1. Pneumothorax
By: Dr. Noshirwan P. Gazder

2. • Presence of air in the pleural space.
• Can be:
a) Spontaneous.
b) Result of iatrogenic injury.
c) Trauma to the lung or chest wall.

3. Classification
1. Spontaneous
Primary:
• No evidence of overt lung disease.
• Occurs mostly in males aged 15-30.
• Air escapes from the lung into the pleural space through rupture of a
small emphysematous bulla or pleural bleb.
• Smoking, tall stature & the presence of apical subpleural blebs are
additional risk factors.

4. Secondary:
• Underlying lung disease.
• Occurs mainly in males above 55 yrs.
• Most commonly COPD or TB patients
• Also seen in asthma, lung abscess, bronchogenic carcinoma etc.

5. 2. Traumatic
• Iatrogenic ( Thoracic Surgery or Biopsy)
• Chest Wall Injury.

6. Types
• Closed spontaneous pneumothorax.
• Open spontaneous pneumothorax.
• Tension pneumothorax.

7. Closed Type
• Closed pneumothorax is when air or gas gets in the pleural space
without any outside wound.
• Communication between airway and the pleural space seals off as the
lung deflates.
• Spontaneous reabsorption of air & re-expansion of lung occur over a
few days or weeks.
• Infection uncommon.

8. Open Type
• Open pneumothorax. Open pneumothorax is when air gets into the
pleural space from an injury to the chest. This can happen with stab
wounds, like from a knife. It can also happen after a gunshot injury.
• Communication fails to seal and air continues to transfer freely
between the lung and pleural space, a bronchopleural fistula.
• Infection can be transmitted leading to empyema.

9. Tension Type
• Tension pneumothorax is the progressive build-up of air within the
pleural space, usually due to a lung laceration which allows air to
escape into the pleural space but not to return.
• Communication between the airway & the pleural space acts as a
one-way valve, Allowing air to enter the pleural space during
inspiration but not to escape on expiration.
• Which leads to a large amount of air accumulating progressively in
the pleural space. Pressure causes mediastinal shift towards the
opposite side with compression of the opposite lung & impairment of
systemic venous return, causing cardiovascular compromise.

10. Symptoms
• Shortness of breath.
• Chest pain, which may be more severe on one side of the chest.
• Sharp pain when inhaling.
• Pressure in the chest that gets worse over time.
• Blue discoloration of the skin or lips.
• Rapid breathing.
• Confusion or dizziness.
• Loss of consciousness or coma.

11. General Examination
• Cyanosis.
• Rapid thready pulse.
• Signs of peripheral circulatory failure in severe cases.

12. Inspection & Palpation
• Dyspnoea.
• Use of accessory muscles of respiration.
• Shift of mediastinum to opposite side.
• Fullness of chest on the affected side.
• Diminished chest movements.
• Marked diminished vocal fremitus on affected side.
• Diminished expansion of the affected hemithorax.

13. Percussion
• Hyper resonant on affected hemithorax.
• Right sided pneumothorax-liver dullness is obliterated and cardiac
dullness is shifted to the opposite side.

14. Auscultation
• Diminished to absent breath sounds.
• Absence of adventitious sounds.
• Diminished vocal resonance.

15. CXR
• Increased radiolucency, with absence of bronchovascular markings
• Extend of mediastinal shift.
• Pleural fluid ,if present.

17. Treatment

18. Primary Pneumothorax
• If the lung edge is < 2cm from the chest wall and the patient is not
breathless, then it resolves normally with out intervention.
• If the patient is having severe symptoms then percutaneous needle
aspiration can be carried out.
• If it fails then intercostal tube drainage is done.

19. Secondary Pneumothorax
• Even a small secondary pneumothorax may cause respiratory failure,
so all such patients require, Intercostal tube drainage [Intercostal
drains are inserted in the 4th ,5th or 6th intercostal space in the
midaxillary line ,connected to an under waterseal].
• If intercostal tube drainage fails then thoracotomy with stapling of
blebs and pleural abrasion is indicated.
• If surgery is contraindicated then pleurodesis should be
done(Intrapleural injection of sclerosing agent)

20. Tension Pneumothorax
• It is a medical emergency.
• A large bore needle is inserted into pleural space through 2nd
intercostal space.
• The needle should be left in place until a thoracostomy tube can be
inserted.

21. Thank You