PNEUMOTHORAX MBBS.weebly.com
Introduction <ul><li>Laennec described the clinical picture of pneumothorax in 1819 </li></ul><ul><li>The modern descripti...
Introduction <ul><li>Secondary pneumothorax is associated with underlying lung disease, whereas primary pneumothorax is no...
Contents <ul><li>What is pneumothorax </li></ul><ul><li>Pathogenesis and mechanisms </li></ul><ul><li>Pathophysiology  </l...
What is Pneumothorax
Classification of pneumothorax <ul><li>Types </li></ul><ul><ul><li>Spontaneous having an unknown cause or occurring as a c...
<ul><li>Spontaneous pneumothoraces are subclassified as: </li></ul><ul><ul><li>Primary spontaneous pneumothorax (PSP) </li...
Pathogenesis and mechanisms <ul><li>In normal people, the pressure in pleural space is negative during the entire respirat...
<ul><li>When a communication develops between an  alveolus  or other  intrapulmonary air space  and pleural space </li></u...
Pathogenesis and mechanisms <ul><li>When a communication develops through the  chest wall  between the atmosphere and the ...
<ul><li>Pneumothorax: </li></ul><ul><ul><li>Negative pressure eliminated </li></ul></ul><ul><ul><ul><li>The lung recoil-sm...
<ul><li>Thoracoscopic studies </li></ul><ul><ul><li>Blebs  </li></ul></ul><ul><ul><ul><li>Air filled spaces between the lu...
<ul><li>Bullae </li></ul><ul><ul><li>Air filled spaces within the lung parenchyma itself </li></ul></ul>Pathophysiology Lu...
Blebs The patient, a 22-year-old male, was admitted to hospital, complaining of left chest pain and palpitations.
<ul><li>Blebs and bullae are also known as emphysema-like changes (ELCs) </li></ul><ul><li>The probable cause of pneumotho...
<ul><li>It is often hard to assess whether bullae are the site of leakage, and where the site of rupture of the visceral p...
<ul><li>PSP </li></ul><ul><li>SSP </li></ul>
Clinical typing of pneumothorax Closed communicated tension Rupture   small  large  valve-like sealed  open  in not out Pr...
Clinical manifestation  <ul><li>Symptom   </li></ul><ul><ul><li>Depend on whether underlying pulmonary disease or not </li...
<ul><li>Happened most patients at rest and some during heavy exercise   </li></ul><ul><li>Chest pain-prickling-like, cutti...
<ul><li>Tension pneumothorax </li></ul><ul><li>risk factors </li></ul><ul><ul><li>Receiving positive-pressure mechanical v...
Tension pneumothorax
<ul><li>Tension pneumothorax </li></ul><ul><ul><li>Distressed with rapid labored respiration </li></ul></ul><ul><ul><li>Cy...
<ul><li>Physical examination </li></ul><ul><ul><li>Depend on size of pneumothorax </li></ul></ul><ul><ul><li>Depend on whe...
<ul><li>Physical examination </li></ul><ul><ul><li>Tactile fremitus is absent </li></ul></ul><ul><ul><li>The percussion no...
Clinical stability <ul><li>Stable patients </li></ul><ul><li>RR: <24/min </li></ul><ul><li>HR: 60-120/min </li></ul><ul><l...
Imaging- Plane chest X-ray film  <ul><li>Establishing the diagnosis </li></ul><ul><li>The characteristics of pneumothorax ...
Plane chest X-ray film <ul><li>In erect patients, pleural gas collects over the apex, and the space between the lung and c...
Plane chest X-ray film <ul><li>It is very important to differentiate the pleural line of a pneumothorax from that of a ski...
Plane chest X-ray film <ul><li>In the absence of underlying lung disease, the pleural line of a pneumothorax usually paral...
Plane chest X-ray film <ul><li>Quantification of the size   </li></ul><ul><li>The size of a pneumothorax, in terms of volu...
<ul><li>BTS  </li></ul><ul><ul><li>The rim of air between the pleura and  the chest wall </li></ul></ul><ul><ul><li>Small ...
<ul><li>Since the volume of a pneumothorax approximates to the ratio of the cube of the lung diameter to the hemithorax di...
<ul><li>A pneumothorax of 2 cm on the PA chest radiograph occupies about 49% of the hemithorax volume </li></ul><ul><ul><l...
CT scanning <ul><li>CT scanning is the most robust approach if accurate size estimates are required </li></ul><ul><li>It i...
