Transcript ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal Defined as the presence of air in the pleural cavity Negative intrapleural pressure: ~ 5mm PNEUMOTHORAX Spontaneous: 1.

ALOK SINHA
Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal
Defined as the presence of air in the pleural
cavity
Negative intrapleural
pressure: ~ 5mm
PNEUMOTHORAX
Spontaneous:
1. Primary spontaneous P.
2. Secondary spontaneous P.
Secondary:
Iatrogenic
traumatic
Primary spontaneous pneumothoraces
 Do not have overt parenchymal disease
 increased shear forces in the apex
 commonly are smokers & tall young males

risk much more pronounced in female
smokers
 Genetic factors - Marfan’s syndrome

Defect of connective tissue
High arched palate
Secondary spontaneous pneumothoraces
(SSP)
occur in the presence of lung disease
COPD
Tuberculosis
sarcoidosis
cystic fibrosis
malignancy
idiopathic pulmonary fibrosis
Sub pleural focus
rupturing in pleural cavity
Pneumocystis carinii pneumonia [PCP]) in patients with AIDS
Iatrogenic pneumothorax
a complication of medical or surgical procedures.
results from
Therapeutic thoracentesis
Positive pressure mechanical ventilation
Pleural biopsy
Central venous catheter insertion
Transbronchial biopsy
routine use of ultrasonography guided diagnostic
thoracentesis is associated with lower rates of
pneumothorax
Intra pleural pressure
(-)
Broncho pleural fistula
Intra pleural pressure
(0)
Intra pleural pressure
(+)
Symptoms:

Sudden onset (usually after a bout of coughing) of
Chest pain
dyspnoea

Asymptomatic when small
Signs:
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•
In sever cases low volume pulse with tachycardia
Collapse & signs of peripheral circulatory failure
Cyanosis
(See when there is tension pneumothorax)
Vitals are normal in closed & open pneumothorax
Inspection:
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Dyspnoea with accessory muscles active
Tracheal shift may be visible – trail’s sign
Fullness of chest on affected side
Diminished chest movement
Palpation:
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Trachea & medistinum shifted to opposite
side
Vocal fremitus – markedly diminished
Diminished expansion of affected hemithorax
Percussion:
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Hyper resonant note on the affected side
Liver dullness obliterated: right sided pneumothorax
Cardiac dullness shifted to opposite side
Auscultation
Vocal resonance reduced/absent
Breath sounds reduced/absent on affected side
 Hamman's sign: refers to a click on auscultation
in time with the heart sounds, due to movement of
pleural surfaces with a left-sided pneumothorax
In open pneumothorax
Amphoric breath sound due to broncho pleural
fistula may be heard
CXR -diagnostic in most cases


visible lung edge and absent lung markings
peripherally
increased lucency & hemidiaphragm depression on
the affected side
CXR appearance may also show features of
underlying lung disease
CT chest may be required
 To differentiate pneumothorax from
bullous disease
 Useful in diagnosing unsuspected
pneumothorax following trauma
 In looking for evidence of underlying
lung disease
Partial pneumothorax
Determined by
1. Degree of breathlessness & lung
2.
3.
4.
5.
collapse
Hypoxia
Evidence of haemodynamic compromise
Presence and severity of any underlying
lung disease
Pneumothorax size
Severe breathlessness out of proportion to
pneumothorax size may be a feature of
tension pneumothorax
Secondary pneumothorax has a significant
mortality (10%), and should be managed more
aggressively. Treat also the underlying
disease
Aspiration
Chest Aspiration
Chest Aspiration
Suction apparatus
Inserting a inter coastal drainage tube
1
2
3
4
5
Aspiration
Indications
Primary pneumothorax Consider aspiration if
patient breathless and/or
pneumothorax large (rim of air > 2 cm on CXR)
Secondary pneumothorax Consider aspiration
patient aged > 50 years (all cases)
with small pneumothorax (rim of air < 2 cm on
CXR)
minimal breathlessness
Chest drainage
Associated with significant morbidity and
even mortality due to subcutaneous
emphysema
not required in the majority of patients with
primary spontaneous pneumothorax
Oxygen
All hospitalized patients should receive
high flow (10 l/min) inspired oxygen
(unless CO2 retention is a problem)
Reduces the partial pressure of nitrogen in
blood, encouraging removal of air from the
pleural space and speeding up resolution
of the pneumothorax
Persistent air leak
Defined as continued bubbling of chest drain 48 hours
after insertion
In indicates:
Inability of lung to expand after the drainage
Broncho pleural fistula - communication with
out side air
Will develop secondary infection and pyopneumothorax
until closed by surgery
Out-patient follow-up
Repeat CXR to ensure resolution of
pneumothorax and normal appearance of
underlying lungs
Discuss risk of recurrence and emphasize
smoking cessation, if appropriate
Advise about flying
Patients should not fly for at least 6 weeks.
avoid flying for a longer period, e.g. 1 year
Advise NEVER TO DIVE in the future, unless
patient has undergone a definitive surgical
procedure
Indications for cardiothoracic
surgical referral
Second ipsilateral pneumothorax
Bilateral spontaneous pneumothorax
Persistent air leak (>5 -7 days of
drainage)
Spontaneous haemothorax
Professions at risk (e.g. pilots, divers)
after first pneumothorax
Chemical pleurodesis
As an alternative for surgery specially in case of
recurrent pneumothorax
seal the visceral to the parietal pleura to
prevent pleural fluid accumulating.
(already described previously)
Tension pneumothorax
Pneumothorax acts as a one-way valve
Progressive increase in pleural pressure
compresses both lungs and mediastinum
Reduced venous return to the heart,
leading to hypotension and cardiac arrest
not related to pneumothorax size can occur with very
small pneumothoraces in the context of air trapping in
the lung from obstructive lung disease
Patients present with
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Acute respiratory distress & agitation
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Hypotension
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Raised jugular venous pressure
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Tracheal deviation away from the
pneumothorax side
Reduced air entry on affected side
May present with cardiac arrest (pulseless electrical
activity)
Acute deterioration in ventilated patients
Management
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Give high-flow oxygen
Insert a needle into second intercostal space
in midclavicular line on side of pneumothorax
Do not wait for a CXR if cardiac arrest has
occurred or the diagnosis is clinically certain
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Hissing air confirms diagnosis. Aspirate air
until the patient is less distressed
Insert chest drain in mid axillary line
afterwards