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  • 1. PNEUMOTHORAX Xie Can Mao 1st Affiliated Hospital of Sun Yat-sen Universty
  • 2. Introduction
    • The term pneumothorax was first coined by Itard, a student of Laennec, in 1803
    • Laennec described the clinical picture of pneumothorax in 1819
    • 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”
  • 3. Introduction
    • The modern description of primary spontaneous pneumothorax occurring in otherwise healthy people was provided by Kjaergard in 1932
    • Primary pneumothorax remains a significant global problem
    • The incidence is 18-28/100 000 per year for men and 1.2-6/100 000 per year for women
  • 4. Introduction
    • Secondary pneumothorax is associated with underlying lung disease, whereas primary pneumothorax is not
    • By definition, there is no apparent precipitating event in either
    • 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
    • Mortality rates in the UK were 0.62/million for men between 1991 and 1995
  • 5. Contents
    • What is pneumothorax
    • Pathogenesis and mechanisms
    • Pathophysiology
    • Clinical typing
    • Clinical manifestation
    • Diagnosis and differentiate diagnosis
    • Treatment
  • 6. What is pneumothorax
    • Pleural cavity is a latent closed space, in which there is no air
    • The total gas pressure of capillaries is 706 mmHg, 54 mmHg less than atmosphere
    • Pneumothorax is defined as air in the pleural space
    • That is, air between the lung and chest wall, or in other term, air between the visceral pleura and the parietal pleura
  • 7. Pneumothorax
  • 8. Classification of pneumothorax
    • Divided into three types
      • Spontaneous having an unknown cause or occurring as a consequence of the nature course of a disease process, such as COPD, tuberculosis
      • Traumatic following any penetrating or non-penetrating chest trauma, with or without bronchial rupture
      • Iatrogenic occurring as the results of diagnostic or therapeutic medical procedure. Intentional or a complication
  • 9.
    • Spontaneous pneumothoraces are subclassified as:
      • Primary spontaneous pneumothorax (PSP)
      • Healthy people, most young people
      • Secondary spontaneous pneumothorax (SSP)
      • Underlying diseases
      • Chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis
    Clinical typing of pneumothorax
  • 10. Pathogenesis and mechanisms
    • In normal people, the pressure in pleural space is negative during the entire respiratory cycle
    • Two opposite forces result in negative pressure in pleural space:
    • inherent outward pull of the chest wall and inherent elastic recoil of the lung
    • The negative pressure will be disappeared if any communication develops
  • 11.
    • When a communication develops between an alveolus or other intrapulmonary air space and pleural space
    • air will flow into the pleural space until there is no longer a pressure difference or until the communication is sealed
    Pathogenesis and mechanisms
  • 12. Pathogenesis and mechanisms
    • When a communication develops through the chest wall between the atmosphere and the pleural space
    • air will enter the pleural space until the pressure gradient is eliminated or the communication is closed
  • 13.
    • Pneumothorax:
      • Negative pressure eliminated
        • The lung recoil-small lung-volume decrease
        • V/Q decrease-shunt increase
      • Positive pressure
        • Compress blood vessels and heart
        • decreased cardiac output
        • Impaired venous return
        • Hypotension
        • Shock
      • Result in
        • A decrease in vital capacity
        • A decrease in PaO 2
  • 14.
    • Thoracoscopic studies
      • Blebs
        • Air filled spaces between the lung parenchyma and the visceral pleura
    Pathophysiology Shows a similar cystic space, completely surrounded by pl pleura
  • 15.
    • Bullae
      • Air filled spaces within the lung parenchyma itself
    Pathophysiology Lung parenchyma Surrounded by fibrous tissue
  • 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. Bullae
  • 18.
    • Blebs and bullae are also known as emphysema-like changes (ELCs)
    • The probable cause of pneumothorax is rupture of an apical bleb or bulla
    • 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
  • 19.
