Review on Pneumothorax by Dr. V. siddhartha, PGIMER, Chandigarh

1. PNEUMOTHORAX
DR.V.SIDDHARTHA
JUNIOR RESIDENT
INTERNAL MEDICINE
PGIMER, Chandigarh.

2. DEFINITION:
ACCUMULATION OF AIR IN
THE PLEURAL SPACE
TERM WAS COINED BY
ITARD IN 1803
LAENNEC IN 1819

3. Classification:
Pneumothorax
Spontaneous
Primary
Secondary
Traumatic
Iatrogenic

4.  3 events:
• 1) Communication between
pleura and alveolus
• 2) Communication between
atmosphere
• 3) Gas producing organism in the
pleural cavity

5. PATHOPHYSIOLOGY:
• Effect on pleural pressure:
• Normal pleural pressure is negative with
respect to alveolar pressure during the entire
respiratory cycle with APICOBASAL gradient
• Magnitude of pleural pressure gradient is 0.25
cm H2O per cm vertical distance
• So if a communication develops between the
pleural space and the alveolus/atmosphere, it
causes increase in the pleural pressure
• Upper lobes > lower lobes

6. Effect on
pulmonary
pressure and
blood gases:
Decrease in Vital capacity, FRC, TLC, and DC
Decrease in arterial PaO2 – low ventilation- perfusion
ratios (airway closure at low lung volumes), anatomic
shunts, alveolar hypoventilation
Pneumothorax that occupies less than 25% of the
hemithorax is not usually associated with significant
shunts
Compromised pulmonary function before the
pneumothorax- significant hypoxemia, alveolar
hypoventilation and respiratory acidosis

7. Resorption of
pleural gases:
• By simple diffusion from the pleural space into
the venous blood.
• Rate of absorption depends on:
(a) Pressure gradient for gases between pleural
space – venous blood
(b) Diffusion properties of gases present in the
pleural space
(c) Area of contact between the pleural gas and
pleura
(d) Permeability of the pleural surface (thickened,
fibrotic pleura will absorb less)

8. PSP (primary
spontaneous
pneumothorax):
Occurs in healthy individuals with no OBVIOUS lung disease
Incidence: Males > Females (3-6:1), Peak age: early 20’s
Risk factors:
Tobacco smoking
Male gender and tall/thin individuals
directly related to the amount of cigarette smoking and the years
of exposure
Lifetime risk is 12% in healthy smoking men as compared to 0.1%
in nonsmokers

9. Family History
 Genetically determined
Birt-Hogg-Dube syndrome: (mutations in
folliculin gene):
Autosomal dominant inheritance , characterized
by spontaneous pneumothorax, benign skin
tumors and renal tumors
Others
Marfan’s syndrome
Homocystinuria
Anorexia nervosa

10. Pathology
implicated:
Rupture of subpleural blebs or bullae on the apical
portion of the upper lobes.
Airway inflammation/Respiratory bronchiolitis
secondary to smoking
Pleural porosity
• Pathology: (from resected specimens)
 Eosinophilic pleuritis
High prevalence of bronchial anomalies in
nonsmokers associated with PSP: M/C was
disproportionate bronchial anatomy

11. Clinical features:
Chest pain
• Acute onset - usually localized to the side of pneumothorax
• Pleuritic in nature
 Dyspnea
• Acute onset
• Usually develops while the patient is at rest

12. Physical
Examination:
(small pneumothoraces
<20% are usually not
detectable)
• Vital signs are usually normal except for
tachycardia
• Side with pneumothorax is larger than c/l
side
• Movements decreased on the affected
side
• Tactile fremitus-absent
• Percussion note – HYPERRESONANT
• Breath sounds - absent/reduced
• With large pneumothorax - tracheal shift
to C/L side
• With large right sided pneumothorax –
lower edge of liver - inferiorly

13. Diagnosis:
Symptoms and P/E consistent with
pneumothorax
Available radiological modalities:
1) CXR: still most common investigation
performed
2) USG lung: especially useful in the intensive
care units
3) NCCT-chest (in unclear cases)
Sensitivity: CT > USG > CXR

14. CXR
Findings:
1) Visualization of visceral pleural line – MUST
2) Convex curve of visceral pleural line ⑊ the contour of chest wall
3) Absence of lung markings distal to pleural line – not necessarily
4) Deep sulcus sign (supine radiograph)

15. CXR:
• In supine position: best areas to search for evidence
Juxta-cardiac area
lateral chest wall and
subpulmonic region
• 2% radiographic pneumothorax corresponds to 50% pneumothorax
by volume
• Pooled sensitivity: 40 -52%
• Pooled specificity: 99-100%

