Transcript Diagnosis and Treatment of Pneumothorax Souheil M. Abdel Nour, MD Moderator: Thomas Roy, MD Pulmonary and Critical Care East Tennessee State University.

Diagnosis and Treatment of
Pneumothorax
Souheil M. Abdel Nour, MD
Moderator: Thomas Roy, MD
Pulmonary and Critical Care
East Tennessee State University
Disclosure Statement of Financial Interest
 I DO NOT have a financial
interest/arrangement or affiliation with one or
more organizations that could be perceived as a
real or apparent conflict of interest in the
context of the subject of this presentation.
Definitions
• Primary Spontaneous Pneumothorax (PSP)
• No underlying lung disease
• Secondary Spontaneous Pneumothorax (SSP)
• Complication of underlying lung disease
• Traumatic Pneumothorax
• Caused by penetrating and or blunt trauma
• Iatrogenic Pneumothorax
• Complication of diagnostic or therapeutic intervention
Prognosis
 Prognosis varies among the pneumothorax




classifications
Recurrence rate is about 28% for PSP and 43% for
SSP over a period of 5 years.
Mortality rate of 1-17% in patients with COPD
5% of patients with COPD died before a chest tube
was placed
Patients with AIDS: inpatient mortality rate of 25%
and a median survival of 3 months after the
pneumothorax.
Difficult Decisions in Thoracic Surgery: An Evidencebased Approach, By Mark K. Ferguson. 2nd ed. 2011
Prognosis
The overall mortality was
1.26 per million per year
for males and 0.62 per
million per year for
females.
Epidemiology of pneumothorax in England.Gupta D, Hansell A, Nichols T, Duong T,
Ayres JG, Strachan D. Thorax. 2000 Aug; 55(8):666-71.
Primary Spontaneous Pneumothorax (PSP)
 No precipitating event
 No known lung disease
 Actually most PSP have unrecognized lung disease
(subpleural bleb)
 The incidence: men 7.4 (USA) - 37 (UK) per 100,000 population per year
 Women << men, 1.2 (USA) – 15.4 (UK) per 100,000 population per year
Matching?!
1.
2.
3.
4.
5.
Pneumatocoele
Cavity
Cyst
Bleb
Bulla
a)
b)
c)
d)
e)
Thin-walled (< 1mm), gas-filled
space in the lung developing in
association with acute
pneumonia
Intrapleural cystic space
Thin-walled, air- or fluid-filled,
with a wall that contains
respiratory epithelium, cartilage,
and smooth muscle
Thin-walled(<1 mm), contained
within the lung ,1 cm in size
when distended-Walls may be
formed by pleura, septa, or
compressed lung tissue
Gas-containing space in the lung
having a wall > 1 mm thick
Air-containing Structures
 Pneumatocoele: Thin-walled (< 1mm), gas-filled space in the lung
developing in association with acute pneumonia, such as staph, and
frequently transient
 Cavity: Gas-containing space in the lung having a wall > 1 mm thick
 Cyst: Thin-walled, air- or fluid-filled, with a wall that contains
respiratory epithelium, cartilage, smooth muscle and glands
 Bleb: Intrapleural cystic space
 Bulla ≥2 bullae (pronounced bully): Thin-walled(<1 mm),
contained within the lung ,1 cm in size when distended-Walls may
be formed by pleura, septa, or compressed lung tissue
Which of these is NOT associated with
an increased risk of recurrence?
Male gender
2. Tall stature in men
3. Low body weight
4. Failure to stop smoking
1.
Recurrence of primary spontaneous pneumothorax.
• Retrospective study of 275 episodes
of PSP in 153 patients over a four year
period
• Incidence of recurrence (54.2%)
• PSP was twice as common in men
• Women were significantly more
likely to develop a recurrence
• Male height was the second most
important factor
• Smoking cessation the only variable
which significantly influenced the risk
of recurrence
Thorax. 1997;52(9):805
Increased incidence of PSP
 Birt-Hogg-Dube syndrome
 Marfan syndrome
 Homocystinuria
 Catamenial pneumothorax (PSP temporally related
to menstruation)
 Anorexia nervosa
Which of the following is Not seen on
physical exam?