    • It is often hard to assess whether bullae are the site of leakage, and where the site of rupture of the visceral pleura is
    • Smoking causes a 9-fold increase in the relative risk of a pneumothorax in females
    • A 22-fold increase in male smokers
    • With a dose-response relationship between the number of cigarettes smoked per day and occurrence of PSP
  • 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. Clinical manifestation
    • Symptom
      • Depend on whether underlying pulmonary disease or not
      • Depend on the speed of pneumothorax occurred
      • Depend on size of pneumothorax
      • Depend on the level of intrapleual pressure
    • The patient with underlying pulmonary disease will undergo severe dyspnea
    • The healthy person will have minimal symptoms although having large volume of pneomothorax
  • 22.
    • Happened most patients at rest and some during heavy exercise
    • Chest pain-prickling-like, cutting-like
      • Having an acute onset
      • Air stimulates pleura
    • Dyspnea
      • Collapsed lung and vital capacity decrease
    • Dry cough
      • Air stimulates pleura
    Clinical manifestation
  • 23.
  • 24.
    • Tension pneumothorax
    • risk factors
      • Receiving positive-pressure mechanical ventilation
      • During cardiopulmonary resuscitation
      • Undergoing hyperbaric oxygen therapy
      • Evolving during the course of spontaneous pneumothorax
    Clinical manifestation
  • 25. Tension pneumothorax
  • 26.
    • Tension pneumothorax
      • Distressed with rapid labored respiration
      • Cyanosis
      • Marked tachycardia
      • Profuse diaphoresis
    • Patient who suddenly deteriorate clinically,
    • be suspected if the patient with
      • Mechanical ventilation
      • Cardiopulmonary resuscitation
    Clinical manifestation
  • 27.
    • Physical examination
      • Depend on size of pneumothorax
      • Depend on whether pleural effusions or not
      • The vital signs usually normal
      • The side with pneumothorax is larger than the contralateral side
      • Chest moves less during the respiratory cycle
    Clinical manifestation
  • 28.
    • Physical examination
      • Tactile fremitus is absent
      • The percussion note is hypersonant
      • The breath sounds are reduced or absent on the affected side
      • The lower edge of the liver may be shifted inferiorly with a right-side pneumothorax
      • The trachea may be shifted toward the contralateral side if the pneumothorax is large
    Clinical manifestation
  • 29. Clinical stability
    • Stable patients
    • RR: <24/min
    • HR: 60-120/min
    • BP: normal
    • SO 2 : >90% (room air)
    • Patient can speak in whole sentences between breaths
    • All above present
    • Unstable patients
    • Not fulfilling the definition of stable
    Evaluate the severity and make decision for treatment
  • 30. Imaging- Plane chest X-ray film
    • Establishing the diagnosis
    • The characteristics of pneumothorax
      • Pleural line
      • No lung markings in pneumothorax
    • The outer margin of visceral pleura separated from the parietal pleura by a lucent gas space devoid of pulmonary vessels
  • 31. Plane chest X-ray film
    • In erect patients, pleural gas collects over the apex, and the space between the lung and chest wall is most notable there
    • In the supine position, gas migrates along the broad ventral surface of lung, making detection on a frontal radiograph difficult
  • 32. Plane chest X-ray film
    • It is very important to differentiate the pleural line of a pneumothorax from that of a skinfold, clothing, tubing, or chest wall artifact
    • 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
  • 33. Plane chest X-ray film
    • In the absence of underlying lung disease, the pleural line of a pneumothorax usually parallels the shape of chest wall
    • Artifactual densities generally do not parallel the course of the chest wall over their entire length
  • 34. Plane chest X-ray film
    • Quantification of the size
    • The size of a pneumothorax, in terms of volume, is difficult to assess accurately from a chest radiograph
    • The simple method to estimate the size
      • Small, a visible rim of < 2 cm between the lung margin and the chest wall
      • Large, a visible rim of ≥2 cm between the lung margin and chest wall
  • 35. Estimation of pneumothorax volume
    • Light equation pneumothorax %=( 1 - L 3 /HT 3 )  100
    • Kircher equation
      • pneumothorax %
      • Thorax area - lung area
      • Thorax area
    • Collins equation
      • 4.2+[4.7  (A+B+C)]
     100 Hemithorax (HT) Lung (L)
  • 36.