16. Radiological Evidence:
 Diagnosis established by
demonstration of pleural
line on chest radiograph PA
view(outer margin of
visceral pleura separated
from the parietal pleura by a
lucent space devoid of
pulmonary vessels)

17. DEEP SULCUS
SIGN

18. PITFALLS (CXR):
• Bullous lung disease
• Large cyst in the lung
• PTE
1) Other lung
diseases with
absent lung
markings:
2) Mistaking
skin fold to a
pleural line
- usually skin
fold is THICK
3) Mistaking
medial border
of the scapula
for
pneumothorax

19. Role of CT-chest: Occult Pneumothorax
1) not routinely indicated with
PSP – no close correlation
between presence of subpleural
blebs and recurrence
2) Regarded as - gold standard
in detection of small
pneumothoraces and in size
estimation.
3)Useful in the presence of
surgical emphysema and
bullous lung disease and
4)For identifying aberrant chest
drain placement or additional
lung pathology

20. USG-chest
• Normal Lung Sliding
• Sea-shore sign
2 step approach to diagnose
pneumothorax

21. Step 1: Pneumothorax
and A’-profile
• A’-profile is the association
of A-line sign with abolition
of lung sliding
• B-line or lung sliding rule
out pneumothorax.

22. Step 2: Search for Lung
Point:
• Lung point is pathognomonic
• Indicating its volume

23. • USG:
• 1) Pooled sensitivity: 87-100%
• 2) Pooled specificity: 91-100%
• 3) Presence of lung sliding definitely rules out pneumothorax with a
NPV of 100%, but not specific
 Pleural symphysis (pleurodesis, fibrosis, adhesions)
 Loss of lung volume (massive atelectasis, pneumonectomy)
• Presence of B-lines, artifact arising from pleura, rules out
pneumothorax with NPV of 100%

24. Quantification:
• 1) Light’s index
• % PNEUMOTHORAX=
• [1-(diameter
lung)3/(diameter
hemithorax)3]
• 2) Collin’s method
• 3) Rhea index

25. Quantification
In general,
these are
preferred
COLLIN’S METHOD
% pneumothorax= 4.2+[4.7x(A+B+C)];
A=distance between apex of partially collapsed
lung and apex of thoracic cavity
B=distance between midpoint of upper half of
collapsed lung &lateral chest wall
C= distance between midpoint of lower half of
collapsed lung &lateral chest wall
RHEA METHOD: uses a nomogram that relates the
average intra-pleural distance to the
pneumothorax size(1cm=10%pneumothorax)

26. Continued:
4) BTS guidelines (2010)
 Lung margin to chest wall
 Small <2cm
 Large > or =2cm
(At the level of Hilum)
5) ACCP guidelines
 Lung apex to cupola
 Small <3cm
 Large >or = 3cm

28. Goals of Management and Options:
• 1) To rid the pleural space of its air
• 2) To decrease the likelihood of a recurrence
Options:
 Observation
 Supplemental oxygen
 Simple aspiration: shorter hospital stay
 Tube thoracostomy with/without instillation of sclerosing agent
 Medical Thoracoscopy with insufflation of talc
 VATS
 Open Thoracotomy

30. Observation:
• Rate of spontaneous absorption is slow
estimated to be 1.25% of the volume of hemithorax q 24hours
• So pneumothorax occupying 15% of hemithorax would take 12 days
for complete resorption
• Pneumothorax < 15% can be considered for observation

31. Supplemental
Oxygen:
Accelerates the rate of pleural air
absorption by a factor of 6
It is recommended that hospitalized
patients with any type of
pneumothorax treated with oxygen
at high concentrations
The higher the concentration of
oxygen used, the faster the
resorption of pneumothorax

32. Simple Aspiration:
• Initial treatment for most patients with PSP >15%
• Site – 2nd anterior ICS at MCL after LA
16-guage needle with an internal polyethylene catheter
attach 3-way stopcock and 60ml syringe to catheter
manually aspirate until no more can be aspirated
(but not >2.5L)

33. Repeat
Access
Do Manual aspiration
No resistance encountered
>2.5L
No lung expansion
Resistance encountered
<2.5L
Lung expanded
Repeat CXR after 4 hours
Expansion
persists
Follow up CXR at
24-72 hoursTube Thoracostomy

