Pneumothorax

1. JAMIA MILLIA ISLAMIA
CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES
PNEUMOTHORAX
SUBMITTED BY – MD ASIF SUBMITTED TO-Dr. JAMAL ALI MOIZ
BPT 4TH YEAR

2. PNEUMOTHORAX
Spontaneous Pneumothorax
• Primary Spontaneous Pneumothorax
• Secondry Spontaneous Pneumothorax
Non-Spontaneous Pneumothorax
• Iatrogenic pneumothorax
• Non-Iatrogenic pneumothorax
Introduction
Spontaneous pneumothoraces occur without any preceding trauma or obvious
precipitating causes. Spontaneous pneumothorax that occurs in patients with no
underlying lung disease is termed primary spontaneous pneumothorax (PSP), while
secondary spontaneous pneumothorax (SSP) refers to those that develop in the
presence of an underlying lung condition, such as COPD, cystic fibrosis, or
Pneumocystis carinii pneumonia.
Nonspontaneous pneumothoraces are classified as traumatic and are subdivided
into non-iatrogenic and iatrogenic. Non-iatrogenic pneumothoraces can develop
following direct or indirect trauma, often to the chest, unrelated to any medical
procedure.
Iatrogenic pneumothoraces result from medical interventions.

3. Tension pneumothorax - progressive accumulation of air in the pleural cavity causing
the shift of mediastinum to the opposite side, resulting in compression of vena cava
and other great vessels, decreased diastolic filling, and ultimately compromised
cardiac output. It occurs when a chest injury causes a one-valve situation when the
air gets into the pleural cavity but is unable to escape freely and thus gets trapped.
Catamenial - is a non-traumatic pneumothorax that occurs in women in
conjunction with their menstrual period. Although not entirely understood, the cause
is believed to be endometriosis of the pleura.

4. Clinical features and Diagnosis
Pneumothorax should be suspected in patients who present with acute dyspnea
and chest pain (classically pleuritic), particularly in those with an underlying risk
factor .
The major competing diagnoses include acute pulmonary embolism, pleuritis,
pneumonia, myocardial ischemia or infarction, pericarditis, and musculoskeletal
pain.
Routine laboratories, electrocardiography, and chest imaging are usually
performed during the diagnostic evaluation process; it is the identification of a
pneumothorax on chest imaging that typically differentiates pneumothorax from
many of these entities. The evaluation of chest pain and dyspnea are discussed
separately.

5. The diagnosis is often made by upright chest radiograph, except tension
pneumothorax which is a clinical diagnosis.
Point of care ultrasound is commonly used in the evaluation patients with
pneumothorax. In fact, ultrasound can rapidly diagnosis pneumothoraces with
better accuracy than standard chest X-ray, while sparing the patient radiation
expsoure.
The definition of large vs. small pneumothorax is by the distance between the
lung margin and chest wall:
•Small pneumothorax: the presence of a visible rim of less than 2 cm between the
lung margin and the chest wall
•Large pneumothorax: the presence of a visible rim of greater than 2 cm between
the lung margin and the chest wall
The chest radiograph is thought to underestimate the size of pneumothorax.

6. Pathophysiology
Negative pressure eliminated
•The lung recoil-small, lung volume decrease
•v/q decrease- shunt increase
Positive pressure establish
•Compress blood vessels and Heart
•Decrease cardiac output
•Impaired venous return
•Hypotension
•Shock
Result in
•Decrease in vital capacity
•Decrease in PaO2

7. Differential diagnosis of non-traumatic spontaneous pneumothorax includes:
pneumonia, acute asthma exacerbation, bronchitis, pulmonary embolism,
aortic dissection, costochondritis, acute coronary syndrome, anxiety or panic
attack, diaphragmatic injuries, GERD, esophageal spasm, mediastinitis,
myocarditis, pericarditis, pleurodynia, tuberculosis, pulmonary empyema,
lung abscess.
Complication
•Conversion to tension pneumothorax
•Hypoxemic Respiratory Failure
•Shock
•Respiratory arrest
•Cardiac arrest
•Empyema
•Re-expansion pulmonary edema