CT scanning bullae pneumothorax
CT scanning bullae pneumothorax pneumothorax
CT scanning pneumothorax
CT scanning Small pneumothorax Subcutaneous emphysema
 
Diagnosis and Differentiation  <ul><li>PSP </li></ul><ul><ul><li>Young, thin, tall man </li></ul></ul><ul><ul><li>Clinical...
<ul><li>Goals  </li></ul><ul><ul><li>To promote lung expansion  </li></ul></ul><ul><ul><li>To eliminate the pathogenesis  ...
Observation - PSP <ul><li>Observation along is advised for small, closed mildly symptomatic spontaneous pneumothoraces </l...
<ul><li>Observation along is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumoth...
<ul><li>Observation along is inappropriate and active intervation is required </li></ul><ul><li>Marked breathlessness in a...
<ul><li>Inhalation of high concentration of oxygen may reduce the total pressure of gases in pleural capillaries by reduci...
<ul><li>The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25 – 1.8% of volume of hemithorax every 24 ...
Aspiration <ul><li>Simple aspiration is recommended as first line treatment for all PSP requiring intervention </li></ul><...
<ul><li>Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful and a v...
Catheter aspiration <ul><li>Catheter aspiration of pneumothorax can be used where the equipment and experience is availabl...
Intercostal tube drainage Fix the catheter and cover with gauze Making a small incision
Intercostal tube drainage
<ul><li>INDICATIONS  </li></ul><ul><ul><li>SSP </li></ul></ul><ul><ul><li>Unstable pneumothorax </li></ul></ul><ul><ul><li...
<ul><li>Position of intercostal tube </li></ul><ul><li>The chest tube should be positioned in the uppermost part of the pl...
<ul><li>The site of chest tube insertion is in the midclavicular line of second and third intercostal </li></ul><ul><li>or...
Observation of drainage <ul><li>No bubble released  </li></ul><ul><ul><li>The lung reexpansion  </li></ul></ul><ul><ul><li...
Complications of intercostal tube drainage <ul><li>Penetration of major organs </li></ul><ul><ul><li>Lung, stomach, spleen...
Chemical pleurodesis <ul><li>Goals  </li></ul><ul><ul><li>Prevention of pneumothorax recurrence  </li></ul></ul><ul><ul><l...
Chemical pleurodesis <ul><li>Sclerosing agents </li></ul><ul><ul><li>Tetracycline </li></ul></ul><ul><ul><li>Minocycline <...
<ul><li>Methods  </li></ul><ul><ul><li>Via chest tube or by surgical mean  </li></ul></ul><ul><ul><li>Administration of in...
<ul><li>Side effect </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Dyspnea <...
Thoracoscopy <ul><li>Medical thoracoscopy </li></ul><ul><li>VATS: video-assisted thoracoscopic surgery </li></ul>
Surgical treatment <ul><li>Indication   </li></ul><ul><ul><li>No response to medical treatment </li></ul></ul><ul><ul><li>...
Complications of pneumothorax  <ul><li>Pyopneumothorax   </li></ul><ul><ul><li>Caused by aspiration or intercostal chest t...
<ul><li>Hemopneumotorax   </li></ul><ul><ul><li>Bleeding in pleural space </li></ul></ul><ul><ul><li>Common cause is ruptu...
Complications
Complications
<ul><li>Mediastinal and subcutaneous emphysema </li></ul><ul><ul><li>Alveoli rupture, the air enter into pulmonary interst...
Complications  Pneumomediastinum  Pneumocardium Pneumoperitoneum Surgical emphysema
Complications  Subcutaneous  emphysema
Complications <ul><li>Treatment  </li></ul><ul><ul><li>Automatic absorption when pneumothorax is gone  </li></ul></ul><ul>...
Recurrent Rates <ul><li>30-50% recurrence after observation or tube thoracostomy. </li></ul><ul><li>Attempts: thoracoscopy...
Case 1 <ul><li>Female, 20 </li></ul><ul><li>Chest pain 3 hours, and suddenly deteriorate dyspnea </li></ul><ul><li>Cyanosi...
Questions  <ul><li>The diagnosis is </li></ul><ul><li>A. pneumothorax </li></ul><ul><li>B. cardiac infarction </li></ul><u...
Questions  <ul><li>Which treatment is the first step </li></ul><ul><li>A. oxygen inhalation </li></ul><ul><li>B. bronchial...
Case 2 <ul><li>Male, 70 </li></ul><ul><li>Dyspnea 24 hours </li></ul><ul><li>No chest pain </li></ul><ul><li>COPD history ...
Questions  <ul><li>The diagnosis is   </li></ul><ul><li>A. AECOPD </li></ul><ul><li>B. asthma episode </li></ul><ul><li>C....