34. ASPIRATION
Simple aspiration can be used as first
line therapy for patients with first time
spontaneous pneumothorax(>15% of
hemithorax)
Advantages- Short hospitalization, no
significant recurrence rates at 1yr.
Disadvantages- Patients with SSP/
recurrence don’t have good results

35. Tube
Thoracostomy:
Potential problems with small
tubes:
1) More prone for kinking
2) Blockage of the tube
3) Clotting from blood or fluid
4) Greater chances of slippage
Rapid evacuation of
pleural air
Small tubes (<14 F)
preferred to large
PSP patients can be
managed on OP basis

36. Tube thoracostomy (after failed simple aspiration)
Lung expanded and no air leak @24hours
yes no
continue chest tube for 24 hours. Apply suction (-20cm of H2O)
reassess and remove tube Reassess
Follow up High-volume low-pressure recommended
(15-20L/min)

37. Recommendations
on Suction and
Clamping:
Suction is not routinely recommended
1) Risk of re-expansion pulmonary edema especially
with PSP
2) No additional advantage
Clamping:
1) Not advised because of risk of tension
pneumothorax
2) To detect small pneumothorax – role is controversial

38. REPE:
Incidence: 14%
Risk factors:
• 1)Duration of pneumothorax prior to drainage (> 3 days)
• 2)Severity of pneumothorax (<30% - very rare)
• 3)Use of suction ( > -20cm of H2O) and rapid expansion
Presentation: 1-24 hours of re-expansion
CXR: patchy or diffuse alveolar infiltrates in re-expanded lung

39. Pathogenesis:
• 1) Increased permeability of the pulmonary capillaries damaged by
mechanical stress during re-expansion of lung
• 2) Reperfusion injury
• 3) Decreased surfactant
• 4) Decreased Lymphatic flow

40. If patient is initially treated with small tube
Lung expanded Not expanded@48 hours
yes place a large tube
No lung expansion/BPF@4-5 days
Other interventions
(insertion of addition tube is not recommended)

41. Conclusion:
• Simple aspiration
for PSP and
iatrogenic pneumothorax
• Tube thoracostomy
for SSP and when
pleurodesis is
indicated.

42. Complications of Tube thoracostomy:

44. CERFOLIO
Classification
for PAL:

45. PAL options:

47. MEDICAL
THORACOSCOPY
Medical thoracoscopy is
performed under local
anesthesia and is usually
combined with sedation
Patient lies in lateral
decubitus position with
hemithorax to be studied
facing upwards
Two techniques used-
single puncture and double
puncture
Xenon light source is used
in both
Site of introduction
depends upon the location
of radiographically
detected abnormality
The usual site is 6th or 7th
ICS between the anterior
and mid axillary line
Talc insufflation and
pleurodesis can be done

48. Medical
Thoracoscopy
vs VATS:
• VATS
• General Anesthesia
• Expensive
• Objectives
• to treat bullous disease
responsible for
pneumothorax
(endoscopic stapling
device)
• To create pleurodesis
• Recurrence rate- 3%
• Medical Thoracoscopy
• Local anesthesia
• Cost effective
• No attempt is made to
treat the blebs
• Talc is insufflated
• Recurrence rates are
higher(5%)

49. VATS vs Open
Thoracotomy:
• VATS
• General Anesthesia
• Recurrence rate- 3%
• Open Thoracotomy
• Only when VATS is failed
• General anesthesia
• Recurrence rates are still
lower (1.1%)
• Some surgeons still prefer
mini-thoracotomy to VATS
REASONS:
• Double lumen intubation
is not required
• Operating time is short
• Good cosmetic result
• Less expensive

50. Identifying
risk of
recurrence:
more then 75% of
recurrences occur on the
same side
Most recurrences occur within FIRST year
Recurrence rate: 25-52%
Men > Women
Age > 60 years
Non-smokers < smokers
Tall and Thin individuals
History of prior recurrence (60% after second recurrence and to > 83% after the
third)
REMEMBER:
1) No significant relationship between size of original pneumothorax or
treatment of original pneumothorax
2) The presence of blebs or bullae on CT-chest does not predict whether the
patient will develop a recurrence

52. NOTE
• Strongly favored VATS over
Conservative management
despite
Longer length of stay and cost
 NNT is high
Five patients will have to
undergo surgical procedure to
avoid one
recurrence

53. JANUARY 30th
2020
• Conservative management is
Non-inferior to intervention group
• Symptoms resolved as quickly as
The symptoms in intervention group
• Fewer adverse events
• Quite safe
• Fewer recurrences during next
12 months than the intervention group

