Encompasses the general overview of pneumothorax based on BTS and ACCP guidelines. Useful for surgeons and MBBS students

1. PNEUMOTH
ORAX
PRESENTER: DR SAURAV SUMAN YADAV
MS GENERAL SURGERY RESIDENT
NATIONAL ACADEMY HEALTH SCIENCES, BIR HOSPITAL

2. Flow of the presentation
• Introduction
• Patho-physiology
• Classification
• Clinical Picture
• Management
• Summary

6. • Term ‘pneumothorax’ first coined by Itard, in 1803
• Refers to air in the pleural cavity (i.e., interspersed between the lung
and the chest wall).
• Description of primary spontaneous pneumothorax was given by
Kjaergard, in 1932
• Incidence is higher in men than women (4:1)
• It is a significant global health problem, with a reported incidence of
18-28/100 000 cases per annum for men and 1.2-6/100 000 for
women
6
Introduction

7. Pathophysiological facts
• The pressure within the pleural space is negative with respect to the alveolar pressure
during the entire respiratory cycle.
• This negative pressure results from the inherent tendency for the lung to collapse (elastic
recoil) and the chest wall to expand.
• The negative intrapleural pressure is not uniform throughout the pleural space; a gradient
of 0.25 cm of water per centimeter of vertical distance can be measured between the apex
and base of the lung.
• At the apex, the pressure is more negative than at the base, and this pressure difference
tends to favor a greater distention of the alveoli located in this region.

8. • When a communication develops between an alveolus and the pleural space, air will move
from the alveolus into the pleural space until there is equalization of pressure or the
communication is sealed.
• The same happens with a communication between the chest wall and pleural cavity.

9. Classification
Pneumothorax
Spontaneous
Primary Secondary
Traumatic
Iatrogenic
Interventional
procedures.
Positive pressure
ventilation
Non iatrogenic
Penetrating
trauma
Blunt trauma.

10. • Spontaneous pneumothorax are sub-classified as:
• Primary spontaneous pneumothorax (PSP)
• Healthy people, most young people
• Secondary spontaneous pneumothorax (SSP)
• Underlying diseases
• Chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis

11. CATEMENIAL PNEUMOTHORAX
• During menstruation
• Due to endometriosis of pleura
• RECURRENT
• Commonly 3 -4 decade of life
• Catamenial pneumothorax is underdiagnosed in women with
pneumothorax.
• A combination of surgical intervention and hormonal manipulation
requires cooperation with thoracic surgeons and gynaecologists.

12. Primary spontaneous pneumothorax
• Occurs due to rupture of apical blebs or bullae.
• Occurs most commonly in smokers
• 1/3 rd will have a recurrence
• Blebs are surrounded at all sides by pleura
• Bullae are surrounded by connective tissue septa of lungs.

13. • Degradation of elastic fibers in the lung --induced by the smoking-
related influx of neutrophils and macrophages.
• Imbalance in the protease–antiprotease and oxidant–antioxidant
systems.
• Inflammation-induced obstruction of the small airways increases
alveolar pressure, resulting in an air leak into the lung interstitium.
• Air then moves to the hilum, causing pneumomediastinum; as
mediastinal pressure rises, rupture of the mediastinal parietal pleura
occurs, causing --- pneumothorax

15. TYPES OF PNEUMOTHORAX
SIMPLE PNEUMOTHORAX
• small (<15%), moderate (15-60%), large (>60%)
• May be occult
• No communication with atmosphere.
• No shift of mediastinium/hemidiapharagm

16. OPEN PNEUMOTHORAX
• Bidirectional flow of air through wound in chest wall (“sucking
chest wound”)
• Equalization of pressure between atmosphere and chest cavity
• Severely impaired ventilation and oxygenation

17. TENSION PEUMOTHORAX
• air leaks through one-way valve, progressively accumulates in pleural
cavity
• increasing pleural air  mediastinal shift  compresses great
vessels, contralateral lung, vena cava  decreased diastolic filling 
decreased CO  rapid (within minutes) onset of hypoxia,
hypotension, refractive shock, acidosis

19. Risk factors
• Receiving positive-pressure mechanical ventilation
• During cardiopulmonary resuscitation
• Undergoing hyperbaric oxygen therapy
• Evolving during the course of spontaneous pneumothorax
• Chest Trauma
19
Tension pneumothorax

20. 20

21. • Happened most patients at rest and some during heavy exercise
• Chest pain-prickling-like, cutting-like
• Having an acute onset
• Air stimulates pleura
• Dyspnea
• Collapsed lung and vital capacity decrease
• Dry cough
• Air stimulates pleura
21
Clinical manifestation

22. • Distressed with rapid labored respiration
• Cyanosis
• Marked tachycardia
• Profuse diaphoresis
• Physical examination
• Tactile fremitus is absent
• Percussion note is hypersonant
• Breath sounds are reduced or absent on the affected side
• The lower edge of the liver may be shifted inferiorly with a right-side
pneumothorax
• The trachea may be shifted toward the contralateral side if the
pneumothorax is large
22
Clinical manifestation

23. Time and Progression of Disease
100
50
30
80
0
10
20
40
Alveolar Hyperventilation
60
70
90
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
Acute Ventilatory Failure
Disease Onset
Point at which disease
becomes severe and patient
begins to become fatigued
Pa
0
2
or
Pa
C0
2
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.

