pneumothorax in ICU


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pneumothorax in ICU

  1. 1. Pneumothorax in ICU <ul><li>Dr Ashok Jadon, MD DNB </li></ul><ul><li>Sr. Consultant & HOD </li></ul><ul><li>Dept. of Anaesthesia </li></ul><ul><li>Tata Motors Hospital, Jamshedpur </li></ul>
  2. 2. Introduction <ul><li>Pneumothorax; air in pleural space </li></ul><ul><ul><li>Air can enter from the outside; injury penetrated the chest wall </li></ul></ul><ul><ul><li>Air can enter from inside, if the lung is torn or ruptured e.g. (pulmonary bleb). </li></ul></ul>
  3. 3. <ul><li>Pneumothorax is the most common serious pleural complication in the ICU </li></ul><ul><li>Pneumothorax may be difficult to diagnose </li></ul><ul><ul><li>when their locations are atypical, </li></ul></ul><ul><ul><li>when the patient has underlying cardiopulmonary disease </li></ul></ul><ul><ul><li>altered mental status </li></ul></ul>
  4. 4. ICU pts : High Risk Group <ul><li>Serious systemic disease </li></ul><ul><li>Hemodynamically unstable; Invasive Procedures </li></ul><ul><li>Ventilator/ Resuscitations </li></ul><ul><li>Postoperative Patients; shifted from another invasive environment </li></ul><ul><li>Trauma; admitted to ICU </li></ul><ul><ul><li>Penetrating Injury of Chest/ Abdomen </li></ul></ul><ul><ul><li># Rib </li></ul></ul><ul><ul><li>Resuscitation </li></ul></ul><ul><ul><li>Central Line </li></ul></ul>
  5. 5. De Lassence et al Anesthesiology. 2006 Jan;104(1):5-13. <ul><li>Incidence 1.4% on day 5 and 3.0% on day 30. </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>History of adult immunodeficiency syndrome </li></ul></ul><ul><ul><li>Diagnosis of acute respiratory distress syndrome </li></ul></ul><ul><ul><li>Cardiogenic pulmonary edema at admission </li></ul></ul><ul><ul><li>Central vein or pulmonary artery catheter insertion </li></ul></ul><ul><ul><li>Use of inotropic agents during the first 24 h </li></ul></ul>Pneumothorax in the intensive care unit: incidence & risk factors,
  6. 6. Close Associations for high incidence <ul><li>Disease; ARDS </li></ul><ul><li>Ventilation; Incidence (4 to 15%). </li></ul><ul><li>Procedures </li></ul><ul><ul><li>Thoracentesis, </li></ul></ul><ul><ul><li>Central venous catheter placement, </li></ul></ul><ul><ul><li>Bronchoscopy </li></ul></ul><ul><ul><li>Pericardiocentesis </li></ul></ul><ul><ul><li>Tracheostomy </li></ul></ul>
  7. 7. Types/ Etiology <ul><li>Spontaneous </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><li>Secondary </li></ul></ul><ul><li>Iatrogenic / Traumatic </li></ul><ul><li>Open/ Close </li></ul><ul><li>Tension Pneumothorax </li></ul>
  8. 8. Spontaneous Pneumothorax <ul><li>This refers to a condition in which the lung collapses with no apparent injury or trauma </li></ul><ul><ul><li>Pulmonary blebs </li></ul></ul><ul><ul><li>COPD; Emphysematous Bullae </li></ul></ul><ul><ul><li>AIDS/ Lung Tumor </li></ul></ul><ul><ul><li>Infective or Infiltrative Lung Disease </li></ul></ul><ul><li>Cigarette smokers & Recreational drug users are at greater risk for spontaneous pneumothorax. </li></ul>
  9. 9. How Mechanical Ventilation Responsible for Pneumothorax ?
  10. 10. Biotrauma Barotrauma and Volutrauma Atelectrauma
  11. 11. Barotrauma and Volutrauma <ul><li>Ventilator-induced lung injury by high levels of mechanical stress and strain that occur when high airway pressures ( Barotrauma) and high volumes (Volutrauma) are delivered . </li></ul><ul><li>This stress and strain can disrupt the pulmonary fibroelastic skeleton and trigger a secondary inflammatory response. </li></ul>
  12. 12. <ul><li>Atelectrauma </li></ul><ul><ul><li>Moderate degrees of stress and strain related to the cyclic opening and closing of parts of the lung may directly induce the release of inflammatory mediators and noxious proteinases. </li></ul></ul>
  13. 14. Relationship between ventilatory settings and barotrauma in the ARDS <ul><li>incidence of barotrauma 0% to 49%, </li></ul><ul><li>High incidence correlated strongly </li></ul><ul><ul><li>P(plat), above 35 cm H2O, </li></ul></ul><ul><ul><li>Compliance below 30 ml/cm H2O </li></ul></ul><ul><li>Aspiration Pneumonia </li></ul><ul><ul><li>In a prospective study 38 percent of patients developed pneumothorax and pneumo-mediastinum. </li></ul></ul>Mohamed Boussarsar Intensive Care Med. 2002 ;28 (4):406-13.