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  1. 1. PNEUMOTHORAX MBBS.weebly.com
  2. 2. Introduction <ul><li>Laennec described the clinical picture of pneumothorax in 1819 </li></ul><ul><li>The modern description of primary spontaneous pneumothorax occurring in otherwise healthy people was provided by Kjaergard in 1932 </li></ul><ul><li>Primary pneumothorax remains a significant global problem </li></ul><ul><li>The incidence is 18-28/100 000 per year for men and 1.2-6/100 000 per year for women </li></ul>
  3. 3. Introduction <ul><li>Secondary pneumothorax is associated with underlying lung disease, whereas primary pneumothorax is not </li></ul><ul><li>Hospital admission rates for combined primary and secondary pneumothorax are reported in the UK at between 5.8/10 000 per year for women and 16.7/10 000 per year for men </li></ul><ul><li>Mortality rates in the UK were 0.62/million for men between 1991 and 1995 </li></ul>
  4. 4. Contents <ul><li>What is pneumothorax </li></ul><ul><li>Pathogenesis and mechanisms </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Clinical typing </li></ul><ul><li>Clinical manifestation </li></ul><ul><li>Diagnosis and differentiate diagnosis </li></ul><ul><li>Treatment </li></ul>
  5. 5. What is Pneumothorax
  6. 6. Classification of pneumothorax <ul><li>Types </li></ul><ul><ul><li>Spontaneous having an unknown cause or occurring as a consequence of the nature course of a disease process, such as COPD, tuberculosis </li></ul></ul><ul><ul><li>Traumatic following any penetrating or non-penetrating chest trauma, with or without bronchial rupture </li></ul></ul><ul><ul><li>Iatrogenic occurring as the results of diagnostic or therapeutic medical procedure. Intentional or a complication </li></ul></ul>
  7. 7. <ul><li>Spontaneous pneumothoraces are subclassified as: </li></ul><ul><ul><li>Primary spontaneous pneumothorax (PSP) </li></ul></ul><ul><ul><ul><li>Healthy people, most young people </li></ul></ul></ul><ul><ul><li>Secondary spontaneous pneumothorax (SSP) </li></ul></ul><ul><ul><ul><li>Underlying diseases </li></ul></ul></ul><ul><ul><ul><li>Chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis </li></ul></ul></ul>Clinical typing of pneumothorax
  8. 8. Pathogenesis and mechanisms <ul><li>In normal people, the pressure in pleural space is negative during the entire respiratory cycle </li></ul><ul><li>Two opposite forces result in negative pressure in pleural space: </li></ul><ul><li>inherent outward pull of the chest wall and inherent elastic recoil of the lung </li></ul><ul><li>The negative pressure will be disappeared if any communication develops </li></ul>
  9. 9. <ul><li>When a communication develops between an alveolus or other intrapulmonary air space and pleural space </li></ul><ul><li>air will flow into the pleural space until there is no longer a pressure difference or until the communication is sealed </li></ul>Pathogenesis and mechanisms
  10. 10. Pathogenesis and mechanisms <ul><li>When a communication develops through the chest wall between the atmosphere and the pleural space </li></ul><ul><li>air will enter the pleural space until the pressure gradient is eliminated or the communication is closed </li></ul>
  11. 11. <ul><li>Pneumothorax: </li></ul><ul><ul><li>Negative pressure eliminated </li></ul></ul><ul><ul><ul><li>The lung recoil-small lung-volume decrease </li></ul></ul></ul><ul><ul><ul><li>V/Q decrease-shunt increase </li></ul></ul></ul><ul><ul><li>Positive pressure </li></ul></ul><ul><ul><ul><li>Compress blood vessels and heart </li></ul></ul></ul><ul><ul><ul><li>decreased cardiac output </li></ul></ul></ul><ul><ul><ul><li>Impaired venous return </li></ul></ul></ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul><ul><ul><ul><li>Shock </li></ul></ul></ul><ul><ul><li>Result in </li></ul></ul><ul><ul><ul><li>A decrease in vital capacity </li></ul></ul></ul><ul><ul><ul><li>A decrease in PaO 2 </li></ul></ul></ul>Pathophysiology
  12. 12. <ul><li>Thoracoscopic studies </li></ul><ul><ul><li>Blebs </li></ul></ul><ul><ul><ul><li>Air filled spaces between the lung parenchyma and the visceral pleura </li></ul></ul></ul>Pathophysiology Shows a similar cystic space, completely surrounded by pl pleura
  13. 13. <ul><li>Bullae </li></ul><ul><ul><li>Air filled spaces within the lung parenchyma itself </li></ul></ul>Pathophysiology Lung parenchyma Surrounded by fibrous tissue
  14. 14. Blebs The patient, a 22-year-old male, was admitted to hospital, complaining of left chest pain and palpitations.