1. Diminished breath sounds, absent fremitus,
and hyperresonance to percussion on the
affected side.
2. Decreased chest excursion on the opposite
side
3. Subcutaneous emphysema may be present.
4. Tracheal deviation from the midline is a rare
and typically
late finding in pneumothorax
.
Physical Exam!!!
 Place your hands on the patient's
back with thumbs pointed
towards the spine. Your hands
should lift symmetrically
outward when the patient takes a
deep breath.
 Processes that lead to asymmetric
lung expansion, as might occur
when anything fills the pleural
space (e.g. air or fluid), may then
be detected as the hand on the
affected side will move outward
to a lesser degree
Typical Clinical Presentation
 Occurs at rest
 Early 20s (rarely after age 40)
 Sudden onset of dyspnea and pleuritic chest pain
 Decreased chest excursion on the affected side, diminished breath
sounds, and hyperresonant percussion
 +/- Subcutaneous emphysema
 Labored breathing + hemodynamic => tension PTX
• Hypoxemia is common
• hypercapnia is unusual
• Acute respiratory alkalosis
Tension Pneumothorax
Evidence Based Medicine
 Supine and lateral XR: trauma Pts- less sensitive
 Expiratory films: no additional benefit
 US: supine trauma
 CT : ‘gold standard’ (small PTX/size estimate)
Underestimate or overestimate?!
USA: over- vs. UK: underestimate
 Guidelines from the USA
(ACCP-Chest 2001)
overestimate the volume in
a localised apical
pneumothorax.
Which of the following is the right answer?
The O2 does not help if the patient is not hypoxic
2. It helps symptomatically but it delays the resorption of
the pleural air
3. No effect on the resorption of the pleural air
4. The rate of resorption can be markedly increased if
supplemental oxygen is administered
1.
Normal rate of resorption is approximately
1.25% of the volume of the hemithorax per 24
hours. However, the rate of resorption
increases six-fold if humidified 100 percent
oxygen is administered!
Secondary Spontaneous
Pneumothorax (SSP)
Secondary Spontaneous Pneumothorax (SSP)
 COPD is the most common cause of SSP, ~50- 70%
 Severity of COPD correlates with likelihood of SSP
 Cystic fibrosis:
 3 to 4% of all patients with CF will have an episode of SSP
 Primary and metastatic lung malignancy (COPD often co



exists)
Necrotizing pneumonia
Pneumocystis jirovecii
Tuberculosis
Catamenial pneumothorax
MATCHING
COPD
2. CF
3. PCP
4. TB
1.
1-b
2-a
3-d
4-c
Rupture of apical
subpleural cysts
b. Rupture of apical blebs
c. Rupture of a cavity into
the pleural space
d. Alveolar and pleural tissue
invasion and rupture of
large subpleural cysts that
are caused by tissue
necrosis.
a.
Less common causes of SSP
 Histiocytosis X
 Interstitial lung disease
 Lymphangioleiomyomatosis
 Metastatic sarcoma
 Sarcoidosis
Clinical Presentation
Depends upon:
Symptoms:
 Volume of air
 Dyspnea
 Rapidity of onset
 Chest pain
 Tension within the
 More severe than PSP
pleural space
 Age and respiratory
reserve
 Infectious cause of SSP
may have cough, fever,
chills, or fatigue!
Could it be a routine CXR? Y/N
Small bore catheters can be safely used in
all the following cases of SSP except?
PTX in a pt with advanced emphysema
2. In COPD with AE.
3. Pts receiving mechanical ventilation
4. Iatrogenic PTX (s/p FNA*)
1.
Thoracostomy tube size in SSP
 Small bore catheters have advantages over larger tubes
 Ease of insertion
 Patient comfort
 Equally efficacious in most patients in retrospective studies
 One possible exception to the use of small bore tubes for
SSP would be patients receiving mechanical ventilation.
 Large bore tubes (24 to 28 fr) in patients receiving
mechanical ventilation
Pigtail catheters vs large-bore chest tubes for management of
secondary spontaneous pneumothoraces in adult
Am J Emerg Med. 2006 Nov;24(7):795-800.
Chest Tube Management
 Water seal device is preferable
 No suction due to the risk of RPE
 Failure of PTX to resolve => suction if it was not initially
applied.
