3 pneumothorax


Published on

Published in: Education
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

3 pneumothorax

  1. 1. PNEUMOTHORAX Xie Can Mao 1st Affiliated Hospital of Sun Yat-sen Universty
  2. 2. Introduction <ul><li>The term pneumothorax was first coined by Itard, a student of Laennec, in 1803 </li></ul><ul><li>Laennec described the clinical picture of pneumothorax in 1819 </li></ul><ul><li>He described most pneumothoraces as occurring in patients with pulmonary tuberculosis, although he recognised that pneumothoraces also occurred in otherwise healthy lungs, a condition he described as “pneumothorax simple” </li></ul>
  3. 3. Introduction <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>
  4. 4. Introduction <ul><li>Secondary pneumothorax is associated with underlying lung disease, whereas primary pneumothorax is not </li></ul><ul><li>By definition, there is no apparent precipitating event in either </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>
  5. 5. 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>
  6. 6. What is pneumothorax <ul><li>Pleural cavity is a latent closed space, in which there is no air </li></ul><ul><li>The total gas pressure of capillaries is 706 mmHg, 54 mmHg less than atmosphere </li></ul><ul><li>Pneumothorax is defined as air in the pleural space </li></ul><ul><li>That is, air between the lung and chest wall, or in other term, air between the visceral pleura and the parietal pleura </li></ul>
  7. 7. Pneumothorax
  8. 8. Classification of pneumothorax <ul><li>Divided into three 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>
  9. 9. <ul><li>Spontaneous pneumothoraces are subclassified as: </li></ul><ul><ul><li>Primary spontaneous pneumothorax (PSP) </li></ul></ul><ul><ul><li>Healthy people, most young people </li></ul></ul><ul><ul><li>Secondary spontaneous pneumothorax (SSP) </li></ul></ul><ul><ul><li>Underlying diseases </li></ul></ul><ul><ul><li>Chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis </li></ul></ul>Clinical typing of pneumothorax
  10. 10. 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>
  11. 11. <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
  12. 12. 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>
  13. 13. <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
  14. 14. <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
  15. 15. <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
  16. 16. Blebs Male , aged 22 Admission for“ explode dyspnea, left chest pain for 2 weeks ” . Historic left pneumotorax. 镜下见:左上叶表面见数个直径 0.5 ~ 3cm 肺大 疱, 部分随呼吸活动膨大缩小 。
  17. 17. Bullae
  18. 18. <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
  19. 19. <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
  20. 20. 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
  21. 21. 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>
  22. 22. <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
  23. 23.
  24. 24. <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
  25. 25. Tension pneumothorax
  26. 26. <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
  27. 27. <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
  28. 28. <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
  29. 29. 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
  30. 30. 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>
  31. 31. 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>
  32. 32. 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>
  33. 33. 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>
  34. 34. 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>
  35. 35. Estimation of pneumothorax volume <ul><li>Light equation pneumothorax %=( 1 - L 3 /HT 3 )  100 </li></ul><ul><li>Kircher equation </li></ul><ul><ul><li>pneumothorax % </li></ul></ul><ul><ul><li>Thorax area - lung area </li></ul></ul><ul><ul><li>Thorax area </li></ul></ul><ul><li>Collins equation </li></ul><ul><ul><li>4.2+[4.7  (A+B+C)] </li></ul></ul> 100 Hemithorax (HT) Lung (L)
  36. 36. <ul><li>BTS guideline(1993) </li></ul><ul><ul><li>Small </li></ul></ul><ul><ul><li>Moderate </li></ul></ul><ul><ul><li>large </li></ul></ul><ul><li>BTS guideline(2003) </li></ul><ul><ul><li>Lung margin to chest wall </li></ul></ul><ul><ul><li>small<2cm </li></ul></ul><ul><ul><li>large ≥ 2cm </li></ul></ul><ul><li>ACCP guideline </li></ul><ul><ul><li>Lung apex to chest top </li></ul></ul><ul><ul><li>Small <3cm </li></ul></ul><ul><ul><li>large≥3cm </li></ul></ul>Estimation of pneumothorax volume
  37. 37. <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
  38. 38. <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
  39. 39. 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>
  40. 40. CT scanning bullae pneumothorax
  41. 41. CT scanning bullae pneumothorax pneumothorax
  42. 42. CT scanning pneumothorax
  43. 43. CT scanning Small pneumothorax Subcutaneous emphysema
  44. 44. Differentiation <ul><li>Asthma and obstructive emphysema </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 conform the diagnosis </li></ul></ul>
  45. 45. <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
  46. 46. 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>
  47. 47. <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
  48. 48. <ul><li>Marked breathlessness in a patient with a small (<2 cm) PSP may herald tension pneumothorax </li></ul><ul><li>Observation along is inappropriate and active intervation is required </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
  49. 49. <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
  50. 50. <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
  51. 51. Simple 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>
  52. 52. <ul><li>Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful </li></ul><ul><li>A volume of < 2.5 L has been aspirated on the first attempt </li></ul><ul><li>The aspiration can be used by needle or catheter </li></ul>Repeated and catheter aspiration