  15. 15. <ul><li>Blebs and bullae are also known as emphysema-like changes (ELCs) </li></ul><ul><li>The probable cause of pneumothorax is rupture of an apical bleb or bulla </li></ul><ul><li>Because the compliance of blebs or bullae in the apices is lower compared with that of similar lesions situated in the lower parts of the lungs </li></ul>Pathophysiology
  16. 16. <ul><li>It is often hard to assess whether bullae are the site of leakage, and where the site of rupture of the visceral pleura is </li></ul><ul><li>Smoking causes a 9-fold increase in the relative risk of a pneumothorax in females </li></ul><ul><li>A 22-fold increase in male smokers </li></ul><ul><li>With a dose-response relationship between the number of cigarettes smoked per day and occurrence of PSP </li></ul>Pathophysiology
  17. 17. <ul><li>PSP </li></ul><ul><li>SSP </li></ul>
  18. 18. Clinical typing of pneumothorax Closed communicated tension Rupture small large valve-like sealed open in not out Pressure P or N atmosphere high After Aspiration N atmosphere high again
  19. 19. Clinical manifestation <ul><li>Symptom </li></ul><ul><ul><li>Depend on whether underlying pulmonary disease or not </li></ul></ul><ul><ul><li>Depend on the speed of pneumothorax occurred </li></ul></ul><ul><ul><li>Depend on size of pneumothorax </li></ul></ul><ul><ul><li>Depend on the level of intrapleual pressure </li></ul></ul><ul><li>The patient with underlying pulmonary disease will undergo severe dyspnea </li></ul><ul><li>The healthy person will have minimal symptoms although having large volume of pneomothorax </li></ul>
  20. 20. <ul><li>Happened most patients at rest and some during heavy exercise </li></ul><ul><li>Chest pain-prickling-like, cutting-like </li></ul><ul><ul><li>Having an acute onset </li></ul></ul><ul><ul><li>Air stimulates pleura </li></ul></ul><ul><li>Dyspnea </li></ul><ul><ul><li>Collapsed lung and vital capacity decrease </li></ul></ul><ul><li>Dry cough </li></ul><ul><ul><li>Air stimulates pleura </li></ul></ul>Clinical manifestation
  21. 21. <ul><li>Tension pneumothorax </li></ul><ul><li>risk factors </li></ul><ul><ul><li>Receiving positive-pressure mechanical ventilation </li></ul></ul><ul><ul><li>During cardiopulmonary resuscitation </li></ul></ul><ul><ul><li>Undergoing hyperbaric oxygen therapy </li></ul></ul><ul><ul><li>Evolving during the course of spontaneous pneumothorax </li></ul></ul>Clinical manifestation
  22. 22. Tension pneumothorax
  23. 23. <ul><li>Tension pneumothorax </li></ul><ul><ul><li>Distressed with rapid labored respiration </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><ul><li>Marked tachycardia </li></ul></ul><ul><ul><li>Profuse diaphoresis </li></ul></ul><ul><li>Patient who suddenly deteriorate clinically, </li></ul><ul><li>be suspected if the patient with </li></ul><ul><ul><li>Mechanical ventilation </li></ul></ul><ul><ul><li>Cardiopulmonary resuscitation </li></ul></ul>Clinical manifestation
  24. 24. <ul><li>Physical examination </li></ul><ul><ul><li>Depend on size of pneumothorax </li></ul></ul><ul><ul><li>Depend on whether pleural effusions or not </li></ul></ul><ul><ul><li>The vital signs usually normal </li></ul></ul><ul><ul><li>The side with pneumothorax is larger than the contralateral side </li></ul></ul><ul><ul><li>Chest moves less during the respiratory cycle </li></ul></ul>Clinical manifestation
  25. 25. <ul><li>Physical examination </li></ul><ul><ul><li>Tactile fremitus is absent </li></ul></ul><ul><ul><li>The percussion note is hypersonant </li></ul></ul><ul><ul><li>The breath sounds are reduced or absent on the affected side </li></ul></ul><ul><ul><li>The lower edge of the liver may be shifted inferiorly with a right-side pneumothorax </li></ul></ul><ul><ul><li>The trachea may be shifted toward the contralateral side if the pneumothorax is large </li></ul></ul>Clinical manifestation