    • BTS guideline(1993)
      • Small
      • Moderate
      • large
    • BTS guideline(2003)
      • Lung margin to chest wall
      • small<2cm
      • large ≥ 2cm
    • ACCP guideline
      • Lung apex to chest top
      • Small <3cm
      • large≥3cm
    Estimation of pneumothorax volume
  • 37.
    • Since the volume of a pneumothorax approximates to the ratio of the cube of the lung diameter to the hemithorax diameter
    • A pneumothorax of 1 cm on the PA chest radiograph occupies about 27% of the hemithorax volume
      • Lung is 9 cm, hemithorax is 10 cm in diameter
    • Equation
      • Volume of pneumothorax = (HT 3 – L 3 ) ÷ HT 3
      • = (10 3 – 9 3 ) ÷ 10 3
      • = (1000 – 729) ÷1000
      • = 0.27
    Plane chest X-ray film
  • 38.
    • A pneumothorax of 2 cm on the PA chest radiograph occupies about 49% of the hemithorax volume
      • Lung is 8 cm, hemithorax is 10 cm in diameter
    • Equation
      • Volume of pneumothorax = (HT 3 – L 3 ) ÷ HT 3
      • = (10 3 – 8 3 ) ÷ 10 3
      • = (1000 – 512) ÷1000
      • = 0.49
    Plane chest X-ray film
  • 39. CT scanning
    • CT scanning is the most robust approach if accurate size estimates are required
    • It is only recommended to difficult cases such as patients in whom the lungs are obscured by overlying surgical emphysema
    • To differentiate a pneumothorax from suspected bulla in complex cystic lung disease
  • 40. CT scanning bullae pneumothorax
  • 41. CT scanning bullae pneumothorax pneumothorax
  • 42. CT scanning pneumothorax
  • 43. CT scanning Small pneumothorax Subcutaneous emphysema
  • 44. Differentiation
    • Asthma and obstructive emphysema
      • Repeated wheezing episode
      • Dyspnea gradually progress
      • In the course of disease, if patients
        • Onset of severe dyspnea, cold sweat, dysphoria
        • No response to bronchial dilators, antibiotics
      • Consider pneumothorax
      • Chest X-ray radiograph to conform the diagnosis
  • 45.
    • Goals
      • To promote lung expansion
      • To eliminate the pathogenesis
      • To decrease pneumothorax recurrence
    • Treatment options according to
      • Classification of pneumothorax
      • Pathogenesis
      • Pneumothorax frequency
      • The extension of lung collapse
      • Severity of disease
      • Complication and concomitant underlying diseases
  • 46. Observation - PSP
    • Observation along is advised for small, closed mildly symptomatic spontaneous pneumothoraces
    • Patients with small PSP and minimal symptoms do not require hospital admission
    • However, it should be stressed before discharge that they should be return directly to hospital in the event of developing breathlessness
    • Most patients in this group who fail this treatment have secondary pneumothoraces
  • 47.
    • Observation along is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothoraces in asymptomatic patients
    • Hospitalisation is recommended in these cases
    • All other cases will require active intervention ( aspiration or chest drain insertion)
    Observation - SSP
  • 48.
    • Marked breathlessness in a patient with a small (<2 cm) PSP may herald tension pneumothorax
    • Observation along is inappropriate and active intervation is required
    • If a patient is hospitalised for observation, supplemental high flow (10 l/min) oxygen should be given where feasible
    Observation - PSP or SSP
  • 49.
    • Inhalation of high concentration of oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen
    • This should increase the pressure gradient between the pleural capillaries and the pleural cavity
    • Thereby increasing absorption of air from the pleural cavity
    Observation - PSP or SSP
  • 50.