24. Imaging- Plain chest X-ray film
• Establishing the diagnosis
• Outer margin of visceral pleura separated
from the parietal pleura by a lucent gas
space devoid of pulmonary vessels
24

25. Chest X-ray in Pneumothorax
• Pleural margin
• Deep sulcus
• Crisp cardiac silhouette
• Hyperlucent hemithorax
• Double diaphragm
• Depressed diaphragm
• Apical pericardial fat

26. • In the absence of underlying lung disease,
the pleural line of a pneumothorax usually
parallels the shape of chest wall
26

27. • Difficult to assess accurately from a chest radiograph
• The simple method to estimate the size
• Small, a visible rim of < 2 cm between the lung margin and the chest wall
• Large, a visible rim of ≥2 cm between the lung margin and chest wall
27
Quantification of the size

28. • BTS guideline(2003)
• Lung margin to chest wall
• Small<2cm
• Large≥2cm
• ACCP guideline
• Lung apex to chest top
• Small <3cm
• Large≥3cm
28
Estimation of pneumothorax volume

29. • Most confirmatory approach if accurate size estimates are required
• It is only recommended to difficult cases such as patients in whom
the lungs are obscured by overlying surgical emphysema
• To differentiate a pneumothorax from suspected bulla in complex
cystic lung disease
29
CT scanning

30. 30
bullae
pneumothorax

34. • Advised for small, closed mildly symptomatic spontaneous
pneumothorax
• Do not require hospital admission
• Most patients in this group who fail this treatment have secondary
pneumothoraces
• Small <20 % unilateral pneumothorax
• Reabsorb air : 1.25%/day
Observation for further progression
34
Observation - PSP

35. • Recommended in patients with
• small SSP of less than 1 cm depth(ACCP guidelines)
• isolated apical pneumothoraces in asymptomatic patients
• Hospitalization is recommended in these cases
35
Observation - SSP

36. Likelihood of resolution
The likelihood of a pneumothorax resolving is classified as follows:
• Very likely to resolve - Small pneumothorax in a hemodynamically stable patient
without significant parenchymal lung disease; small iatrogenic pneumothorax
• May resolve - Large pneumothorax in a normal lung (eg, PSP or iatrogenic
pneumothorax)
• Unlikely to resolve - Secondary pneumothorax, enlarging pneumothorax (suggests
a continuing air leak)
• Will not resolve, could be fatal - Tension pneumothorax; unrecognized air leak

37. ALL OTHER CASES WILL REQUIRE ACTIVE
INTERVENTION !!

38. Needle thoracostomy
In case of Tension pneumothorax:
• 14G/16G IV canula
• 10cc syringe needle
Inserted in 2nd intercostal region in mid clavicular region

40. INDICATIONS
• Unstable pneumothorax
• Severe dyspnea
• Large lung collapse
• Open or tension pneumothoraces
• Frequent recurrent pneumothoraces
• Simple aspiration or catheter aspiration drainage is unsuccessful in controlling
symptoms
40
Intercostal tube drainage

42. Common patient positions for chest drain insertion

43. Operative tube thoracostomy
• The physician’s index finger is
used to enlarge the opening and
to explore the pleural space
43

44. • Placement of chest tube
intrapleurally using large
hemostat
44

45. 45
Intercostal tube drainage

46. Observe the drainage.
No bubble released ??
• The chest tube is obstructed by secretion or blood clot
• The chest tube shift to chest wall, the hole of the chest tube is
located in the chest wall
OR
Lungs has re-expanded!
46

47. Beware!
• Rapid removal of fluid rom the pleural cavity can cause ROPE (re-
expansion pulmonary edema)
• So to minimize the risk, CLAMP if patient develops
• Cough
• SOB
• Drop in saturation
• To be in safer side, after drainage of 1 to 1.5 l of fluid from the pleural cavity,
better clamp the chest tube for 2 hours and observe the patient for above
mentioned clinical findings.

48. When to remove the chest tube?
• When lungs have fully expanded
• How to check?
CLAMP TRIAL:
• Clamp the chest tube and repeat the CXR in 2hrs/4hrs/6 hrs.
• If air do not re-accumulate then the tube can be removed.