  26. 26. Clinical stability <ul><li>Stable patients </li></ul><ul><li>RR: <24/min </li></ul><ul><li>HR: 60-120/min </li></ul><ul><li>BP: normal </li></ul><ul><li>SO 2 : >90% (room air) </li></ul><ul><li>Patient can speak in whole sentences between breaths </li></ul><ul><li>All above present </li></ul><ul><li>Unstable patients </li></ul><ul><li>Not fulfilling the definition of stable </li></ul>Evaluate the severity and make decision for treatment
  27. 27. Imaging- Plane chest X-ray film <ul><li>Establishing the diagnosis </li></ul><ul><li>The characteristics of pneumothorax </li></ul><ul><ul><li>Pleural line </li></ul></ul><ul><ul><li>No lung markings in pneumothorax </li></ul></ul><ul><li>The outer margin of visceral pleura separated from the parietal pleura by a lucent gas space devoid of pulmonary vessels </li></ul>
  28. 28. Plane chest X-ray film <ul><li>In erect patients, pleural gas collects over the apex, and the space between the lung and chest wall is most notable there </li></ul><ul><li>In the supine position, gas migrates along the broad ventral surface of lung, making detection on a frontal radiograph difficult </li></ul>
  29. 29. Plane chest X-ray film <ul><li>It is very important to differentiate the pleural line of a pneumothorax from that of a skinfold, clothing, tubing, or chest wall artifact </li></ul><ul><li>Careful inspection of the film may show that the artifact extends beyond the thorax, or that lung markings are visible beyond the apparent pleural line </li></ul>
  30. 30. Plane chest X-ray film <ul><li>In the absence of underlying lung disease, the pleural line of a pneumothorax usually parallels the shape of chest wall </li></ul><ul><li>Artifactual densities generally do not parallel the course of the chest wall over their entire length </li></ul>
  31. 31. Plane chest X-ray film <ul><li>Quantification of the size </li></ul><ul><li>The size of a pneumothorax, in terms of volume, is difficult to assess accurately from a chest radiograph </li></ul><ul><li>The simple method to estimate the size </li></ul><ul><ul><li>Small, a visible rim of < 2 cm between the lung margin and the chest wall </li></ul></ul><ul><ul><li>Large, a visible rim of ≥2 cm between the lung margin and chest wall </li></ul></ul>
  32. 32. <ul><li>BTS </li></ul><ul><ul><li>The rim of air between the pleura and the chest wall </li></ul></ul><ul><ul><li>Small <1cm </li></ul></ul><ul><ul><li>Moderate :1- 2cm </li></ul></ul><ul><ul><li>Large >2cm </li></ul></ul><ul><li>ACCP </li></ul><ul><ul><li>The apex-to-cupola distance </li></ul></ul><ul><ul><li>Small <3cm </li></ul></ul><ul><ul><li>Large ≥ 3cm </li></ul></ul>Estimation of pneumothorax volume
  33. 33. <ul><li>Since the volume of a pneumothorax approximates to the ratio of the cube of the lung diameter to the hemithorax diameter </li></ul><ul><li>A pneumothorax of 1 cm on the PA chest radiograph occupies about 27% of the hemithorax volume </li></ul><ul><ul><li>Lung is 9 cm, hemithorax is 10 cm in diameter </li></ul></ul><ul><li>Equation </li></ul><ul><ul><li>Volume of pneumothorax = (HT 3 – L 3 ) ÷ HT 3 </li></ul></ul><ul><ul><li>= (10 3 – 9 3 ) ÷ 10 3 </li></ul></ul><ul><ul><li>= (1000 – 729) ÷1000 </li></ul></ul><ul><ul><li>= 0.27 </li></ul></ul>Plane chest X-ray film Hemithorax (HT) Lung (L)
  34. 34. <ul><li>A pneumothorax of 2 cm on the PA chest radiograph occupies about 49% of the hemithorax volume </li></ul><ul><ul><li>Lung is 8 cm, hemithorax is 10 cm in diameter </li></ul></ul><ul><li>Equation </li></ul><ul><ul><li>Volume of pneumothorax = (HT 3 – L 3 ) ÷ HT 3 </li></ul></ul><ul><ul><li>= (10 3 – 8 3 ) ÷ 10 3 </li></ul></ul><ul><ul><li>= (1000 – 512) ÷1000 </li></ul></ul><ul><ul><li>= 0.49 </li></ul></ul>Plane chest X-ray film Hemithorax (HT) Lung (L)
  35. 35. CT scanning <ul><li>CT scanning is the most robust approach if accurate size estimates are required </li></ul><ul><li>It is only recommended to difficult cases such as patients in whom the lungs are obscured by overlying surgical emphysema </li></ul><ul><li>To differentiate a pneumothorax from suspected bulla in complex cystic lung disease </li></ul>