  14. 15. Pneumothorax Traumatic/ Procedure related <ul><li>Direct trauma to the chest wall from either blunt or penetrating trauma causes this condition </li></ul><ul><li>Thoracentesis (54%) </li></ul><ul><li>Central vein/pulmonary artery catheterization (40%) </li></ul><ul><li>Bronchoscopy /transbronchial lung biopsy (23%) </li></ul>
  15. 16. Pneumothorax; Central Venous Line <ul><li>Internal jugular, </li></ul><ul><li>subclavian, or </li></ul><ul><li>Femoral Vein </li></ul><ul><li>There is no difference in the rates of pneumothorax for internal jugular versus subclavian vein placement </li></ul>Ruesch S, Walder B, Tramer M. Complications of Central Venous Catheters: Internal Jugular versus Subclavian access-A Systematic Review. Crit Care Med. 2002;30:454-60.
  16. 17. Pneumothorax after insertion of central venous catheters in the intensive care unit: association with month of year and week of month <ul><li>Highest in July and August and in the first week of the month (beginning of intensive care unit (ICU) rotation). </li></ul><ul><li>The rate of PTX after insertion of CVCs is greatest in the last week of the month(2.7%) than during the first, second or third weeks (1.7%, 1.8% and 1.4%, respectively). </li></ul>Najib T Ayas- Quality and Safety in Health Care 2007; 16 :252-255
  17. 18. Symptoms <ul><li>Sharp, stabbing chest pain that worsens on breathing or with deep inspiration. Pain often radiates to the shoulder and or back </li></ul><ul><li>A dry, hacking cough may occur because of irritation of the diaphragm. </li></ul>
  18. 19. Tension Pneumothorax <ul><li>When the pleural pressure is positive throughout respiratory cycle </li></ul><ul><li>“ Ball-valve mechanism” </li></ul><ul><li>Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration </li></ul>
  19. 20. Epidemiology <ul><li>Kolef reviewed 464 ICU patients </li></ul><ul><ul><li>28 (6%) developed pneumothorax </li></ul></ul><ul><ul><li>9 patients missed the initial diagnosis </li></ul></ul><ul><ul><li>3 (33%) developed tension pneumothorax </li></ul></ul><ul><ul><li>In diagnosed 19 patients only 1 (5%) develop pneumothorax </li></ul></ul><ul><li>Tocino & coworkers </li></ul><ul><ul><li>Missed pneumothorax 34/112 (30%) </li></ul></ul><ul><ul><li>16/34 patients developed tension pneumothorax </li></ul></ul>
  20. 21. Clinical picture <ul><li>Distressed </li></ul><ul><li>Rapid labored breathing </li></ul><ul><li>Cyanosis </li></ul><ul><li>Profuse diaphoresis </li></ul><ul><li>Marked tachycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Decreased breath sounds </li></ul><ul><li>Hyper resonance on percussion </li></ul>
  21. 22. Etiology of symptoms <ul><li>Hypoxia </li></ul><ul><ul><li>Decreased PaO2 </li></ul></ul><ul><ul><li>Perfusion of atelectatic lung </li></ul></ul><ul><li>Decrease venous return </li></ul><ul><ul><li>increase intrathoracic pressure </li></ul></ul><ul><ul><li>Decreased CO & SV </li></ul></ul>
  22. 23. Investigations A A A A A
  23. 24. Hallmark: air between two pleural spaces <ul><li>Why they are missed? </li></ul><ul><li>Unfortunately, it is difficult to make a radiographic diagnosis of a pneumothorax on portable x-ray films taken in the ICU setting. </li></ul><ul><li>X-ray Upright-air in Apex </li></ul><ul><li>X-ray In ICU; supine , semi supine </li></ul><ul><li>In addition, concurrent lung disease may lead to different distributions of free air in the pleural space than in patients with relatively normal lungs. </li></ul>
  24. 25. Distribution of air
  25. 26. Always look for…. <ul><li>Subtle radiographic signs of pneumothorax </li></ul><ul><li>Relative hyperlucency over the upper abdominal quadrants </li></ul><ul><li>Deep costophrenic angle (the deep sulcus sign) </li></ul>