 Keep the chest tube until a procedure is performed to
prevent recurrent SSP
 Pt declines preventive interventions => clamp tube 12hrs
after the lung has expanded radiographically and no
further air leak is detected via the chest tube.
Heimlich Valve
 Stable patients & >90%
expanded, but + air leak =>
Heimlich Valve and
discharge
 Advantage: avoid a longterm hospitalization
 However, a separate
procedure to prevent a
recurrent SSP is typically
performed in patients who
are surgical candidates
Persistent air leakage
 More common and persist longer in SSP
 Persistent air leaks may be due to subpleural bullae
or cysts or to necrotic lung
 Air leak > 3 days => spontaneous closure is less
likeley and need additional interventions
Persistent air leakage
VATS or open thoracotomy
Blood patch or chemical
pleurodesis
 For surgical candidates
 Not candidates for surgery
 Persistent leak and/or
 Pleural blood patch: persistent
incomplete expansion (<90%)
 Preferred procedure is stapling or
resection of blebs + mechanical
pleurodesis
air leak complicating ARDS
 Chemical pleurodesis via chest
tube-tetracycline derivative or
talc
 Success is much lower than
with VATS
Conservative management: Spontaneous resolution has been described with
conservative management after as long as 14 days
Preventing recurrence
 Recurrence of SSP is common and life-threatening
 50% recurrent SSP over 3 years among patients with a SSP due
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to COPD
Intervention in almost all patients treated for an initial SSP
(even if with full re-expansion and no evidence of persistent
air leak)
Intervention=control the leak + prevent recurrence
(pleurodesis)
Performed within 3 to 5 days of hospitalization
3 options: thoracotomy, VATS and chemical pleurodesis.
Recurrence rates of video-assisted
thoracoscopic versus open surgery
in the prevention of recurrent
pneumothoraces:
a systematic review of randomised and nonrandomised trials.
Lancet. 2007 Jul;370(9584):329-35.
Surgical options: open thoracotomy vs. VATS
 Lower recurrence rates with open procedures (1 % vs. 5%
with VATS)
 Greater blood loss, more postoperative pain, and longer
hospital stays with open thoracotomy
 Preferred intervention in most patients: VATS with stapling of
blebs followed by obliteration of the pleural space
 Emphysema + meet inclusion and exclusion criteria for
LVRS=> LVRS at the same time
Nonsurgical chemical pleurodesis
 For patients who refuse VATS or are not operative
candidates=> chemical pleurodesis (better than no
further intervention)
 Not as effective as the VATS
 Reduces the SSP recurrence to ~ 15 %
 Choice of a sclerosant is controversial
Am J Respir Crit Care Med. 2000;162(6):2023.
Other potential questions!!
Lung transplant candidates
Air travel
 Avoid chemical
 Air travel is postponed
pleurodesis
 It does not preclude
future lung
transplantation
 VATS-apical
pleurodesis.
for at least two weeks in
PSP.
 In SSP ? not known.
 Simple drainage vs.
pleurodesis influences
the risk of recurrence
 Potential in-flight
hypoxemia.
Tube Thoracostomy Management
Some physiology!!
 The mechanics of ventilation relate to the negative
intrathoracic pressure that draws air into the lungs during
spontaneous respiration.
 This negative pressure is best maintained in the pleural
space.
 Collections of air, fluid, or blood in the pleural space not
only compress the lung tissue but also cause the pleural
pressures to become positive, causing inappropriate
ventilation!
How Chest Tubes Work?!
 Chest drainage systems work by combining the
following 3 efforts:
Expiratory positive pressure from the patient helps
push air and fluid out of the chest (eg, cough,
Valsalva maneuver).
2. Gravity helps fluid drainage as long as the chest
drainage system is placed below the level of the
patient’s chest.
3. Suction can improve the speed at which air and fluid
are pulled from the chest
1.
Few points!!
 Contraindications
 No absolute contraindications exist for chest drain insertion.
 Radiography
 Serial chest radiographs are needed to monitor and confirm the
expansion of the lung.
 Antibiotics
 Antibiotics are not needed during the presence of a chest drain
for a simple pneumothorax or hydrothorax.
