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(Pneumothorax
- 1. Pneumothorax By Dr. MD ABDULLAH SALEEM 1
- 2. What is pneumothorax Pneumothorax is defined as presence of air or gas in the pleural space (OR) air between the lung and chest wall, in other term, air between the visceral pleura and the parietal pleura 2
- 3. Mechanism 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. (outward pull of the chest wall and elastic recoil of the lung) The negative pressure will be disappeared if any communication develops . 3
- 4. 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 the communication is sealed 4
- 5. Pathophysiology Negative pressure eliminated The lung recoil-& lung-volume decrease V/Q low –anatomic shunt hypoxia Positive pressure ◦ Compress blood vessels and heart ◦ Decreased cardiac output ◦ Impaired venous return ◦ Hypotension Result in ◦ A decrease in vital capacity ◦ A decrease in PaO2 5
- 6. CLASSIFICATION OF PNEUMOTHORAX 6 Pneumothorax Spontaneous Primary Secondary Traumatic Iatrogenic Interventional procedures. Positive pressure ventilation Non iatrogenic Penetrating trauma Blunt trauma.
- 7. Primary spontaneous pneumothorax It occurs in young healthy individuals without underlying lung disease. It is due to rupture of apical sub-pleural bleb or bullae Predisposing factors: Smoking. Tall, thin male. Airway inflammation (distal) Structural abnormalities of bronchial tree Genetic contribution 7
- 8. Secondary spontaneous pneumothorax: It is seen in pt with underlying lung disease. INFECTION: Tb Acute bacteria pneumonia Copd Obstructive lung disease ILD Fibrosis Eosinophilic granuloma Sarcoidosis Lymphangioleiomyomatosis.. Malignancy: Primary lung carcinoma Complication of chemotherpy Connective tissue disease Scleroderma Marfans syndrome Catamenial pneumothorax Pulmonary infract Wegegner’s granulomatosis… 8
- 9. Clinical manifestation Dyspnea Chest pain ( pleuritic) Uncommon manifestation Cough Hemoptysis Orthopnea Cyanosis Mod tachycardia 9
- 10. Traumatic pneumothorax Accidental trauma:(non-iatrogenic) Blunt trauma: with fracture ribs. Penetrating trauma: stab wound or gun shot injury. Iatrogenic : Positive pressure ventilation: Alveolar rupture interstitial emphysema pneumothorax. Interventional procedures: Biopsy, thoraco-centesis, CVP line,trachestomy etc.. 10
- 11. 11 clinical type of PNX Pneumothorax Closed pneumothorax Open pneumothorax Tension pneumothorax
- 12. 12 Closed pneumothorax Open pneumothorax Tension pneumothorax The pleural tear Is sealed The pleural tear is open The pleural tear act as a ball & valve mechanism The pleural cavity pressure is < the atmospheric pressure The pleural cavity pressure is = the atmospheric pressure The pleural cavity pressure is > the atmospheric pressure
- 13. Clinical manifestation Tension pneumothorax ◦ Distressed with rapid labored respiration ◦ Cyanosis ◦ Marked tachycardia Patient who suddenly deteriorate clinically, be suspected in the patient with ◦ Mechanical ventilation ◦ Cardiopulmonary resuscitation 13
- 14. Physical examination ◦ Depend on size of pneumothorax ◦ The vital signs usually normal ◦ Unilateral Chest movements ◦ The trachea may be shifted toward the contralateral side if the pneumothorax is large ◦ 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 14
- 16. Radiological manifestation cxray in erect position cxray in supine position 16
- 21. 21
- 22. Quantification of the size 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 Light index Measure transverse Diameters of lung and Compare it with diameter hemithorax 22 22 Hemithorax (HT) Lung (L)
- 23. CT scanning It is recommended in 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 23
- 24. 24 CT can diagnose easily pneumothroax
- 25. 25 25 CT scanning Small pneumothorax Subcutaneous emphysema
- 26. MANAGMENT Goals ◦ To promote lung expansion ◦ To eliminate the pathogenesis ◦ To decrease pneumothorax recurrence Treatment options according to ◦ Classification of pneumothorax ◦ Pathogenesis ◦ The extension of lung collapse ◦ Severity of disease ◦ Complication and concomitant underlying diseases 26