  36. 36. CT scanning bullae pneumothorax
  37. 37. CT scanning bullae pneumothorax pneumothorax
  38. 38. CT scanning pneumothorax
  39. 39. CT scanning Small pneumothorax Subcutaneous emphysema
  40. 41. Diagnosis and Differentiation <ul><li>PSP </li></ul><ul><ul><li>Young, thin, tall man </li></ul></ul><ul><ul><li>Clinical history (chest pain) and physical examination </li></ul></ul><ul><ul><li>Chest radiograph </li></ul></ul><ul><li>SSP (COPD and Asthma) </li></ul><ul><ul><li>Repeated wheezing episode </li></ul></ul><ul><ul><li>Dyspnea gradually progress </li></ul></ul><ul><ul><li>In the course of disease, if patients </li></ul></ul><ul><ul><ul><li>Onset of severe dyspnea, cold sweat, dysphoria </li></ul></ul></ul><ul><ul><ul><li>No response to bronchial dilators, antibiotics </li></ul></ul></ul><ul><ul><li>Consider pneumothorax </li></ul></ul><ul><ul><li>Chest X-ray radiograph to confirm the diagnosis </li></ul></ul>
  41. 42. <ul><li>Goals </li></ul><ul><ul><li>To promote lung expansion </li></ul></ul><ul><ul><li>To eliminate the pathogenesis </li></ul></ul><ul><ul><li>To decrease pneumothorax recurrence </li></ul></ul><ul><li>Treatment options according to </li></ul><ul><ul><li>Classification of pneumothorax </li></ul></ul><ul><ul><li>Pathogenesis </li></ul></ul><ul><ul><li>Pneumothorax frequency </li></ul></ul><ul><ul><li>The extension of lung collapse </li></ul></ul><ul><ul><li>Severity of disease </li></ul></ul><ul><ul><li>Complication and concomitant underlying diseases </li></ul></ul>Treatment
  42. 43. Observation - PSP <ul><li>Observation along is advised for small, closed mildly symptomatic spontaneous pneumothoraces </li></ul><ul><li>Patients with small PSP and minimal symptoms do not require hospital admission </li></ul><ul><li>However, it should be stressed before discharge that they should be return directly to hospital in the event of developing breathlessness </li></ul><ul><li>Most patients in this group who fail this treatment have secondary pneumothoraces </li></ul>
  43. 44. <ul><li>Observation along is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothoraces in asymptomatic patients </li></ul><ul><li>Hospitalisation is recommended in these cases </li></ul><ul><li>All other cases will require active intervention ( aspiration or chest drain insertion) </li></ul>Observation - SSP
  44. 45. <ul><li>Observation along is inappropriate and active intervation is required </li></ul><ul><li>Marked breathlessness in a patient with a small (<2 cm) PSP may herald tension pneumothorax </li></ul><ul><li>If a patient is hospitalised for observation, supplemental high flow (10 l/min) oxygen should be given where feasible </li></ul>Observation - PSP or SSP
  45. 46. <ul><li>Inhalation of high concentration of oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen </li></ul><ul><li>This should increase the pressure gradient between the pleural capillaries and the pleural cavity </li></ul><ul><li>Thereby increasing absorption of air from the pleural cavity </li></ul>Observation - PSP or SSP
  46. 47. <ul><li>The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25 – 1.8% of volume of hemithorax every 24 hours </li></ul><ul><li>The addition of high flow oxygen therapy has been shown to result in a 4-fold increase in the rate of peumothorax reabsorption during the periods of oxygen supplementation </li></ul>Observation - PSP or SSP
  47. 48. Aspiration <ul><li>Simple aspiration is recommended as first line treatment for all PSP requiring intervention </li></ul><ul><li>Simple aspiration is less likely to succeed in secondary pneumothoraces and in this situation, is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients under the age of 50 years </li></ul><ul><li>Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge </li></ul>
  48. 49. <ul><li>Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful and a volume of < 2.5 L has been aspirated on the first attempt </li></ul>Aspiration