 The antibiotic cephalexin can be used to prevent the
development of an empyema when a chest drain has been used in
thoracic trauma.
Positioning: Emergent and elective chest drains
are usually placed in the triangle of safety
 The “safe triangle” is the
area bordered by the
anterior border of the
latissimus dorsi, the lateral
border of the pectoralis
major muscle, a line
superior to the horizontal
level of the nipple, and
apex below the axilla
Drainage System: underwater Seal Bottle
 The underwater seal bottle is the most
important element in pleural drainage.
 Low -resistance, one-way valve.
 The underwater seal is an anti-reflux
valve.
 Water can be drawn up the tube only to
the height equal to the negative
intrathoracic pressure (usually up to -20
cm of water).
Drainage System :Trap Bottle
 When excessive fluid drains from the
chest, the level of fluid in the underwater
seal is raised. This increases resistance to
further outflow of fluid from the chest.
 To decrease this resistance, a trap bottle is
introduced between the chest tube and the
underwater seal.
Drainage System: suction Regulator Bottle
 To obtain a suction of -20 cm of
water, set the tip of the tube 20 cm
below the surface of the fluid. Now,
increase the vacuum gradually until
air bubbles gently and constantly
through the atmospheric vent in the
water during both phases of
respiration.
 The role of suction is now being
debated. Some schools of thought say
suction delays the sealing of air leaks
from the underlying lung
Multifunction Chest Drainage System
 Follow the manufacturer’s
instructions for adding water to
the chambers.
 This is usually 2 cm in the water
seal chamber and 20 cm in the
suction control chamber.
 Slowly increase vacuum until
gentle bubbling appears in the
suction control chamber.
Pearls!
 The collection chamber should be kept below the level of the
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


patient’s chest at all times.
Absence of fluid oscillations may indicate obstruction of the
drainage system by clots or kinks, loss of subatmospheric pressure,
or complete reexpansion of the lung.
Persistent bubbling indicates a continuing bronchopleural air leak.
Clamping a pleural drain in the presence of a continuing air leak
results in a tension pneumothorax.
Clamp tubes only for procedures related to the tube or bottle (eg,
to change the tube or bottle, to empty the bottle, to reconnect an
accidental disconnection of the tube at any of the joints).
Troubleshooting chest drain management
 Column is not oscillating:
 Tube has been blocked
 Restore patency by squeezing, milking, and even
flushing the drainage tubing
 Restoration of patency= respiration-related swing in
the draining tube
 Tubes got disconnected:
 Not a great disaster!
 Reconnect the tubes and ask the patient to cough
Troubleshooting chest drain management
 Leak around the tube:
 First r/o partial block in the draining system
 A single suture may need to be placed along the side of
the tube to narrow the wound and seal the leak
 Use of tapes and heavy dressings to occlude such leaks is
not useful
 Underwater seal bottle broken:
 A broken bottle has to be replaced immediately
 Then ask the patient to cough.
Chest Drain Complications
 Blocked tube due to poor positioning:
 Trapped in the major fissure of the lung
 Tube needs to be withdrawn and reinserted
 Cardiac dysrhythmia:
 The tube abut the mediastinum
 Try withdrawing the tube 2-3 cm.
 If this does not resolve the problem=> reinserted at a
separate location.
Chest drain complications
 Persistent pneumothorax:
 Clear any obstructions and seal any leaks in the
drainage system.
 If no leak or obstruction is found, apply suction of up
to -20 cm of water to the drainage system.
 Infections:
 Range from wound infection to empyemas.
 Reflect breaks in sterility and incorrect management of
the chest drain.
 Re-expansion pulmonary edema:
 Large effusions are drained in a short period of time
 Prevented by gradual decompression
Failure of the lung to fully reexpand
(rarely due to blockage of the tubes)
Bronchial blockage
 Collapse , usually by
retained sputum
 Fiberoptic bronchoscopy
helps clear secretions and
rule out other causes of
bronchial obstruction [eg,
tumor]
Fibrinous "peel" (cortex)
over the lung
 Thickened visceral pleura
over the collapsed lung
tissue
 Delayed treatment of an
empyema
 Decortication
http://www.surgicalcriticalcare.net/Guide
lines/chest_tube_2009
Thank You