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
Postoperative Patients; shifted from another invasive environment
Trauma; admitted to ICU
Penetrating Injury of Chest/ Abdomen
De Lassence et al Anesthesiology. 2006 Jan;104(1):5-13.
Incidence 1.4% on day 5 and 3.0% on day 30.
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
Ventilation; Incidence (4 to 15%).
Central venous catheter placement,
Iatrogenic / Traumatic
This refers to a condition in which the lung collapses with no apparent injury or trauma
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.
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
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
Central vein/pulmonary artery catheterization (40%)
Bronchoscopy /transbronchial lung biopsy (23%)
Pneumothorax; Central Venous Line
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
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.
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
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
Rapid labored breathing
Decreased breath sounds
Hyper resonance on percussion
Etiology of symptoms
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.
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%.
Resolve over days to weeks
Supplemental oxygen and observation
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 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.
Paucity of clinical data describing the prognostic factors associated with patient outcomes
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%.
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.
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