8. CT SCAN OF COLLAPSED LUNG

9. Management and treatment
Conservative management
•Aspiration
•Tube drainage
•Thoracosopy
Intermediate mangement
•Plurodesis
•Cautersation
•Pleural abrasion
Invasive management
•Pleurectomy
•Bullectomy
•VATS
•Thoracotomy

10. Aspiration- needle aspiration done with a needle inserted anteriorly into 2nd
intercostal space on the side of pneumothorax. The patient should be position
in a semi-reclining position to allow air to collect at apex of the lung.
Indication is 15% to 30% lung collapse.
Chest tube- A chest tube (or intercostal drain) is the most definitive initial
treatment of a pneumothorax. Chest tube is typically inserted in an area under
the axilla (armpit) called the “safe triangle”, where damage to internal organs
can be avoided.
Pleurodesis- Pleurodesis for the management of SP is intended to achieve
symphysis between parietal and visceral pleura and to prevent relapse of
pneumothorax. Mechanical pleural abrasion or pleurectomy can damage the
mesothelial layer and achieve symphysis. However, it is known from more
recent studies that the mesothelium itself can act as the initiator of the
biological cascade leading to fibrinogenesis . The cellular and molecular
mechanisms involved in pleurodesis include: activation of the coagulation
cascade of the pleura; fibrin deposition; fibroblast recruitment, activation and
proliferation; and collagen deposition
Results of chemical pleurodesis tend to be worse than when using surgical
approaches, talc pleurodesis has been found to have the best results.

11. Pleural abrasion- These are performed by mechanical gauze abrasion, alone
without treatment of ELCs. A study carried out on mongrel dogs compared
various methods of pleurodesis, e.g. tetracycline, talc poudrage, mechanical
abrasion, neodymium/yttrium-aluminium-garnet laser photocoagulation and
argon beam electrocoagulation of
the parietal pleura.
Thoracotomy- The operation is performed under general anaesthesia. The
intrathoracic procedure consists of excision of blebs and bullae, usually by
stapling, and the treatment of smaller bullous lesions with electrocoagulation or
a laser.
VATS- High-risk patients, usually elderly patients with severe underlying lung
disease, can undergo VATS under local and epidural anaesthesia or even under
local anaesthesia and sedation . Application of sealants over air leaks and stapled
resection of bullae and talc poudrage can be performed safely.
Three ports are generally necessary, one for the thoracoscope and two for the
lung graspers and stapling devices.

13. PHYSIOTHERAPY MANAGEMENT
Indications for Physiotherapy
Lung collapse
Increased work of breathing
Thick sputum plugs predisposing to ventilation difficulty
Blood gas abnormalities
Sputum retention
Goals for Physiotherapy
To reinflate collapse lung areas
To improve distribution of ventilation
To increase oxygenation
Maintain airway clearance
Improve exercise tolerance

14. Physiotherapy Management
To reduce work of breathing
Body positioning
Breathing control
Relaxation technique
To improve ventilation
Localised thoracic expansion exercise
Sputum mobilisation techniques
Postural drainage
Deep breathing exercise
Percussion, shaking and vibrations
Sputum removal techniques
Coughing and huffing
Airway suctioning

15. Physiotherapy outcome evaluation includes
• Respiratory rate
•Breathing pattern
•Sputum quantity
•Auscultation
•Cough sound
•Oxygen requirement
•SpO2
•Arterial blood gases
•Chest x-ray changes
•Muscle strength
•Functional performance

16. Reference
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3. Management of spontaneous pneumothorax:
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4. Zarogoulidis P, Kioumis I, Pitsiou G, Porpodis K, Lampaki S, Papaiwannou A,
Katsikogiannis N, Zaric B, Branislav P, Secen N, Dryllis G, Machairiotis N, Rapti
A, Zarogoulidis K. Pneumothorax: from definition to diagnosis and treatment. J
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adults. Postgraduate Medical Journal 2000;76:399-404.
6. Roberts, D J. et al. Clinical Presentation of Patients With Tension
Pneumothorax, Annals of Surgery: June 2015 - Volume 261 - Issue 6 - p 1068-
1078