49. • Goals
• To prevent pneumothorax recurrence
• To produce inflammation of pleura and adhesions
• Indications
• Persist air leak and repeated pneumothorax
• Bilateral pneumothoraces
• Complicated with bullae
• Lung dysfunction, but not fit for surgery.
49
Chemical pleurodesis

50. Sclerosing agents
• Tetracycline
• Minocycline
• Doxycline
• Talcum powder
• Erythromycin
50

51. Methods
• Via chest tube or by surgical mean
• Administration of intrapleural local anaesthesia, 200 – 400 mg lidocaine
intrapleurally injection
• Agents diluted by 60 – 100 ml saline
• Injected to pleural space
• Clamp the tube 1 – 2 hours
• Drainage again
• Observed by chest X-ray film, if air of pleural space is absorption, remove the
chest tube
• If pneumothorax still exist, repeated pleurodesis
51

52. Indication
• Second ipsilateral pneumothorax.
• First contralateral pneumothorax.
• Synchronous bilateral spontaneous pneumothorax.
• Persistent air leak (despite 5–7 days of chest tube drainage) or
failure of lung re-expansion.
• Spontaneous haemothorax.
• Professions at risk (eg, pilots, divers).
• Pregnancy.
52
Surgical treatment

53. • Penetration of major organs
• Lung, stomach, spleen, liver, heart and great vessels
• Pleural infection
• Empyema, the rate of 1%
• Surgical emphysema
• Subcutaneous emphysema
53
Complications of chest tube insertion

54. PYOPNEUMOTHORAX
• Caused by aspiration or intercostal chest tube insertion (iatrogenic)
• Also results from necrotic pneumonia, lung abscess, or caseous pneumonia
• Chest X-ray shows hydropneumothorax
• Effusion is purulent
• Antibiotics and intercostal drainage
• Surgical mean
54

55. HEMOPNEUMOTORAX
• Bleeding in pleural space
• Common cause is rupture of vessels in adhesions
• When lung re-expansion, bleeding will stop
• When bleeding persists, surgical ligation will be needed
• Blood transfusion ma be required.
55

56. MEDIASTINAL AND SUBCUTANEOUS EMPHYSEMA
• Alveoli rupture, the air enter into pulmonary interstitial, and then goes into
mediastinal and subcutaneous tissues
• After aspiration or intercostal chest tube insertion, the air enters the
subcutaneous by the needle hole or incision – surgical emphysema
• Physical exam – crepitus is present
• Automatic absorption when pneumothorax is gone
• Inhalation of high concentration of oxygen
• Making a small incision in suprasternal pit for draining the air from mediastinal and
subcutaneous tissues
56

57. 57
Pneumomediastinum Pneumocardium
Pneumoperitoneum
Surgical emphysema

58. 58
Subcutaneous
emphysema

59. Discharge and follow up

60. One liners!!
• Smoking has been implicated in this etiological pathway, the smoking habit being
associated with a 12% risk of developing pneumothorax in healthy smoking men
compared with 0.1% in non-smokers.
• Although it is to some extent counterintuitive, there is no evidence that a
relationship exists between the onset of pneumothorax and physical activity,
the onset being as likely to occur during sedentary activity.

61. • Suction should not be routinely employed. Caution is required because of the
risk of RPO. High-volume low-pressure suction systems are recommended.
• It has been suggested that optimal suction should entail pressures of −10 to
−20 cm H2O (compared with normal intra-pleural pressures of between −3.4 and
−8 cm H2O, according to the respiratory cycle), with the capacity to increase the
air flow volume to 15–20 l/min.

62. • Recurrence is more common in pregnancy, poses risks to the mother and fetus,
and requires close cooperation between chest physicians, obstetricians and
thoracic surgeons.
• In pediatric age group, finding of decreased breath sounds can be difficult as a
result of conducted sounds. Hence, early CXR is better approach.

63. • Standard erect chest x-rays in inspiration are recommended for the initial
diagnosis of pneumothorax, rather than expiratory films. They are usually
conclusive.
• CT scan images are regarded as the ‘gold standard’ in the detection of small
pneumothoraces and in size estimation.

64. • Percutaneous needle aspiration or thoracic drain? Needle aspiration is effective
for the initial management of spontaneous pneumothorax.
• Small- or large-bore chest tubes? Still Debatable. For initial management of
spontaneous pneumothorax comparable results have been shown with small
bore chest tubes decreasing the total hospital stay and expenditure.

65. Roughly 1% of patients admitted with COVID-19 develop pneumothorax. This can
occur without pre-existing lung disease or mechanical ventilation.
Two thirds of patients survive, but age >70 years and acidosis are associated with
poor prognosis.

67. Further reading
• https://www.whittington.nhs.uk/document.ashx?id=6069
• https://emedicine.medscape.com/article/424547-clinical
• https://thorax.bmj.com/content/65/Suppl_2/ii18
• https://erj.ersjournals.com/content/56/5/2002697

68. THANK YOU!