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Diseases of Pleura  Dr Yog Raj Khinchi
Pleural Effusion
Pleural effusion: Introduction• Collection of excess quantity of fluid in pleural space• Inflammatory or non inflammatory ...
Pleural effusion: Classification• Transudates: due to diseases that affect the  filtration of pleural fluid- CHF & hypopro...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural Effusion fluid         Tests            Transudate       Exudates     Exudates                                    ...
Pleural effusion: Causes•   Bacterial pneumonias - Most common•   TB, CCF, Hypoproteinemia•   Obstruction to lymphatic dra...
Pleural effusion: 3 Types1. Dry or plastic pleurisy2. Serofibrinous or serosanguineous pleurisy3. Purulent pleurisy or emp...
1. Dry pleurisy or plastic pleurisy  Associated with• Acute bacterial infections• Tuberculosis• Connective tissue disorder...
Dry pleurisy: Pathology• Involvement of visceral pleura with small amount of  yellow serous fluid• Adhesion between pleura...
Dry pleurisy: Clinical manifestations• Signs & symptoms of primary disease• Dull pleural pain, exaggerated by deep  inspir...
Dry pleurisy: Treatment• Treat underlying condition• If pneumonia is not present- strapping of chest to  restrict expansio...
2. Serofibrinous pleurisy• Infections of lungs• Inflammatory conditions of mediastinum• Less commonly with- SLE, RF, neopl...
Serofibrinous pleurisy: Clinical features• Initially signs and symptoms of dry pleurisy• Asymptomatic if effusion is small...
Serofibrinous pleurisy: Clinical features...• In infants- bronchial breath sounds instead of absent  breath sounds• Fricti...
X-ray chest: Pleural Effusion
Serofibrinous pleurisy: Treatment• Treat underlying cause• Thoracocentesis, up to 1 Liter of fluid• Tube thoracostomy in o...
3. Purulent pleurisy / Empyema• Pus or microorganism in pleural fluid• Microorganism- by smear or culture  In the absence ...
Empyema: Predisposing factors•   Pneumonia in ½ of cases•   Preceding H/O of pustules•   Blunt trauma to chest/surgery/tho...
Empyema: Etiology•   Staphylococcus aureus, epidermidis•   Streptococcus pneumoniae, viridans•   H influenzae•   Pseudomon...
Stages of Empyema• Exudative (1 to 3 days):  parapneumonic effusion• Fibrino purulent (4 to 14 days):  polymorpho nuclear ...
Empyema: Exudative stage•   Fluid is thin•   Cellular content is low•   Lungs are expandable•   Pleural fluid- pH >7.3, gl...
Empyema: Fibrino purulent stage• pH and glucose level fall, LDH rises• Purulent and vicious, accumulation of neutrophils  ...
Empyema: Organizing stage• Thick pleura prevent entry of anti microbial drugs in  the pleural space- drug resistance• Rest...
Empyema: Clinical features• Common in poor socioeconomic group• Peak incidence 0-3 years• Chills, fever, dyspnoea, chest p...
Empyema: Clinical features...• Large fluid- fullness of intercostal spaces, diminished  chest excursions• Shift of mediast...
Empyema: Investigation & Diagnosis• History and examination findings• Confirm the presence of empyema, etiological agent  ...
Empyema: Investigation...• USG- confirms, for thoracocentesis, pleural catheter  placement, transudates anechoic, exudates...
Empyema: Aspirate Investigation• Aspirate- Cell count and differential, Grams stain, culture,  pH, protein, glucose, LDH, ...
Empyema: Treatment  Aims• Control infection• Drainage of pus• Expansion of lungs
Empyema drainage• Inter costal drainage (ICD), under water seal, large  catheter inserted in the site of pus accumulation•...
Empyema: Inter Costal Drainage (ICD)
Empyema: X-Ray chestBefore & After Inter costal drainage (ICD)
Empyema: Antimicrobial therapyOrganism         Drugs         Alternate    Duration Staph     Clox + Amino      3rd gen Cep...