  26. 27. Role of Ultrasound in Diagnosis <ul><li>Disappearance of &quot;lung sliding&quot; was observed in 100% </li></ul><ul><li>In this series, sensitivity was 95.3%, specificity 91.1%, and negative predictive value 100% (p<0.001). </li></ul><ul><li>Conclusions: Ultrasound was a sensitive test for detection of pneumothorax, although false-positive cases were noted. The principal value of this test was that it could immediately exclude anterior pneumothorax. </li></ul>
  27. 28. CT Thorax
  28. 29. Pneumothorax Prevention during CVCs <ul><li>Remove patient from ventilator before advancing the needle. </li></ul><ul><li>Choose the right side rather than left, </li></ul><ul><li>Avoid multiple attempts when possible </li></ul><ul><li>Check post procedure x-ray, </li></ul>
  29. 30. Ultrasound Guided CVCs <ul><li>Success with ultrasound guidance was 100%, compared with 88% when ultrasound was not used. </li></ul><ul><li>incidence of carotid puncture was reduced from 8.3% to 1.7%. </li></ul>
  30. 31. Treatment <ul><li>Small pneumothorax </li></ul><ul><ul><li>Resolve over days to weeks </li></ul></ul><ul><ul><li>Supplemental oxygen and observation </li></ul></ul><ul><li>Spontaneous pneumothorax </li></ul><ul><ul><li>Asymptomatic –f/u with serial CXR </li></ul></ul><ul><ul><li>Symptomatic –chest tube </li></ul></ul><ul><ul><li>Recurrent pneumothorax – CT to evaluate need for thoracotomy </li></ul></ul>
  31. 32. Tension pneumothorax; Treatment <ul><li>Pneumothorax can be life-threatening. </li></ul><ul><li>The immediate treatment is tube thoracostomy, or the insertion of a chest tube. </li></ul><ul><li>Chest tubes are generally inserted using local anesthesia. </li></ul><ul><li>The chest tube is left in place until the lung leak seals on its own; this usually occurs within two to five days. </li></ul>
  32. 33. Thoracostomy (Chest tube)
  33. 34. Pulmonary blebs <ul><li>Pulmonary blebs can be resected, preventing future pneumothorax. </li></ul><ul><li>Thoracoscopic surgical procedure. </li></ul><ul><li>A stapling device is inserted into the chest during, and the segment of lung with blebs is stapled across and then removed </li></ul>
  34. 35. complications of air of pleural parenchyma <ul><li>Sub-pleural air cysts ; </li></ul><ul><ul><li>Secondary infections in the cysts, Pseudomonas sepsis & death. </li></ul></ul><ul><li>Systemic Gas Embolism </li></ul><ul><ul><li>It is possible for extra-alveolar air to enter the systemic circulation if there is a bronchovenous communication and an adequate pressure gradient. </li></ul></ul>
  35. 36. Prognosis <ul><li>Paucity of clinical data describing the prognostic factors associated with patient outcomes </li></ul>
  36. 37. Prognosis <ul><li>Seven patients (12%) had to undergo external suction and pleurodesis for persistent air leaks. </li></ul><ul><li>Five patients still had air leaks, and the chest tube was not removed during their ICU stay. </li></ul><ul><li>The mean duration of ICU stay was 24 ± 19 days (median, 17.5 days). </li></ul><ul><li>The mean duration of chest tube drainage was 10 ± 11 days (median, 6 days). </li></ul><ul><li>The mortality rate for patients with pneumothorax was 68%. </li></ul>
  37. 38. Prognosis contd.. <ul><li>Patients with procedure-related pneumothorax had a lower risk of mortality. </li></ul><ul><li>Patients who had tension pneumothorax and concurrent septic shock had a higher risk of mortality. </li></ul><ul><li>pneumothorax due to barotrauma, tension pneumothorax, and concurrent septic shock were significantly and independently associated with death. </li></ul>
  38. 39. Conclusion
  39. 41. Twist in Tale..
  40. 42. CXR with recurrent right-sided pneumothorax, despite thoracostomy tube in place CT scan with giant bullae and anterior pneumothorax after insertion of a second thoracostomy tube
  41. 43. Message <ul><li>Put Chest Drain; Be Happy </li></ul><ul><li>But, Be Observant and Do Follow -Up </li></ul><ul><li>Not only Till Patient Go Home </li></ul><ul><li>Later on too. </li></ul>
  42. 44. Thank You