Pneumothorax

Pneumothorax Defined

 Definition – 

“What?” “Pneumo” “Thorax” –

gas chest cavity   Analagous to Pleural Effusion Pathophysiology –

“How?

 Pleural space  Baseline (-) pressure space  Parietal Pleura  Visceral Pleura  Normal inspiration  Diaphragm  Transmit (-) Pressure  Pathologic inspiration  XS gas disrupts transmission of ( ) pressure

Types of Pneumothorax

 Spontaneous Pneumothorax  Primary - rupture of subpleural bleb 

“Jimmy is a tall, wiry, 21-year old male, who plays trombone in the marching band….”

 Secondary underlying lung/pleural disease  #1 – emphysema  Chronic bronchitis, asthma, TB, …  Traumatic Pneumothorax  Open  Chest wall is penetrated : outside air enters pleural space  Closed  Chest wall is intact Ex. Fractured rib

Types of Pneumothorax 2

 Tension Pneumothorax  “Ball-valve mechanism”   Injury to pleura creates a

tissue flap

that opens on inspiration and closes on expiration One of our own patients  Variations  Hemo-thorax  Chylo-thorax  Injury to thoracic duct  Empyema  Parapneumonic effusions in community acquired pneumonia

Symptoms

 Dyspnea  Pleuritic chest pain  Nerve endings at pleural capsule  Sense of impending doom  Sudden onset  Tension pneumothorax  Spontaneous pneumothorax

Physical Exam - Signs

 Unstable patients vs. Stable patients  Vital Signs  Asymmetric chest expansion  Deviated trachea  Diminished breath sounds unilaterally  Hyper-resonance unilaterally  Decreased tactile fremitus

Diagnosis

 Unstable patient 

Thoracentesis

 Rapid release of air  Vital signs stabilize rapidly  Stable patient 

CXR

 Monitor size by measuring distance from lateral lung margin to chest wall  Be sure that pneumothorax is not expanding

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 hemi diaphragm  Chest CT  Not routine  Only to assess the need for surgery (thoracotomy)

Treatment

 Small pneumothorax  Resolve over days to weeks  Supplemental oxygen and observation  Tension pneumothorax  Immediate decompression via chest tube or needle thoracostomy  Spontaneous pneumothorax    Asymptomatic – outpatient, f/u with serial CXR Symptomatic – inpatient, chest tube Recurrent pneumothorax – CT to evaluate need for thoracotomy

Tube Thoracostomy

 a.k.a. Chest tube