Empyema: Treatment...• Based on culture and sensitivity• Monotherapy not recommended• In anerobic infection- Clindamycin: ...
Empyema: Thrombolytic therapy• Multiloculated empyema by thoracostomy tube• Streptokinase 2,50,000 unit or urokinase 1,00....
Empyema: Surgical therapy• Remains febrile and dyspnoeic after IV antibiotics  and thorcostomy drain• Pleural thickening- ...
Empyema: Complications•   Bronchopleural fistula•   Cutaneous fistula•   Pyopneumothorax•   Purulent pericarditis•   Pulmo...
Empyema: Prognosis• In adequately treated cases prognosis is excellent• Follow up pulmonary functions suggest that residua...
Pyopneumothorax
Pneumothorax• Presence of gas in the  Pleural space
Pneumothorax: Classification• Spontaneous pneumothorax  Primary , Secondary• Traumatic pneumothorax• Iatrogenic pneumothor...
Traumatic PneumothoraxClosed            Open
Pneumothorax: Causes• Rupture of pleural blebs   • Transthoracic aspiration• Penetrating or non           needle  penetrat...
Clinical Signs & Symptoms• Severity depends on the extent of the lung collapse.• Simple pneumothorax - asymptomatic or che...
Tension Pneumothorax: Signs/Symptoms• Clinical Presentation - Chest pain (90%), Dyspnea  (80%), Anxiety, Fatigue• Physical...
Tension Pneumothorax  Lung parenchymal or    bronchial injury    one-way valve      air trapping  mediastinal structures  ...
Pneumothorax: Differential Diagnosis•   Bronchogenic Cyst•   Congenital Lung Malformations•   Cystic Adenomatoid Malformat...
Investigations• Chest X-ray• Pulse oxymetry : SpO2• Arterial blood gas: arterial pO2
Pneumothorax: Treatment  Without continued air leak, asymptomatic and mildly  symptomatic small pneumothorax• 100% oxygen•...
Tension Pneumothorax: Treatment• Severe respiratory and circulatory embarrassment• Emergency Needle aspiration• Either imm...
Decompression by Needle / ICD• 2nd intercostal space on the mid clavicular line• Upper border of the lower rib• Needle / I...
Indications for ICD1.   Pneumothorax2.   Hemothorax3.   Hemopneumothorax4.   Tension pneumothorax5.   Empyema6.   Chylotho...
X-ray Pneumothorax: Before Treatment
X-ray Pneumothorax: After Treatment
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5 diseases of pleura

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Transcript of "5 diseases of pleura"

  1. 1. Diseases of Pleura Dr Yog Raj Khinchi
  2. 2. Pleural Effusion
  3. 3. Pleural effusion: Introduction• Collection of excess quantity of fluid in pleural space• Inflammatory or non inflammatory causes
  4. 4. Pleural effusion: Classification• Transudates: due to diseases that affect the filtration of pleural fluid- CHF & hypoproteinemia• Exudates: inflammation or injury increases pleural membrane permeability to proteins and various types of cells
  5. 5. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lympho Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  6. 6. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  7. 7. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy <1000 >1000 >5000 PMN Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  8. 8. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  9. 9. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  10. 10. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  11. 11. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  12. 12. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Turbid yellowMicroscopy No Cells Predominantly Pus cells LymphocytesPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.2 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  13. 13. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  14. 14. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  15. 15. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  16. 16. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho /M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  17. 17. Pleural Effusion fluid Tests Transudate Exudates Exudates (tubercular) (Empyema)Physical appearance Clear Straw coloured Cloudy / TurbidMicroscopy <1000 >1000 >5000 PMNs Lympho/M Lymphocytes Pus cellsPleural fluid protein < 3 gm/dl >3 gm/dl >3 gm/dlPleural fluid Protein / <0.5 >0.5 >0.5Serum proteinPleural fluid LDH / <0.6 >0.6 >0.6Serum LDHPleural fluid pH >7.3 <7.3 <7.2Pleural fluid glucose >40 mg/dl <40 mg/dl <40 mg/dl
