax may not be a contraindication if healed and associatedwith

normal lung function, including flow-volume loop and thoracicCTscan1
[Link] Thoracic Society guidelines on respiratory aspects of fitness for diving British Thoracic Society Fitness to Dive
Group, a Subgroup of the British Thoracic Society Standards of Care Committee Thorax 2003;58:3–13
 Tension pneumothorax

• A tension pneumothorax is said to be present when the

intrapleural pressure exceeds atmospheric pressure
throughout expiration and often during inspiration
.
• risk factors
– Receiving positive-pressure mechanical ventilation
– During cardiopulmonary resuscitation
– Undergoing hyperbaric oxygen therapy
– Evolving during the course of spontaneous
pneumothorax
84
 Clinical manifestation

• Tension pneumothorax
– Distressed with rapid labored respiration
– Cyanosis
– Engorged neck veins
– Marked tachycardia
– Profuse diaphoresis
– Hypotension
– Hypoxemia
– mediastinal shift to the contralateral side
– unilateral chest hyperinflation 85
Tension pneumothorax

86
 Treatment
• When the diagnosis of a tension pneumothorax is considered,
the patient should be given a high concentration of oxygen to alleviate the
extreme hypoxemia.

• Radiographic documentation may not be possible in an emergency situation.

• Tension pneumothorax is a clinical diagnosis and therapy should not be held

up by confirmation of the chest radiograph.

• A large-bore (14G/ 4.5cm)needle should be inserted into the second anterior

intercostal space.

• Optimally the needle should be connected to a syringe partly filled with

sterile saline.

• Air bubbling outward through the fluid confirms the diagnosis.

• The needle should be left in place, and the patient should be prepared for
immediate tube thoracostomy.
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
 Reexpansion Pulmonary Edema

• Rexpansion pulmonary edema is characterized by development of unilateral

pulmonary edema in a lung that has been rapidly reinflated following a variable
period of collapse secondary to pleural effusion or pneumothorax.
 Reexpansion Pulmonary Edema

• The exact mechanisms are not known.

[Link] to increased permeability of the pulmonary vasculature.

[Link] alternate hypothesis is that reexpansion pulmonary edema is due

to a reperfusion injury .
 Clinical Manifestations
• Increased dyspnea , coughing or chest tightness during or
immediately following chest tube placement.

• Other symptoms include , tachypnea, tachycardia, fever, hypotension,

nausea, vomiting, and cyanosis.

• The symptoms progress for 24 to 48 hours, and the chest radiograph

reveals pulmonary edema throughout the ipsilateral lung.

• Pulmonary edema may also develop in the contralateral lung .

• The treatment of reexpansion pulmonary edema is primarily
supportive .

• with intravenous fluids

• oxygen

• Use of Diuresis is debatable.

Prevention:
stop the procedure if patient develop chest tightness,chest
pain,shortness of breath from their baseline.
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