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pneumothorax
- 1. Pneumothorax Definition; accumulation of air within pleural space
- 3. Anterior & Posterior junction lines
- 4. Bleb & Bulla
- 5. Ethiological Classification Gunshot, stab wound, RTAs, Explosions CV Catheter insertion, Mechanical ventilation, lung biopsy, Post pull pneumothorax
- 6. 1. Primary / idiopathic spontaneous pneumothorax (80%) Cause: rupture of subpleural blebs in lung apices 2. Secondary spontaneous pneumothorax (20%): • (a) Air-trapping disease: Chronic obstructive pulmonary disease is the most common predisposing disorder • (b) Pulmonary Infection: lung abscess, necrotizing pneumonia, hydatid disease, pertussis, acute bacterial pneumonia, Staphylococcus aureus, Pneumocystis carinii pneumonia • (c) Granulomatous disease: tuberculosis, coccidioidomycosis, sarcoidosis, berylliosis • (d) Malignancy: • (e) Connective tissue disorder: scleroderma, rheumatoid disease, Marfan syndrome, Ehlers-Danlos syndrome • (f) Pneumoconiosis: silicosis, berylliosis • (g) Vascular disease: pulmonary infarction • (h) Catamenial pneumothorax • (i) Neonatal disease: meconium aspiration, respirator therapy for hyaline membrane • disease • (j) Cx of honeycomb lung:
- 7. Pneumothorax X-Ray Typically demonstrate: • visible visceral pleural edge is seen as a very thin, sharp white line • no lung markings are seen peripheral to this line • peripheral space is radiolucent compared to the adjacent lung • lung may completely collapse • subcutaneous emphysema and pneumomediastinum may also be present
- 8. Tension Pneumothorax Intrapleural pressure exceeds atmospheric pressure in lung during expiration - (check-valve mechanism)
- 9. Tension Pneumothorax Hyperexpanded ipsilateral chest Mediastinal shift to contralateral side Contralateral displacement of anterior junction line “deep sulcus” sign = on frontal view larger lateral costodiaphragmatic recess than on opposite side Flattening / inversion of ipsilateral hemidiaphragm Total / subtotal collapse of ipsilateral lung Collapse of SVC / IVC / right heart border decreased systemic venous return + decreased cardiac output Sharp delineation of visceral pleural by dense pleural space N.B.: Medical emergency!
- 10. Fractures of the ribs 3-8 with obvious displacement of the 5th and 6th ribs. The thin pleural line and the lack of the pulmonary vessels in the right apex are clearly visible reflecting a pneumothorax
- 11. Skinfold vs Pleural line
- 13. Pneumothorax in Supine Patient • 1. Anteromedial pneumothorax (earliest location) • 2. Subpulmonic / anterolateral pneumothorax (2nd most common location) • 3. Apicolateral pneumothorax (least common location) • 4. Posteromedial pneumothorax (in presence of lower lobe collapse) • 5. Pneumothorax → outlines pulmonary ligament FIGURE 2. Anatomic localization of the pleural recesses according to the hilum and lung. A, Suprahilar anteromedial pleural recess. B, Infrahilar anteromedial pleural recess. C, Subpulmonic pleural recess. D, Posteromedial pleural recess. E, Apicolateral pleural recess.