  18. 18. Pleural effusion: Causes• Bacterial pneumonias - Most common• TB, CCF, Hypoproteinemia• Obstruction to lymphatic drainage• Collagen vascular disease• Malignancies, Rheumatoid arthritis• Aspiration pneumonia, traumatic• Pulmonary embolism, chylothorax
  19. 19. Pleural effusion: 3 Types1. Dry or plastic pleurisy2. Serofibrinous or serosanguineous pleurisy3. Purulent pleurisy or empyema
  20. 20. 1. Dry pleurisy or plastic pleurisy Associated with• Acute bacterial infections• Tuberculosis• Connective tissue disorders- rheumatic fever
  21. 21. Dry pleurisy: Pathology• Involvement of visceral pleura with small amount of yellow serous fluid• Adhesion between pleural surfaces• Pleural thickening• Fibrothorax due to fibrin deposition and severe adhesions
  22. 22. Dry pleurisy: Clinical manifestations• Signs & symptoms of primary disease• Dull pleural pain, exaggerated by deep inspiration,cough, straining, referred to shoulder and back• Increased dullness on percussion and decreased breath sounds• Leathery, rough inspiratory and expiratory friction rub early in the disease• X-ray- haziness at the pleural surface or a dense, sharply demarcated shadow
  23. 23. Dry pleurisy: Treatment• Treat underlying condition• If pneumonia is not present- strapping of chest to restrict expansion and analgesics• Strapping and cough suppressants not given if pneumonia is present
  24. 24. 2. Serofibrinous pleurisy• Infections of lungs• Inflammatory conditions of mediastinum• Less commonly with- SLE, RF, neoplasms
  25. 25. Serofibrinous pleurisy: Clinical features• Initially signs and symptoms of dry pleurisy• Asymptomatic if effusion is small• Large effusion: cough, dyspnoea, retractions, orthopnoea, cyanosis• Shift of mediastinum away from affected side, fullness of intercostal space, diminished tactile vocal fremitus• Dullness to flatness on percussion• Decreased or absent breath sounds
  26. 26. Serofibrinous pleurisy: Clinical features...• In infants- bronchial breath sounds instead of absent breath sounds• Friction rub in the early stages• X-ray: homogenous opacity obliterating the normal pulmonary marking, obliteration of costophrenic angles and widening of interlobar fissure
  27. 27. X-ray chest: Pleural Effusion
  28. 28. Serofibrinous pleurisy: Treatment• Treat underlying cause• Thoracocentesis, up to 1 Liter of fluid• Tube thoracostomy in older child with parapneumonic effusion if pleural fluid pH<7.2 or glucose <50mg/dl
  29. 29. 3. Purulent pleurisy / Empyema• Pus or microorganism in pleural fluid• Microorganism- by smear or culture In the absence of these:• pH of pleural fluid < 7.2• Lactic dehydrogenase (LDH) >1000IU/L• Glucose <than 40mg/dl• Lactate > 45mg/ml
  30. 30. Empyema: Predisposing factors• Pneumonia in ½ of cases• Preceding H/O of pustules• Blunt trauma to chest/surgery/thoracocentesis• Viral infections (chickenpox, measles)• Severe malnutrition• Neglected foreign body• Extension from subphrenic, amoebic liver abscess• CHD• Peridontal disease, steroid, immunodeficiency
  31. 31. Empyema: Etiology• Staphylococcus aureus, epidermidis• Streptococcus pneumoniae, viridans• H influenzae• Pseudomonas aeroginosa• E coli• Klebsiella aerogenes• Mycobacterium tuberculosis• Fungal/ EH (rare)
