pneumothorax in ICU
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    pneumothorax in ICU pneumothorax in ICU Presentation Transcript

    • Pneumothorax in ICU
      • Dr Ashok Jadon, MD DNB
      • Sr. Consultant & HOD
      • Dept. of Anaesthesia
      • Tata Motors Hospital, Jamshedpur
    • Introduction
      • Pneumothorax; air in pleural space
        • Air can enter from the outside; injury penetrated the chest wall
        • Air can enter from inside, if the lung is torn or ruptured e.g. (pulmonary bleb).
      • Pneumothorax is the most common serious pleural complication in the ICU
      • Pneumothorax may be difficult to diagnose
        • when their locations are atypical,
        • when the patient has underlying cardiopulmonary disease
        • altered mental status
    • ICU pts : High Risk Group
      • Serious systemic disease
      • Hemodynamically unstable; Invasive Procedures
      • Ventilator/ Resuscitations
      • Postoperative Patients; shifted from another invasive environment
      • Trauma; admitted to ICU
        • Penetrating Injury of Chest/ Abdomen
        • # Rib
        • Resuscitation
        • Central Line
    • De Lassence et al Anesthesiology. 2006 Jan;104(1):5-13.
      • Incidence 1.4% on day 5 and 3.0% on day 30.
      • Risk factors
        • History of adult immunodeficiency syndrome
        • Diagnosis of acute respiratory distress syndrome
        • Cardiogenic pulmonary edema at admission
        • Central vein or pulmonary artery catheter insertion
        • Use of inotropic agents during the first 24 h
      Pneumothorax in the intensive care unit: incidence & risk factors,
    • Close Associations for high incidence
      • Disease; ARDS
      • Ventilation; Incidence (4 to 15%).
      • Procedures
        • Thoracentesis,
        • Central venous catheter placement,
        • Bronchoscopy
        • Pericardiocentesis
        • Tracheostomy
    • Types/ Etiology
      • Spontaneous
        • Primary
        • Secondary
      • Iatrogenic / Traumatic
      • Open/ Close
      • Tension Pneumothorax
    • Spontaneous Pneumothorax
      • This refers to a condition in which the lung collapses with no apparent injury or trauma
        • Pulmonary blebs
        • COPD; Emphysematous Bullae
        • AIDS/ Lung Tumor
        • Infective or Infiltrative Lung Disease
      • Cigarette smokers & Recreational drug users are at greater risk for spontaneous pneumothorax.
    • How Mechanical Ventilation Responsible for Pneumothorax ?
    • Biotrauma Barotrauma and Volutrauma Atelectrauma
    • Barotrauma and Volutrauma
      • Ventilator-induced lung injury by high levels of mechanical stress and strain that occur when high airway pressures ( Barotrauma) and high volumes (Volutrauma) are delivered .
      • This stress and strain can disrupt the pulmonary fibroelastic skeleton and trigger a secondary inflammatory response.
      • Atelectrauma
        • Moderate degrees of stress and strain related to the cyclic opening and closing of parts of the lung may directly induce the release of inflammatory mediators and noxious proteinases.
    •  
    • Relationship between ventilatory settings and barotrauma in the ARDS
      • incidence of barotrauma 0% to 49%,
      • High incidence correlated strongly
        • P(plat), above 35 cm H2O,
        • Compliance below 30 ml/cm H2O
      • Aspiration Pneumonia
        • In a prospective study 38 percent of patients developed pneumothorax and pneumo-mediastinum.
      Mohamed Boussarsar Intensive Care Med. 2002 ;28 (4):406-13.
    • Pneumothorax Traumatic/ Procedure related
      • Direct trauma to the chest wall from either blunt or penetrating trauma causes this condition
      • Thoracentesis (54%)
      • Central vein/pulmonary artery catheterization (40%)
      • Bronchoscopy /transbronchial lung biopsy (23%)
    • Pneumothorax; Central Venous Line
      • Internal jugular,
      • subclavian, or
      • Femoral Vein
      • There is no difference in the rates of pneumothorax for internal jugular versus subclavian vein placement
      Ruesch S, Walder B, Tramer M. Complications of Central Venous Catheters: Internal Jugular versus Subclavian access-A Systematic Review. Crit Care Med. 2002;30:454-60.
    • Pneumothorax after insertion of central venous catheters in the intensive care unit: association with month of year and week of month
      • Highest in July and August and in the first week of the month (beginning of intensive care unit (ICU) rotation).
      • The rate of PTX after insertion of CVCs is greatest in the last week of the month(2.7%) than during the first, second or third weeks (1.7%, 1.8% and 1.4%, respectively).
      Najib T Ayas- Quality and Safety in Health Care 2007; 16 :252-255
    • Symptoms
      • Sharp, stabbing chest pain that worsens on breathing or with deep inspiration. Pain often radiates to the shoulder and or back
      • A dry, hacking cough may occur because of irritation of the diaphragm.