- 27. TREATMENT OPTIONS FOR PSP AND SSP Observation O2 treatment Simple aspiration Small catheter aspiration Chest tube drainage Thoracoscopy (VAT with blebtomy & VAT with pleurectomy) Open (axillary) thoracotomy 27
- 28. Observation - PSP Small, closed mildly symptomatic spontaneous pneumothorax. Do not require hospital admission It should be stressed to patient that they should be return directly to hospital in the event of developing breathlessness. 28
- 29. Observation - SSP Observation along is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothorax in asymptomatic patients Hospitalization is recommended in these cases All other cases will require active intervention ( aspiration or chest drain insertion) 29
- 30. 30 Marked breathlessness in a patient with a small (<2 cm) PSP may develop tension pneumothorax Observation 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
- 31. 31 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 O2 TREATMENT-- PSP or SSP
- 32. 32 The rate of resolution/reabsorption of spontaneous pneumothorax 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
- 33. 33 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
- 34. 34 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 Catheter aspiration
- 35. Intercostal tube drainage INDICATIONS ◦ Unstable pneumothorax ◦ Severe dyspnea ◦ Large lung collapse ◦ Open or tension pneumothorax ◦ Recurrent pneumothorax ◦ Simple aspiration or catheter aspiration drainage is unsuccessful in controlling symptoms 35
- 36. 36 36 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
- 37. 37 37 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
- 38. 38 Trocar tube thoracostomy Insertion of trocar into the pleural space.
- 39. 39 Trocar tube thoracostomy Insertion of the chest tube through the trocar
- 40. 4 Operative tube thoracostomy The physician’s index finger is used to enlarge the opening and to explore the pleural space Placement of chest tube Intrapleurally using large hemostat
- 41. 41 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.
- 42. 42 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
- 43. 43 Chemical pleurodesis Goals ◦ To prevent pneumothorax recurrence ◦ To produce inflammation of pleura and adhesions Indications ◦ Persist air leak and repeated pneumothorax ◦ Bilateral pneumothorax ◦ Complicated with bullae ◦ Lung dysfunction, not tolerate to operation
- 44. 44 Chemical pleurodesis Sclerosing agents ◦ Tetracycline ◦ Doxycline ◦ Talc ◦ Erythromycin The instillation of sclerosing agents into the pleural space lead to an aseptic inflammation with dense adhesions.
- 45. 45 Methods ◦ Via chest tube or by surgical mean ◦ Administration of intrapleural local anaesthesia, 200 – 300 mg lidocaine intrapleurally injection ◦ Agents diluted by 60 – 100 ml saline ◦ Injected to pleural space ◦ Clamp the tube 4hours ◦ 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
- 46. 46 46 Side effct ◦ Chest pain ◦ Fever ◦ Dyspnea ◦ Acute respiratory distress syndrome ◦ Acute respiratory failure Chemical pleurodesis
- 47. 47 Surgical treatment Indications ◦ 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
- 48. Thoracoscopy- VATs It is being increasly used in ot with recurrent psp-ssp Recent studies show VATs it may be the procedure of choice and it has very less complication when compare to other open surgery Pleural belbs causes pneumothorax which can be treated by a method called endostapling or suturefollowed by pleurodosis 48
- 49. Axillary (open) thoracotomy Transaxillary minithoracotomy is preferred .when VATs isnot available Open thotacotomy with suturing of blebs and pleural abrasion is done Recurrence High risk professions B/L or tension pneumothorax 49 INDICATIONS
- 50. 50 Complications of pneumothorax Pyopneumothorax ◦ Caused by aspiration or intercostal chest tube insertion (iatrogenic) ◦ Also results from necrotic pneumonia, lung abscess, or caseous pneumonia Hydropneumothorax. Hemopneumotorax ◦ Bleeding in pleural space. ◦ Common cause is rupture of vessels in adhesions. ◦ When lung re-expansion, bleeding will stop. ◦ When bleeding persists, surgical ligation will be needed.
- 51. 51 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. Subcutaneous emphysema
- 52. 52 THANK YOU
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