  49. 50. Catheter aspiration <ul><li>Catheter aspiration of pneumothorax can be used where the equipment and experience is available </li></ul>
  50. 51. Intercostal tube drainage Fix the catheter and cover with gauze Making a small incision
  51. 52. Intercostal tube drainage
  52. 53. <ul><li>INDICATIONS </li></ul><ul><ul><li>SSP </li></ul></ul><ul><ul><li>Unstable pneumothorax </li></ul></ul><ul><ul><li>Severe dyspnea </li></ul></ul><ul><ul><li>Large lung collapse </li></ul></ul><ul><ul><li>Open or tension pneumothoraces </li></ul></ul><ul><ul><li>Frequent recurrent pneumothoraces </li></ul></ul><ul><ul><li>Simple aspiration or catheter aspiration drainage is unsuccessful in controlling symptoms </li></ul></ul>Intercostal tube drainage
  53. 54. <ul><li>Position of intercostal tube </li></ul><ul><li>The chest tube should be positioned in the uppermost part of the pleural space, where residual air accumulates </li></ul><ul><li>This procedure permits the air in the pleural space to be evacuated rapidly </li></ul>Intercostal tube drainage
  54. 55. <ul><li>The site of chest tube insertion is in the midclavicular line of second and third intercostal </li></ul><ul><li>or anterior axillary line of fifth and sixth intercostal </li></ul>Intercostal tube drainage
  55. 56. Observation of drainage <ul><li>No bubble released </li></ul><ul><ul><li>The lung reexpansion </li></ul></ul><ul><ul><li>The chest tube is obstructed by secretion or blood clot </li></ul></ul><ul><ul><li>The chest tube shift to chest wall, the hole of the chest tube is located in the chest wall </li></ul></ul><ul><li>If the lung reexpansion, removing the chest tube 24 hours after reexpansion </li></ul><ul><li>Otherwise, the chest tube will be inserted again or regulated the position </li></ul>
  56. 57. Complications of intercostal tube drainage <ul><li>Penetration of major organs </li></ul><ul><ul><li>Lung, stomach, spleen, liver, heart and great vessels </li></ul></ul><ul><ul><li>Occur more commonly when a sharp metal trocar is inappropriately applied </li></ul></ul><ul><li>Pleural infection </li></ul><ul><ul><li>Empyema, the rate of 1% </li></ul></ul><ul><li>Surgical emphysema </li></ul><ul><ul><li>Subcutaneous emphysema </li></ul></ul>
  57. 58. Chemical pleurodesis <ul><li>Goals </li></ul><ul><ul><li>Prevention of pneumothorax recurrence </li></ul></ul><ul><ul><li>To produce inflammation of pleura and adhesions </li></ul></ul><ul><li>Indications </li></ul><ul><ul><li>Persist air leak and repeated pneumothorax </li></ul></ul><ul><ul><li>Bilateral pneumothoraces </li></ul></ul><ul><ul><li>Complicated with bullae </li></ul></ul><ul><ul><li>Lung dysfunction, not tolerate to operation </li></ul></ul>
  58. 59. Chemical pleurodesis <ul><li>Sclerosing agents </li></ul><ul><ul><li>Tetracycline </li></ul></ul><ul><ul><li>Minocycline </li></ul></ul><ul><ul><li>Doxycline </li></ul></ul><ul><ul><li>Talc </li></ul></ul><ul><ul><li>Erythromycin </li></ul></ul><ul><li>The instillation of sclerosing agents into the pleural space should lead to an aseptic inflammation with dense adhesions, leading ultimately to pleural symphysis </li></ul>
  59. 60. <ul><li>Methods </li></ul><ul><ul><li>Via chest tube or by surgical mean </li></ul></ul><ul><ul><li>Administration of intrapleural local anaesthesia, 200 – 400 mg lidocaine intrapleurally injection </li></ul></ul><ul><ul><li>Agents diluted by 60 – 100 ml saline </li></ul></ul><ul><ul><li>Injected to pleural space </li></ul></ul><ul><ul><li>Clamp the tube 1 – 2 hours </li></ul></ul><ul><ul><li>Drainage again </li></ul></ul><ul><ul><li>Observed by chest X-ray film, if air of pleural space is absorption, remove the chest tube </li></ul></ul><ul><ul><li>If pneumothorax still exist, repeated pleurodesis </li></ul></ul>Chemical pleurodesis
  60. 61. <ul><li>Side effect </li></ul><ul><ul><li>Chest pain </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Acute respiratory distress syndrome </li></ul></ul><ul><ul><li>Acute respiratory failure </li></ul></ul>Chemical pleurodesis