- 14. Anteromedial pneumothorax (earliest location) • outline of medial diaphragm under cardiac silhouette • Improved definition of mediastinal contours (SVC, azygos vein, left subclavian artery, anterior junction line, superior pulmonary vein, heart border, IVC, pericardial fat-pad)
- 15. Subpulmonic Pneumothorax • Signs of subpulmonic pneumothorax 1.Hyperlucent upper quadrant of the abdomen 2.Deep lateral costophrenic sulcus 3.Visualization of the anterior costophrenic sulcus 4.A sharply outlined diaphragm in spite of parenchymnal disease has also been used as a sign of subpulmonic pneumothorax
- 16. Sonographic Features of Normal Lung • • BATWING SIGN • • PLEURAL LINE • • SLIDING LUNG • • A LINES AND B LINES • • LUNG PULSE
- 17. Batwing Sign
- 18. PLEURAL LINE/SLIDING SIGN: • Most important finding in normal aerated lung • Two different patterns are displayed: motionless portion above the pleural line – Horizontal waves • • Sliding below the pleural line – granular pattern (sand) in M mode. • • The resulting picture resembles waves crashing onto the sand – Seashore sign (indicating normal aerated lung) Stratosphere sign/Barcode Sign
- 19. Lung Sliding
- 21. Normal Lung vs Pneumothorax
- 22. Pneumothorax Size BTS guidelines; Distance btw pleura n chest wall A. Less than 1cm - Very small B. 1-2 cm - Moderate C. Greater than 2 - Very large.
- 23. Pneumothorax Size LIGHTS METHOD Pneumothorax % Size of PTX: ratio of lung diameter cubed to hemithorax diameter cubed
- 24. Neonatal Pneumothorax Signs of neonatal pneumothorax are 1. “large hyperlucent hemithorax” sign 2. “medial stripe” sign
- 25. Catamenial Pneumothorax • [kata, Greek = according to; men, Greek = month] • = recurrent spontaneous pneumothorax during menstruation associated with endometriosis of the diaphragm; R >> L
- 26. FAST Exam
Editor's Notes
- CT Anterior junction line Xray 1 posterior junction line
- 1. Primary / idiopathic spontaneous pneumothorax (80%) Cause: rupture of subpleural blebs in lung apices Age: 20.40 years; M€F = 8€1; esp. in patients with tall asthenic stature; mostly in smokers . chest pain (69%), dyspnea Prognosis: recurrence in 30% on same side, in 10% on contralateral side Rx: simple aspiration (in > 50% success) / tube thoracostomy (in 90% effective) 2. Secondary spontaneous pneumothorax (20%): (a) Air-trapping disease: spasmodic asthma, diffuse emphysema, Langerhans cell histiocytosis, lymph-angiomyomatosis, tuberous sclerosis, cystic fibrosis . Chronic obstructive pulmonary disease is the most common predisposing disorder of secondary spontaneous pneumothorax. (b) Pulmonary infection: lung abscess, necrotizing pneumonia, hydatid disease, pertussis, acute bacterial pneumonia, Staphylococcus aureus, Pneumocystis carinii pneumonia (c) Granulomatous disease: tuberculosis, coccidioidomycosis, sarcoidosis, berylliosis (d) Malignancy: primary lung cancer, lung metastases (esp. osteosarcoma, pancreas, adrenal, Wilms tumor) (e) Connective tissue disorder: scleroderma, rheumatoid disease, Marfan syndrome, Ehlers-Danlos syndrome (f) Pneumoconiosis: silicosis, berylliosis 1423 (g) Vascular disease: pulmonary infarction (h) Catamenial pneumothorax (i) Neonatal disease: meconium aspiration, respirator therapy for hyaline membrane disease (j) Cx of honeycomb lung: pulmonary fibrosis, cystic fibrosis, sarcoidosis, scleroderma, eosinophilic granuloma, interstitial pneumonitis, Langerhans cell histiocytosis, rheumatoid lung, idiopathic pulmonary hemosiderosis, pulmonary alveolar proteinosis, biliary cirrhosis
- hyperexpanded ipsilateral chest √ mediastinal shift to contralateral side √ contralateral displacement of anterior junction line √ “deep sulcus” sign = on frontal view larger lateral costodiaphragmatic recess than on opposite side √ flattening / inversion of ipsilateral hemidiaphragm √ total / subtotal collapse of ipsilateral lung √ collapse of SVC / IVC / right heart border ← decreased systemic venous return + decreased cardiac output √ sharp delineation of visceral pleural by dense pleural space N.B.: Medical emergency!