54. • Study opinion:
• When to opt conservative management in PSP with large
pneumothorax?
• 1) Hemodynamically stable
• 2) Patient is informed and agrees to the approach
• 3) Readily available for OPD follow up
• 4) Not planning for air travel or scuba diving

55. Advice:
1) SMOKING CESSATION 2) RETURN TO WORK
AND RESUME NORMAL
PHYSICAL ACTIVITY
ONCE ALL SYMPTOMS
HAVE SUBSIDED
3) AIR TRAVEL: NO
EVIDENCE THAT AIR
TRAVEL PER SE
PRECIPITATES
RECURRENCE
CAN TRAVEL AFTER 1
WEEK OF FULL
RESOLUTION
4) DIVING: SHOULD BE
DISCOURAGED
PERMANENTLY
UNLESS A VERY SECURE
DEFINITIVE PREVENTION
STRATEGY HAS BEEN
PERFORMED
EXAMPLE: SURGICAL
PLEURECTOMY

56. Secondary
Spontaneous
Pneumothorax:
• SSP occur as a complication
of
Underlying lung disease
• M/C: COPD and tuberculosis
• More serious d/t underlying
already compromised lung
function
• High recurrence rate (40-
80%)

57. C/F and P/E:
• 1) Dyspnea frequently out of proportion to size of
pneumothorax
• 2) Chest pain
• 3) Physical Examination is less helpful:
Already have hyperinflated lungs
Decreased vocal fremitus
Hyper-resonant percussion notes and
Distant breath sounds over both lung fields
• 4) So threshold should be lower in a patient of COPD
presenting with SOB especially associated with chest
pain

58. Management:
• Aspiration – not recommended
• Nearly every patient – hospitalized for at least
24 hours – tube thoracostomy
• Tube thoracostomy – less efficacious
Mean time for lung to expand is – 5 days
In 20% - lung remains unexpanded
• Prevention of recurrence is most important
• If lung does not expand after 72 hours or there
is PAL > 3 days
option: VATS > medical thoracoscopy

59. Accepted indications for surgical advice:

60. Unfit or Refuses Further Invasive Procedures:
• Medical Pleurodesis

62. Indications of Pleurodesis in Pneumothorax:
• 1) PSP with any one of the following:
second episode of PSP
PAL: > 3-5 days
Haemopneumothorax
B/L pneumothorax
Professions at risk : aircraft personnel, divers
• 2) SSP

65. Agents for Pleurodesis:
Chemical agents:
• Talc
• Iodopovidone
• Antimicrobials: Tetracyclines (tetracycline, minocycline, doxycycline)
• Cytotoxic agents: (bleomycin, mitoxantrone, mitomycin, carboplatin)
• Bevacizumab
• Silver nitrate
• Sodium hydroxide
• 50% glucose

71. Pneumothorax
secondary to
AIDS:
Ominous prognostically
High mortality
Very likely to have a
recurrent
pneumothorax or C/L
pneumothorax
• Etiologies:
• 1) PCP – m/c (CD4+ < 200)
• 2) H/O receiving nebulized
pentamidine prophylaxis
• 3) Bacterial pneumonia
• 4) Pulmonary Tuberculosis
• 5) Pulmonary cryptococcosis
• Management:
• Difficult to treat:
Necrotizing inflammation
• Early ICTD and surgical
referral
• Appropriate treatment for
PCP and HIV
• Definitive Treatment -
VATS

72. Pneumothorax in Cystic Fibrosis:
• High prevalence and mortality with advanced stage of disease
• Chronic airway inflammation
Important risk factors:
• 1) FEV1 < 30% of predicted (risk increases by 50%)
• 2) Presence of Pseudomonas aeruginosa, Burkholderia cepacian or
Aspergillus in the airways
• 3) Use of Dornase alfa (Bronchospasm – acute decline in FEV1)

73. Management:
• 1) Chest tube alone has a recurrence of about – 37% - 50%
• 2) Recurrent pneumothorax + fit for surgery
- TOC is partial pleurectomy
• 3) Unfit for surgery: Pleurodesis
 Pleural procedures including pleurodesis do not have significant
adverse effect on outcome of subsequent transplantation

74. Tension Pneumothorax: Emergency
• Intrapleural pressure > atmospheric pressure in E + I
• Sudden deterioration: reduced CO with hypoxemia
PPV
YES
Alveolar
rupture
NO
One way
valve process