    • Tension Pneumothorax
      • When the pleural pressure is positive throughout respiratory cycle
      • “ Ball-valve mechanism”
      • Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration
    • Epidemiology
      • Kolef reviewed 464 ICU patients
        • 28 (6%) developed pneumothorax
        • 9 patients missed the initial diagnosis
        • 3 (33%) developed tension pneumothorax
        • In diagnosed 19 patients only 1 (5%) develop pneumothorax
      • Tocino & coworkers
        • Missed pneumothorax 34/112 (30%)
        • 16/34 patients developed tension pneumothorax
    • Clinical picture
      • Distressed
      • Rapid labored breathing
      • Cyanosis
      • Profuse diaphoresis
      • Marked tachycardia
      • Hypotension
      • Decreased breath sounds
      • Hyper resonance on percussion
    • Etiology of symptoms
      • Hypoxia
        • Decreased PaO2
        • Perfusion of atelectatic lung
      • Decrease venous return
        • increase intrathoracic pressure
        • Decreased CO & SV
    • Investigations A A A A A
    • Hallmark: air between two pleural spaces
      • Why they are missed?
      • Unfortunately, it is difficult to make a radiographic diagnosis of a pneumothorax on portable x-ray films taken in the ICU setting.
      • X-ray Upright-air in Apex
      • X-ray In ICU; supine , semi supine
      • In addition, concurrent lung disease may lead to different distributions of free air in the pleural space than in patients with relatively normal lungs.
    • Distribution of air
    • Always look for….
      • Subtle radiographic signs of pneumothorax
      • Relative hyperlucency over the upper abdominal quadrants
      • Deep costophrenic angle (the deep sulcus sign)
    • Role of Ultrasound in Diagnosis
      • Disappearance of "lung sliding" was observed in 100%
      • In this series, sensitivity was 95.3%, specificity 91.1%, and negative predictive value 100% (p<0.001).
      • Conclusions: Ultrasound was a sensitive test for detection of pneumothorax, although false-positive cases were noted. The principal value of this test was that it could immediately exclude anterior pneumothorax.
    • CT Thorax
    • Pneumothorax Prevention during CVCs
      • Remove patient from ventilator before advancing the needle.
      • Choose the right side rather than left,
      • Avoid multiple attempts when possible
      • Check post procedure x-ray,
    • Ultrasound Guided CVCs
      • Success with ultrasound guidance was 100%, compared with 88% when ultrasound was not used.
      • incidence of carotid puncture was reduced from 8.3% to 1.7%.
    • Treatment
      • Small pneumothorax
        • Resolve over days to weeks
        • Supplemental oxygen and observation
      • Spontaneous pneumothorax
        • Asymptomatic –f/u with serial CXR
        • Symptomatic –chest tube
        • Recurrent pneumothorax – CT to evaluate need for thoracotomy
    • Tension pneumothorax; Treatment
      • Pneumothorax can be life-threatening.
      • The immediate treatment is tube thoracostomy, or the insertion of a chest tube.
      • Chest tubes are generally inserted using local anesthesia.
      • The chest tube is left in place until the lung leak seals on its own; this usually occurs within two to five days.
    • Thoracostomy (Chest tube)
    • Pulmonary blebs
      • Pulmonary blebs can be resected, preventing future pneumothorax.
      • Thoracoscopic surgical procedure.
      • A stapling device is inserted into the chest during, and the segment of lung with blebs is stapled across and then removed
    • complications of air of pleural parenchyma
      • Sub-pleural air cysts ;
        • Secondary infections in the cysts, Pseudomonas sepsis & death.
      • Systemic Gas Embolism
        • It is possible for extra-alveolar air to enter the systemic circulation if there is a bronchovenous communication and an adequate pressure gradient.
    • Prognosis
      • Paucity of clinical data describing the prognostic factors associated with patient outcomes
    • Prognosis
      • Seven patients (12%) had to undergo external suction and pleurodesis for persistent air leaks.
      • Five patients still had air leaks, and the chest tube was not removed during their ICU stay.
      • The mean duration of ICU stay was 24 ± 19 days (median, 17.5 days).
      • The mean duration of chest tube drainage was 10 ± 11 days (median, 6 days).
      • The mortality rate for patients with pneumothorax was 68%.
    • Prognosis contd..
      • Patients with procedure-related pneumothorax had a lower risk of mortality.
      • Patients who had tension pneumothorax and concurrent septic shock had a higher risk of mortality.
      • pneumothorax due to barotrauma, tension pneumothorax, and concurrent septic shock were significantly and independently associated with death.
    • Conclusion
    •  
    • Twist in Tale..
    • CXR with recurrent right-sided pneumothorax, despite thoracostomy tube in place CT scan with giant bullae and anterior pneumothorax after insertion of a second thoracostomy tube
    • Message
      • Put Chest Drain; Be Happy
      • But, Be Observant and Do Follow -Up
      • Not only Till Patient Go Home
      • Later on too.
    • Thank You