This document discusses different types of pneumothorax including closed, open, and tension pneumothorax. Closed pneumothorax results from blunt chest trauma causing a rib fracture and air entering the pleural space, which then seals off. Open pneumothorax involves a penetrating chest injury creating a passage for air entry. Tension pneumothorax occurs when a one-way valve forms, allowing air to enter on inspiration but not exit, gradually increasing pressure. Management involves needle decompression for tension pneumothorax or chest tube placement connected to suction for other types to drain air and re-expand the lung.

1. Presented by: Dr. Kalatan Mohanta
1st year PGT
Deptt. Of Orthopaedics, SMCH

2. INTRODUCTION
PNEUMOTHORAX :
 It is the abnormal collection of air within the pleural
space.

3.  Pneumothorax is primarily classified as:
- Traumatic
- Non-traumatic/ Spontaneous

4. PNEUMOTHORAX
Traumatic Non-traumatic
Primary Secondary
occurring in persons with no occurring in persons with a known
known history of lung disease history of lung disease, such as COPD

5.  Pneumothorax may also be classified as:
- Closed
- Open
- Tension / Valvular

6. CLOSED TRAUMATIC PNEUMOTHORAX
 Most common cause is following blunt trauma to the
chest wall leading to rib fracture.
 Causes increased intrathoracic pressure and alveolar
rupture.
 Air escapes into the pleural space and the
communication is sealed off.
 Air can neither enter nor leave the pleural space.
 Trapped air is slowly reabsorbed and the lung
reexpands completely in 2-4 weeks.

7. OPEN TRAUMATIC PNEUMOTHORAX
 It can occur following penetrating injury to the chest.
 Results in formation of passage from the external
environment into the pleural space.
 When air is drawn into the pleural space through this
passageway, it is known as a “sucking chest wound”.

8.  It can also occur following :
Pulmonary barotrauma (following breathing
compressed air as seen in scuba divers)
Iatrogenic causes (transthoracic needle aspiration,
central venous catheterization, positive pressure
ventilation)

9.  Pulmonary barotrauma/ Iatrogenic cause
 Communication between bronchus and pleura remains
patent
 Results in formation of bronchopleural fistula
 Intrapleural and atmospheric pressure remains the same
throughout the respiratory cycle, as air can move freely via
the bronchopleural fistula
 Prevents reexpansion of collapsed lung
 In addition, bronchopleural fistula
facilitates spread of infection into the
pleural space leading to empyema.

10. TENSION (VALVULAR) PNEUMOTHORAX
 It occurs when a disruption occurs involving the visceral
pleura, parietal pleura or the tracheobroncheal tree
following chest trauma.
 The disruption results in formation of a one-way valve.
 During inspiration, coughing, sneezing or straining, air is
pumped into the pleural space through the valvular
opening, but does not allow it to escape.
 The volume of non-absorbable intrapleural air increases
with each inspiration, and the intrapleural pressure
becomes much higher than the atmospheric pressure.

11.  The high intrapleural pressure results in compression
of ipsilateral lung and subsequent hypoxia.
 It also causes gross shifting of the mediastinum to the
opposite side with consequent compression of
contralateral lung as well.
 There occurs compression of the vena cavae entering
into the right atrium, resulting in compromised
venous return to the heart.

12. Injury to the lung
Valvular air leak
Lung collapse
Mediastinal shift to opposite side
Increased intrapleural pressure
Decreased venous return
Decreased ventilation
Hypoxia and cardiac arrest

14. HAEMOTHORAX :
 It is the collection of blood in the pleural cavity.
 It causes pleurisy as blood is irritant to pleura.
 Massive haemothorax may result in shock.

15. CLINICAL FEATURES
CLOSED PNEUMOTHORAX:
 Trivial breathlessness which improves over a few days.
 Pleural space infection is uncommon.

16. OPEN PNEUMOTHORAX:
 Breathlessness
 Hyper-resonant note on lung percussion
 Tracheal deviation towards contralateral side
 Absence of breath sounds on the affected side
 Fever and systemic disturbances (if pleural space infection
sets in)

17. TENSION PNEUMOTHORAX:
 Rapid progressive breathlessness
 Tachycardia
 Tachypnoea
 Rapid thready pulse
 Central cyanosis
 Hypotension
 Jugular venous distension
 Severe tracheal/ mediastinal shift
 Hyper-resonant note on percussion
 Total absence of breath sounds on affected side during
auscultation

18. HAEMOTHORAX:
 Sharp chest pain
 Dyspnoea
 Diminished breath sounds on affected side
 Dull note on percussion
 Features of shock

19. MANAGEMENT
CLOSED PNEUMOTHORAX:
 Asymptomatic patients:
- Need no treatment.
- Serial radiographic monitoring is required till the
lung re-expands.
 If patient is breathless and pneumothorax is large:
- Evacuation of air using a syringe and needle,
a three-way tap and an underwater seal system.
- Inserting a chest tube into the pleural cavity and
connecting it to a water seal drainage system.

20. OPEN PNEUMOTHORAX:
 A trial of chest tube insertion with low-pressure suction
may be tried.
 Usually requires surgical closure.
- Cauterization of the opening.
- Video-assisted thoracoscopic surgery may be used
for cutting and release of adhesions that prevent
the closure of the fistula.
- Open thoracotomy and
direct closure of the fistula.

21. TENSION PNEUMOTHORAX:
 It is an emergency, and should be treated urgently.
 A wide bore needle (usually a spinal needle 25G) is inserted
in mid-clavicular line in the 5th intercostal space.
 This converts tension pneumothorax into simple
pneumothorax.
 The other end of the needle is attached to a long rubber
tubing, the end of which is connected to an underwater
seal.
 High flow oxygen is administered.

22.  After initial stabilization of the patient, chest X-ray is
done.
 Definitive management consists of introduction of
intercostal tube (ICT) in the 5th intercostal space in the
mid-axillary line which is connected to a water seal
drainage system.
 Antibiotics and analgesics are added.

23. HAEMOTHORAX:
 ICT placement in the mid-axillary line in the 6th
intercostal space.
 Antibiotics, analgesics.
 Bronchodilators.
 Thoracotomy
- if initial chest tube output of 1500ml of blood or
persistent drainage of 200-300 ml/hr.
- clotted haemothorax.

24. INTERCOSTAL TUBE DRAINAGE
 It is the method of draining fluid/blood/air collected in
the pleural cavity safely, so as to allow the underlying
lung to expand.
 Commonly the tube is inserted in the 5th intercostal
space slightly anterior to the mid-axillary line.
 In case of haemothorax or pyothorax, the tube is put in
the 6th intercostal space.
 Location of tube insertion is in the “triangle of safety”

25. TRIANGLE OF SAFETY:
 Anteriorly- lateral border of pectoralis major.
 Posteriorly- anterior border of latissimus dorsi.
 Inferiorly- an imaginary line superior to the horizontal
level of the nipple.

26. Position of the patient- supine with head up
Triangle of safety is selected
Local anaesthesia is infiltrated
Sharp dissection is done only to cut the skin
Blunt dissection with finger and artery forceps till the pleura is reached
(serratus and intercostal muscle fibres are separated)
Tube is introduced obliquely- a short tunnel is made
The drain is retained with a good suture and vertical mattress
suture for wound closure
Tube is connected to underwater seal apparatus

28.  Movement of air column during respiration should be
checked.
 Quantity of fluid or blood collecting should be
observed.
 Chest X-ray should be done immediately to assess the
position of the ICT.
 Oxygen supplementation is often needed.
 Patient should be monitored thoroughly.

29. THANK YOU