  53. 53. Catheter aspiration <ul><li>Catheter aspiration of pneumothorax can be used where the equipment and experience is available </li></ul>
  54. 54. Intercostal tube drainage Fix the catheter and cover with gauze Making a small incision Using a forceps to extend the hole Inserting a catheter into pleural cavity
  55. 55. Intercostal tube drainage
  56. 56. <ul><li>INDICATIONS </li></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
  57. 57. <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
  58. 58. <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
  59. 59. Guidewire tube thoracostomy <ul><li>Making a small skin incision slightly larger than the diameter of the chest tube </li></ul>
  60. 60. <ul><li>Introduction of 18-gauge needle into the pleural space </li></ul>Guidewire tube thoracostomy
  61. 61. <ul><li>Insertion of wire with “J” end into the pleural space </li></ul>Guidewire tube thoracostomy
  62. 62. <ul><li>With guidewire in space, the tract is enlarged by advancing progressively larger dilators over the wire guide </li></ul>Guidewire tube thoracostomy
  63. 63. <ul><li>Introduction the chest tube inserter/chest tube assembly over the guidewire </li></ul>Guidewire tube thoracostomy
  64. 64. <ul><li>The guidewire and chest tube inserter have been removed, leaving the chest tube positioned with the pleural space </li></ul>Guidewire tube thoracostomy
  65. 65. Trocar tube thoracostomy <ul><li>Insertion of trocar into the pleural space </li></ul><ul><li>Note the position of the hands, the position of the trocar relative to the ribs </li></ul>
  66. 66. Trocar tube thoracostomy <ul><li>Insertion of the chest tube through the trocar </li></ul>
  67. 67. Operative tube thoracostomy <ul><li>The physician’s index finger is used to enlarge the opening and to explore the pleural space </li></ul>Is it brutal? No!
  68. 68. <ul><li>Placement of chest tube intrapleurally using large hemostat </li></ul>Operative tube thoracostomy
  69. 69. Drainage system
  70. 70. One bottle system <ul><li>Consists of one bottle that serves as both a collection container and a water seal </li></ul><ul><li>The chest tube is connected to a rigid straw inserted through a stopper into a sterile bottle </li></ul><ul><li>Enough sterile saline solution is instilled into the bottle so that the tip of the rigid straw is about 2 cm below the surface of the saline solution </li></ul><ul><li>The bottle’s stopper must have a vent to prevent pressure from building up when air or fluid coming from the pleural space enters the bottle </li></ul>
  71. 71. One bottle system
  72. 72. <ul><li>This system works as follow </li></ul><ul><ul><li>When the pleural pressure is positive, the pressure in the rigid straw becomes positive </li></ul></ul><ul><ul><li>If the pressure inside the rigid straw is greater than the depth to which the straw is inserted into the saline solution, air will enter the bottle </li></ul></ul><ul><ul><li>Air will be vented to the atmosphere </li></ul></ul><ul><ul><li>If the pleural pressure is negative, saline will be drawn from the bottle into the rigid straw and no extra air will enter the system </li></ul></ul>One bottle system
  73. 73. Three bottle system <ul><li>Three bottle system consists of </li></ul><ul><ul><li>Collection bottle – for collecting pleural fluid </li></ul></ul><ul><ul><li>Water seal bottle – for regulating pressure </li></ul></ul><ul><ul><li>Suction control bottle – connect to the negative pressure pump, for suction of the air of pleural space, pres level: -10 - -20 cm H 2 O </li></ul></ul>
  74. 74. <ul><li>When suction is applied to the suction-control bottle, air enter this bottle through its rigid straw if the pressure in the bottle is more negative than the depth to which the straw is submerged </li></ul>Three bottle system
  75. 75. 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>
  76. 76. 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>It occurs 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>
  77. 77. Chemical pleurodesis <ul><li>Goals </li></ul><ul><ul><li>To prevent 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>
  78. 78. 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>
  79. 79. <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
  80. 80. <ul><li>Side effct </li></ul><ul><li>Chest pain </li></ul><ul><li>Fever </li></ul><ul><li>Dyspnea </li></ul><ul><li>Acute respiratory distress syndrome </li></ul><ul><li>Acute respiratory failure </li></ul>Chemical pleurodesis
  81. 81. 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>
  82. 82. Complications of pneumothorax <ul><li>Pyopneumothorax </li></ul><ul><ul><li>Caused by aspiration or intercostal chest tube insertion (iatrogenic) </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>
  83. 83. <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
  84. 84. Complications
  85. 85. Complications
  86. 86. <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 – surgical emphysema </li></ul></ul><ul><li>Physical exam – crepitus is present </li></ul>Complications
  87. 87. Complications Pneumomediastinum Pneumocardium Pneumoperitoneum Surgical emphysema
  88. 88. Complications Subcutaneous emphysema
  89. 89. 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>
  90. 90. Case study <ul><li>Female, 20 </li></ul><ul><li>Chest pain 3 hours, and suddenly dyspnea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Marked tachycardia </li></ul><ul><li>Profuse diaphoresis </li></ul>
  91. 91. Questions <ul><li>The diagnosis is </li></ul><ul><li>A. PSP </li></ul><ul><li>B. SSP </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>
  92. 92. Questions <ul><li>Which choice is right </li></ul><ul><li>Stable </li></ul><ul><li>unstable </li></ul><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>
  93. 93. Case study <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>
  94. 94. Questions <ul><li>The diagnosis is </li></ul><ul><li>A. AECOPD </li></ul><ul><li>B. asthma episode </li></ul><ul><li>C. PSP </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>