  32. 32. Stages of Empyema• Exudative (1 to 3 days): parapneumonic effusion• Fibrino purulent (4 to 14 days): polymorpho nuclear & fibrin accumulation• Organizing stage (after 14 days): fibroblasts grow and producing an inelastic membrane
  33. 33. Empyema: Exudative stage• Fluid is thin• Cellular content is low• Lungs are expandable• Pleural fluid- pH >7.3, glucose >60mg/dl, pleural fluid /serum glucose ratio >0.5, LDH < 1000 IU/L, Gram stain and culture negative
  34. 34. Empyema: Fibrino purulent stage• pH and glucose level fall, LDH rises• Purulent and vicious, accumulation of neutrophils and fibrin• Tendency for loculations and limiting membranes• purulent fluid, PH <7.10, glucose <40mg/dl LDH >1000IU/L, Gram stain & culture +ve
  35. 35. Empyema: Organizing stage• Thick pleura prevent entry of anti microbial drugs in the pleural space- drug resistance• Restrict lung movement
  36. 36. Empyema: Clinical features• Common in poor socioeconomic group• Peak incidence 0-3 years• Chills, fever, dyspnoea, chest pain, referred pain, night sweat, malaise, cough, ↑sputum production• Pain abdomen & ileus• Tachypnoeic, anxious, pleural rub (disappear after fluid accumulates)
  37. 37. Empyema: Clinical features...• Large fluid- fullness of intercostal spaces, diminished chest excursions• Shift of mediastinum• Dullness to percussion, decreased air entry, decreased tactile & vocal fremitus
  38. 38. Empyema: Investigation & Diagnosis• History and examination findings• Confirm the presence of empyema, etiological agent & complications• Polymorph predominance, rarely leukopenia• X-ray chest- blunting of costophrenic angle, opacification of hemithorax with mediastinal shift to opposite side , lateral decubitus for small volume
  39. 39. Empyema: Investigation...• USG- confirms, for thoracocentesis, pleural catheter placement, transudates anechoic, exudates echoic or anechoic, limiting membrane suggest loculation• CT scan- confirm fluid, loculation, pleural thickening• Pleurocentesis / thoracocentesis
  40. 40. Empyema: Aspirate Investigation• Aspirate- Cell count and differential, Grams stain, culture, pH, protein, glucose, LDH, AFB stain & culture• Uncomplicated parapneumonic effusion:- pH>7.3, glucose> 60mg/dl, LDH,1000IU/L,• Complicated parapneumonic effusion:- pH<7.1, glucose<60mg, LDH>1000IU/L, microbes on Grams stain• Tuberculous empyema:- AFB <25% cases, Pleural biopsy & culture >90%, adenosine de aminase (ADA) >70U/L, PCR
  41. 41. Empyema: Treatment Aims• Control infection• Drainage of pus• Expansion of lungs
  42. 42. Empyema drainage• Inter costal drainage (ICD), under water seal, large catheter inserted in the site of pus accumulation• Loculated fluid/pus- drainage continued for 1 week• Chest tube kept till drainage is nil or < 30 ml/day
  43. 43. Empyema: Inter Costal Drainage (ICD)
  44. 44. Empyema: X-Ray chestBefore & After Inter costal drainage (ICD)
  45. 45. Empyema: Antimicrobial therapyOrganism Drugs Alternate Duration Staph Clox + Amino 3rd gen Cephlo 1-4wk + CloxPneumo PenicillinG Ceftriaxone 1-2wk H influ Cefurox/ceftrioxone Chlorompenic 1-2wk /CefotaxPseudom Ceftazidine Impenum Cefoperazone Cilastatin, Aztreonam
  46. 46. Empyema: Treatment...• Based on culture and sensitivity• Monotherapy not recommended• In anerobic infection- Clindamycin: 6-12wk• MRSA- Vancomycin• Antibiotics till afebrile, WBC normal, thoracostomy yield <50ml/day, X-ray clearing• H influenzae & S pneumoniae: 7-14 days• S aureus: 3-4 wk, anerobic: (variable) 6-12wk
  47. 47. Empyema: Thrombolytic therapy• Multiloculated empyema by thoracostomy tube• Streptokinase 2,50,000 unit or urokinase 1,00.000 unit in 100ml normal saline instilled through tube & clamped for 3 hrs