    • The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25 – 1.8% of volume of hemithorax every 24 hours
    • 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
    Observation - PSP or SSP
  • 51. Simple aspiration
    • Simple aspiration is recommended as first line treatment for all PSP requiring intervention
    • 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
    • Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge
  • 52.
    • Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful
    • A volume of < 2.5 L has been aspirated on the first attempt
    • The aspiration can be used by needle or catheter
    Repeated and catheter aspiration
  • 53. Catheter aspiration
    • Catheter aspiration of pneumothorax can be used where the equipment and experience is available
  • 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. Intercostal tube drainage
  • 56.
      • Unstable pneumothorax
      • Severe dyspnea
      • Large lung collapse
      • Open or tension pneumothoraces
      • Frequent recurrent pneumothoraces
      • Simple aspiration or catheter aspiration drainage is unsuccessful in controlling symptoms
    Intercostal tube drainage
  • 57.
    • Position of intercostal tube
    • The chest tube should be positioned in the uppermost part of the pleural space, where residual air accumulates
    • This procedure permits the air in the pleural space to be evacuated rapidly
    Intercostal tube drainage
  • 58.
    • The site of chest tube insertion is in the midclavicular line of second and third intercostal
    • or anterior axillary line of fifth and sixth intercostal
    Intercostal tube drainage
  • 59. Guidewire tube thoracostomy
    • Making a small skin incision slightly larger than the diameter of the chest tube
  • 60.
    • Introduction of 18-gauge needle into the pleural space
    Guidewire tube thoracostomy
  • 61.
    • Insertion of wire with “J” end into the pleural space
    Guidewire tube thoracostomy
  • 62.
    • With guidewire in space, the tract is enlarged by advancing progressively larger dilators over the wire guide
    Guidewire tube thoracostomy
  • 63.
    • Introduction the chest tube inserter/chest tube assembly over the guidewire
    Guidewire tube thoracostomy
  • 64.
    • The guidewire and chest tube inserter have been removed, leaving the chest tube positioned with the pleural space
    Guidewire tube thoracostomy
  • 65. Trocar tube thoracostomy
    • Insertion of trocar into the pleural space
    • Note the position of the hands, the position of the trocar relative to the ribs
  • 66. Trocar tube thoracostomy
    • Insertion of the chest tube through the trocar
  • 67. Operative tube thoracostomy
    • The physician’s index finger is used to enlarge the opening and to explore the pleural space
    Is it brutal? No!
  • 68.
    • Placement of chest tube intrapleurally using large hemostat
    Operative tube thoracostomy
  • 69. Drainage system
  • 70. One bottle system
    • Consists of one bottle that serves as both a collection container and a water seal
    • The chest tube is connected to a rigid straw inserted through a stopper into a sterile bottle
    • 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
    • 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
  • 71. One bottle system
  • 72.
    • This system works as follow
      • When the pleural pressure is positive, the pressure in the rigid straw becomes positive
      • 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
      • Air will be vented to the atmosphere
      • 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
    One bottle system
  • 73. Three bottle system
    • Three bottle system consists of
      • Collection bottle – for collecting pleural fluid
      • Water seal bottle – for regulating pressure
      • 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
  • 74.
    • 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
    Three bottle system
  • 75. Observation of drainage
    • No bubble released
      • The lung reexpansion
      • The chest tube is obstructed by secretion or blood clot
      • The chest tube shift to chest wall, the hole of the chest tube is located in the chest wall
    • If the lung reexpansion, removing the chest tube 24 hours after reexpansion
    • Otherwise, the chest tube will be inserted again or regulated the position
  • 76. Complications of intercostal tube drainage
    • Penetration of major organs
      • Lung, stomach, spleen, liver, heart and great vessels
      • It occurs more commonly when a sharp metal trocar is inappropriately applied
    • Pleural infection
      • Empyema, the rate of 1%
    • Surgical emphysema
      • Subcutaneous emphysema
  • 77. Chemical pleurodesis
    • Goals
      • To prevent pneumothorax recurrence
      • To produce inflammation of pleura and adhesions
    • Indications
      • Persist air leak and repeated pneumothorax
      • Bilateral pneumothoraces
      • Complicated with bullae
      • Lung dysfunction, not tolerate to operation
  • 78. Chemical pleurodesis
    • Sclerosing agents
      • Tetracycline
      • Minocycline
      • Doxycline
      • Talc
      • Erythromycin
    • The instillation of sclerosing agents into the pleural space should lead to an aseptic inflammation with dense adhesions, leading ultimately to pleural symphysis
  • 79.