75. • Barotrauma:
• 1) PEEP > 10 cm of H2O
• 2) Mean airway pressure >
30
• 3) Peak inspiratory pressure
> 50
• 4) PEEP especially when
combined with VCV
• 5) Plateau pressure > 35
• 6) Lung compliance <
30mL/cm H2O
NOTE:
monitor plateau pressure in
VCV
Decreasing tidal volume if
on pressure support

76. Clinical
Manifestations:
Clinical
diagnosis
Patient appears distressed with rapid labored breathing
Diaphoresis
Cyanosis
Marked tachycardia
Hypotension
O/E: Distended neck veins, hypoxemia, hypotension, tracheal
deviation to opposite side of pneumothorax, unilateral chest
hyperinflation and subcutaneous emphysema

77. Diagnosis:
 ABG- hypoxemia, respiratory acidosis
 CXR
 1) Mediastinal shift to the opposite side
 2) Diaphragmatic depression
 3) Rib cage expansion
 4) Subcutaneous emphysema
USG
• NOTE: Degree of lung collapse is an unreliable sign for or against the
presence of a tension pneumothorax

78.  Tension pneumothorax may also
develop because of
• Improper connection of one-way valve
to chest tube
• Malposition of the chest tube

79. Management:
Tension
pneumothorax
Hypoxia
High concentration
of O2
Needle aspiration
Definitive
Tube thoracostomy
(silicon catheter)

80. Iatrogenic
Pneumothorax:
• Incidence is high and likely to increase
• Particularly high in ICU
• Particularly with ARDS
• Substantial morbidity
• At present,
m/c/c is transthoracic needle aspiration
CVC (IJV > subclavian line) and
thoracentesis follow

81. Two primary factors
related are
1.Depth of the lesion
Lesions in the LL
Greater lesion depth
Lesion size < 2cm
Needle trajectory
< 45 degree
2.Severity of the
underlying lung
With emphysema,
3 times increased risk of
having chest tube
drainage

82. Preventive
Measures?
• 1) Lung biopsy tract plug
• 2) Use of fibrin glue as a sealant
• 3) 2-4ml of normal saline into the whole
puncture access during extraction of trocar
needle
• 4) Use of USG guidance for CVC and
thoracentesis
• 5) Using newer ventilatory modes which
ventilate with lower peak inspiratory pressures
and lower mean airway pressures
 The presence of mediastinal emphysema may
precede development of pneumothorax

84. Treatment:
How does it
Differ?
• Asymptomatic to varying degree of symptoms
• No/mild symptoms + < 40% of hemithorax – observation +
O2
• More symptomatic or > 40% or enlarging size – evacuate the
air
• In general, most patients should be treated with aspiration
• Only if lung doesn’t expand – Chest tube
• Recurrence is not likely – need not try to create pleurodesis
• when pneumothorax occurs in PPV – immediate chest tube
prevents tension
• Chest tube at least for 48 hours after air-leak stops if patient
continues to receive mechanical ventilation

85. Catamenial Pneumothorax:
• Usually in third or fourth decade of life
• Recurrent pneumothorax that occurs within 72 hours of onset of
menses
• Classically develop chest pain, dyspnea and sometimes hemoptysis
• Usually right sided (90%)
• Association – Pelvic endometriosis
• High recurrence rate (In fact HIGHEST) – 50-100%
• Diagnosis – not difficult if possibility is considered

86. • Thoracic
Endometrial
Syndrome Catamenial pneumothorax
Catamenial haemothorax
Catamenial haemoptysis
Lung nodules
(purple/brown)

87. • Pathogenesis:
Air gained access to
peritoneal cavity during
menstruation, entered
pleural cavity through
diaphragmatic defects
Leakage of air from lung
owing to subpleural
endometrial implants

88. MANAGEMENT:
Management
Thoracic surgical
techniques
Diaphragmatic
resection or plication
of fenestrations
Mesh/Patch over
fenestrations
Electrocoagulation of
endometrial deposits
and pleurodesis
Hormonal therapy
GnRH analogues
Danazol
Surgical menopause

89. Take Home Message:
• The role of observation in large but mildly symptomatic PSP is gaining momentum
and yet to be incorporated into new guidelines
• Patients in profession with high risk of recurrence of PSP should undergo
definitive therapy at first presentation
• Heimlich flutter valve can be used to mobilize patient with prolonged chest tube
drainage
• With SSP, chemical pleurodesis is indicated only if patient is unfit for operative
interventions or is reluctant
• Tension pneumothorax is a medical emergency
• Catamenial pneumothorax should be suspected in any young female with
recurrent pneumothoraces
• Imaging modalities include CXR/USG and CT

90. •THANK YOU