  48. 48. Empyema: Surgical therapy• Remains febrile and dyspnoeic after IV antibiotics and thorcostomy drain• Pleural thickening- decortication• Non expansion of lung• Bronchopleural fistula• Video assisted thoracoscopic surgery in multi loculated effusion• Thorocoscopic debridement and irrigation in multiloculated effusion
  49. 49. Empyema: Complications• Bronchopleural fistula• Cutaneous fistula• Pyopneumothorax• Purulent pericarditis• Pulmonary abscess• Peritonitis secondary to rupture through diaphragm• Septic complications - meningitis, arthritis, osteomyelitis
  50. 50. Empyema: Prognosis• In adequately treated cases prognosis is excellent• Follow up pulmonary functions suggest that residual disease is uncommon
  51. 51. Pyopneumothorax
  52. 52. Pneumothorax• Presence of gas in the Pleural space
  53. 53. Pneumothorax: Classification• Spontaneous pneumothorax Primary , Secondary• Traumatic pneumothorax• Iatrogenic pneumothorax• Tension Pneumothorax
  54. 54. Traumatic PneumothoraxClosed Open
  55. 55. Pneumothorax: Causes• Rupture of pleural blebs • Transthoracic aspiration• Penetrating or non needle penetrating injuries • Thoracentesis• Pneumonia • Central intravenous• Asthma catheters• Cystic fibrosis • Mechanical Ventilation• COPD/ Bronchitis • Resuscitative efforts• Inhalation of some toxic substances, most notably crack cocaine
  56. 56. Clinical Signs & Symptoms• Severity depends on the extent of the lung collapse.• Simple pneumothorax - asymptomatic or chest pain, dyspnea.• Extensive pneumothorax often produces pleuritic chest pain, dyspnea, tachypnea, cyanosis, Hyperresonance to percussion on the affected side.• Decreased breath sounds on the involved side.• If pneumothorax due to trauma - look for contusions or abrasions on the chest wall or a small puncture wound that does not allow free movement of air between the outside and the pleural cavity.
  57. 57. Tension Pneumothorax: Signs/Symptoms• Clinical Presentation - Chest pain (90%), Dyspnea (80%), Anxiety, Fatigue• Physical examination - Respiratory distress and/or arrest, Cyanosis, Tracheal deviation, Pulsus paradoxus, Tachypnea, Tachycardia, Hypotension, Jugular venous distension• Hyperresonance of the chest wall on percussion• Unilaterally decreased or absent lung sounds• Increasing resistance to providing adequate ventilation assistance• Mental status changes, including decreased alertness and/or consciousness• Abdominal distension
  58. 58. Tension Pneumothorax Lung parenchymal or bronchial injury one-way valve air trapping mediastinal structures - pushed to the contralateral side.mediastinum impinges on and compresses the contralateral lung
  59. 59. Pneumothorax: Differential Diagnosis• Bronchogenic Cyst• Congenital Lung Malformations• Cystic Adenomatoid Malformation• Pleural Effusion, Pyo pneumothorax
  60. 60. Investigations• Chest X-ray• Pulse oxymetry : SpO2• Arterial blood gas: arterial pO2
  61. 61. Pneumothorax: Treatment Without continued air leak, asymptomatic and mildly symptomatic small pneumothorax• 100% oxygen• Sedation
  62. 62. Tension Pneumothorax: Treatment• Severe respiratory and circulatory embarrassment• Emergency Needle aspiration• Either immediately or after needle aspiration a chest tube (ICD) should be inserted and attached to underwater seal drainage
  63. 63. Decompression by Needle / ICD• 2nd intercostal space on the mid clavicular line• Upper border of the lower rib• Needle / ICD have to be connected to the underwater sealed drainage
  64. 64. Indications for ICD1. Pneumothorax2. Hemothorax3. Hemopneumothorax4. Tension pneumothorax5. Empyema6. Chylothorax
  65. 65. X-ray Pneumothorax: Before Treatment
  66. 66. X-ray Pneumothorax: After Treatment
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