    • Methods
      • Via chest tube or by surgical mean
      • Administration of intrapleural local anaesthesia, 200 – 400 mg lidocaine intrapleurally injection
      • Agents diluted by 60 – 100 ml saline
      • Injected to pleural space
      • Clamp the tube 1 – 2 hours
      • Drainage again
      • Observed by chest X-ray film, if air of pleural space is absorption, remove the chest tube
      • If pneumothorax still exist, repeated pleurodesis
    Chemical pleurodesis
  • 80.
    • Side effct
    • Chest pain
    • Fever
    • Dyspnea
    • Acute respiratory distress syndrome
    • Acute respiratory failure
    Chemical pleurodesis
  • 81. Surgical treatment
    • Indication
      • No response to medical treatment
      • Persist air leak
      • Hemopneumothorax
      • Bilateral pneumothoraces
      • Recurrent pneumothorax
      • Tension pneumothorax failed to dainage
      • Thicken pleura makes lung unable to reexpansion
      • Multiple blebs or bullae
  • 82. Complications of pneumothorax
    • Pyopneumothorax
      • Caused by aspiration or intercostal chest tube insertion (iatrogenic)
      • Also results from necrotic pneumonia, lung abscess, or caseous pneumonia
    • Chest X-ray shows hydropneumothorax
    • The pleural effusion is purulent
    • Antibiotics and intercostal drainage
    • Surgical mean
  • 83.
    • Hemopneumotorax
      • Bleeding in pleural space
      • Common cause is rupture of vessels in adhesions
      • When lung reexpansion, bleeding will stop
    • When bleeding persists, surgical ligation will be needed
    • Infusion
  • 84. Complications
  • 85. Complications
  • 86.
    • Mediastinal and subcutaneous emphysema
      • Alveoli rupture, the air enter into pulmonary interstitial, and then goes into mediastinal and subcutaneous tissues
      • After aspiration or intercostal chest tube insertion, the air enters the subcutaneous by the needle hole or incision – surgical emphysema
    • Physical exam – crepitus is present
  • 87. Complications Pneumomediastinum Pneumocardium Pneumoperitoneum Surgical emphysema
  • 88. Complications Subcutaneous emphysema
  • 89. complications
    • Treatment
      • Automatic absorption when pneumothorax is gone
      • Inhalation of high concentration of oxygen
      • Making a small incision in suprasternal pit for draining the air from mediastinal and subcutaneous tissues
  • 90. Case study
    • Female, 20
    • Chest pain 3 hours, and suddenly dyspnea
    • Cyanosis
    • Marked tachycardia
    • Profuse diaphoresis
  • 91. Questions
    • The diagnosis is
    • A. PSP
    • B. SSP
    • C. pulmonary embolism
    • D. Asthma episode
    • The type of pneumothorax is
    • A. closed
    • B. open
    • C. tension
    • D. hemothorax
  • 92. Questions
    • Which choice is right
    • Stable
    • unstable
    • Which treatment is the first step
    • A. oxygen inhalation
    • B. bronchial dilators
    • C. aspiration
    • D. chest tube drainage
  • 93. Case study
    • Male, 70
    • Dyspnea 24 hours
    • No chest pain
    • COPD history 20 ys
    • Cyanosis
    • Marked tachycardia
  • 94. Questions
    • The diagnosis is
    • A. AECOPD
    • B. asthma episode
    • C. PSP
    • D. SSP
    • Which treatment prefer
    • A. oxygen therapy
    • B. aspiration
    • C. chest tube
    • D. surgical procedure