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
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6. CLASSIFICATION OF PNEUMOTHORAX
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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
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15. Lab investigations
and Diagnosis
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16. Radiological manifestation
cxray in erect position cxray in supine position
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17. Small pneumothorax
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18. 18
Small pneumothorax

19. 19
pneumothorax with mediastinal
shift

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Pneumothorax ?

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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
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CT can diagnose easily
pneumothroax

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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
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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.
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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)
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 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

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 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

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 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

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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

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 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

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 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

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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

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Trocar tube thoracostomy
 Insertion of trocar into the pleural space.

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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

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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.

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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

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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

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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.

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 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

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 Side effct
◦ Chest pain
◦ Fever
◦ Dyspnea
◦ Acute respiratory distress syndrome
◦ Acute respiratory failure
Chemical pleurodesis

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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
suturefollowed by pleurodosis
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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
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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.

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 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

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THANK YOU

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