- Skin folds mimicking a right pneumothorax (arrows). The laterally located blood vessels, the wide margin of the lines, and the orientation of the lines that is inconsistent with the edge of a slightly collapsed lung help to differentiate them from a real pneumothorax.
- . Large, avascular bullae or thin-walled cysts have concave rather than convex inner margins and do not exactly conform to the normal shape of the costophrenic sulcus when they occur at the lung base Large bullae simulating pneumothorax. The left lung is lucent, devoid of vessels, and almost completely replaced by bullae. The bullae have concave margins (arrows), unlike pneumothorax, in which the lung margin is convex and parallels the chest wall.
- In a patient with adult respiratory distress syndrome (ARDS)and an anteromedial pneumothorax (arrowheads), the contour of the ascending aorta, AO, azygos vein, AZ, and superior vena cava, SVC, remain sharply defined even when parenchymal disease is present in the right upper lobe. In the presence of an anteromedial pneumothorax, the lateral wall ofthe left subclavian artery, SCA, and aortic knob become sharply outlined. A pleural line is seen which is displaced laterally (arrowheads). The cardiophrenic sulcus becomes the preferential site for pleural air collection in the supine position, when the air volume is small. In this young patient with head and chesttrauma, a deep anterior cardiophrenic angle is the first evidence of pneumothorax (arrowhead).
- The hyperlucent right and left upper quadrants with well defined, deep costophrenic sulci are secondary to a subpulmonic pneumothorax in this patientwith head and chesttrauma. The clear outline of the apex of the heart is also due to the subpulmonic pneumothorax. In this patient with head and myocardial trauma, deep costophrenic sulci bilaterally raise the suspicion of bilateral n spite of parenchymal disease in this patient with ARDS, the hemidiaphragms are sharply outlined by bilateral subpulmonic pneumothoraces to the level of the posterior costophrenic sulci (arrowheads). The undersurfaces of the uplifted lower lobes
- NORMAL LUNG FINDINGS IN THORACIC ULTRASOUND • BATWING SIGN • PLEURAL LINE • SLIDING LUNG • A LINES AND B LINES • LUNG PULSE • POWER/ DOPPLER SLIDE SIGN PLEURAL LINE/SLIDING SIGN: Most important finding in normal aerated lung • Sonographer visualizes the hyperechoic pleural line in between two ribs moving back and forth • Lung sliding corresponds to the to and fro movement of the visceral pleural on the parietal pleura occuring with respiration. • Two different patterns are displayed: motionless portion above the pleural line – Horizontal waves • Sliding below the pleural line – granular pattern (sand) in M mode. • The resulting picture resembles waves crashing onto the sand – Seashore sign (indicating normal aerated lung)
- Stratosphere sign/Barcode Sign
- • B-LINES OR COMET-TAIL ARTIFACTS: are reverberation artifacts appearing as hyper echoic vertical lines that extend from the pleura to the edge of the screen. • Comet-tail artifacts move with lung sliding and respiratory movements • These artifacts are seen in normal lung due to acoustic impedance differences between the water and air • Excessive “B-lines” on the other hand may be abnormal – indicating interstitial edema A-lines are a type of reverberation artifact, equally spaced, horizontal lines originating from the hyperechoic pleural line. In normal lung, B-lines extend out and erase the “A-lines” A-LINES • “A-lines” are thoracic artifacts that help in the diagnosis of pneumothorax. • The space between each A-line corresponds to the same distance between the skin surface and the parietal pleura. • In the normal patient, B lines extend from the pleural line and erase the A lines • “A-lines” will be present in a patient with pneumothorax but “B -lines” will not be seen. • If lung sliding is absent with the presence of “A-lines” the sensitivity and specificity for occult pneumothorax is 95 and 94 % respectively
- Two lesser known signs of neonatal pneumothorax are presented : the “large, hyperlucent hemithorax” sign and the “medial stripe” sign. I
- Catamenial Epilepsy, Hemoptysis, Anaphylaxis