  61. 62. Thoracoscopy <ul><li>Medical thoracoscopy </li></ul><ul><li>VATS: video-assisted thoracoscopic surgery </li></ul>
  62. 63. Surgical treatment <ul><li>Indication </li></ul><ul><ul><li>No response to medical treatment </li></ul></ul><ul><ul><li>Persist air leak </li></ul></ul><ul><ul><li>Hemopneumothorax </li></ul></ul><ul><ul><li>Bilateral pneumothoraces </li></ul></ul><ul><ul><li>Recurrent pneumothorax </li></ul></ul><ul><ul><li>Tension pneumothorax failed to dainage </li></ul></ul><ul><ul><li>Thicken pleura makes lung unable to reexpansion </li></ul></ul><ul><ul><li>Multiple blebs or bullae </li></ul></ul>
  63. 64. Complications of pneumothorax <ul><li>Pyopneumothorax </li></ul><ul><ul><li>Caused by aspiration or intercostal chest tube insertion </li></ul></ul><ul><ul><li>Also results from necrotic pneumonia, lung abscess, or caseous pneumonia </li></ul></ul><ul><li>Chest X-ray shows hydropneumothorax </li></ul><ul><li>The pleural effusion is purulent </li></ul><ul><li>Antibiotics and intercostal drainage </li></ul><ul><li>Surgical mean </li></ul>
  64. 65. <ul><li>Hemopneumotorax </li></ul><ul><ul><li>Bleeding in pleural space </li></ul></ul><ul><ul><li>Common cause is rupture of vessels in adhesions </li></ul></ul><ul><ul><li>When lung reexpansion, bleeding will stop </li></ul></ul><ul><li>When bleeding persists, surgical ligation will be needed </li></ul><ul><li>Infusion </li></ul>Complications
  65. 66. Complications
  66. 67. Complications
  67. 68. <ul><li>Mediastinal and subcutaneous emphysema </li></ul><ul><ul><li>Alveoli rupture, the air enter into pulmonary interstitial, and then goes into mediastinal and subcutaneous tissues </li></ul></ul><ul><ul><li>After aspiration or intercostal chest tube insertion, the air enters the subcutaneous by the needle hole or incision </li></ul></ul><ul><li>Physical exam – crepitus is present </li></ul>Complications
  68. 69. Complications Pneumomediastinum Pneumocardium Pneumoperitoneum Surgical emphysema
  69. 70. Complications Subcutaneous emphysema
  70. 71. Complications <ul><li>Treatment </li></ul><ul><ul><li>Automatic absorption when pneumothorax is gone </li></ul></ul><ul><ul><li>Inhalation of high concentration of oxygen </li></ul></ul><ul><ul><li>Making a small incision in suprasternal pit for draining the air from mediastinal and subcutaneous tissues </li></ul></ul>
  71. 72. Recurrent Rates <ul><li>30-50% recurrence after observation or tube thoracostomy. </li></ul><ul><li>Attempts: thoracoscopy, surgery, pleurodesis. </li></ul>
  72. 73. Case 1 <ul><li>Female, 20 </li></ul><ul><li>Chest pain 3 hours, and suddenly deteriorate dyspnea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Marked tachycardia </li></ul><ul><li>Profuse diaphoresis </li></ul>
  73. 74. Questions <ul><li>The diagnosis is </li></ul><ul><li>A. pneumothorax </li></ul><ul><li>B. cardiac infarction </li></ul><ul><li>C. pulmonary embolism </li></ul><ul><li>D. Asthma episode </li></ul><ul><li>The type of pneumothorax is </li></ul><ul><li>A. closed </li></ul><ul><li>B. open </li></ul><ul><li>C. tension </li></ul><ul><li>D. hemothorax </li></ul>
  74. 75. Questions <ul><li>Which treatment is the first step </li></ul><ul><li>A. oxygen inhalation </li></ul><ul><li>B. bronchial dilators </li></ul><ul><li>C. aspiration </li></ul><ul><li>D. chest tube drainage </li></ul>
  75. 76. Case 2 <ul><li>Male, 70 </li></ul><ul><li>Dyspnea 24 hours </li></ul><ul><li>No chest pain </li></ul><ul><li>COPD history 20 ys </li></ul><ul><li>Cyanosis </li></ul><ul><li>Marked tachycardia </li></ul>
  76. 77. Questions <ul><li>The diagnosis is </li></ul><ul><li>A. AECOPD </li></ul><ul><li>B. asthma episode </li></ul><ul><li>C. primary pneumx </li></ul><ul><li>D. SSP </li></ul><ul><li>Which treatment prefer </li></ul><ul><li>A. oxygen therapy </li></ul><ul><li>B. aspiration </li></ul><ul><li>C. chest tube </li></ul><ul><li>D. surgical procedure </li></ul>
  77. 78. Thank you!

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