Pneumothorax

1. PNEUMOTHORAX
DR.G.SURESH KUMAR
ASST.PROFFESOR

2. DEFINITION
 Pneumothorax is defined as the
presence of air within the pleural
cavity.

3. Pneumothorax can not occur without
a breach in integrity of either visceral
or parietal pleura or both.
MECHANISM

4. Classification
primary secondary
spontaneous
pneumothorax
non-iatrogenic
accidental artificial
iatrogenic
traumatic
pneumothorax
pneumothorax

5. CLASSIFICATION

6. Classification
 Acute / chronic
 Small / large
 Partial / complete
 Encysted / generalized

7. Primary sp. pneumothorax
 Occurs in apparently healthy individuals.
 Peak incidence-3rd decade
 Male :Female ratio varies from 3:1 to 12:1
 Results from rupture of pulmonary bleb i.e
 Localised collection of air within the celluar layers
of visceral pleura or bullae i.e sharply demarcated
foci of emphysema > 1 cm in diameter.
 Blebs arise due to congenital weakness in the
connective tissue of sub pleural alveoli.

8.  Blebs are multiple,bilateral most commonly
occur at the lung apices.
PROBABLE REASONS ARE:
1. Regional differences in mechanical stress
2. Gravity dependent pressure gradient
3. Relative ischemia at the apex of the lung makes
it susceptable to infection so that blebs may
develop as a result of inflammation.

9. Predisposing factors
 Tall and thin body habitus
 Family history of sp. Px
 Tobacco smoking
 Sharp inner border to the first or second
ribs.

10. Secondary sp. pneumothorax
 Pulm. TB
 Ch. Bronchitis and emphysema
 Bronchial asthma
 Suppurative lung disease
 HIV
 Cystic fibrosis
 Catamenial px

11. Rare causes are
 ILD,Silicosis, sarcoidosis,histiocytosis X
 Wegener’s granulomatosis,rheumatoid dis.
 Systemic sclerosis,pulm. Alveolar
proteinosis,Marfan’s syndrome ,Ehlers –
Danlos syndrome, tuberous sclerosis ,
Hydatid disease,Bronchogenic carcinoma ,
Cavitating pulm. Infarction.

12. Sp.bilateral pneumothorax
 Rupture of bil. Apical blebs / bullae
 Extensive bil. Emphysema
 Cystic lung disease
 Staph. Infection-pneumatoceles
 Miliary T.B
 H.I.V

13. Traumatic pneumothorax
Non – iatrogenic
 Open and closed chest injury, barotrauma
Iatrogenic(accidental)
 Paracentisis thoracis,Pleural biopsy
 Transbronchial biopsy
 Percutaneous lung biopsy/aspiration
 Central venous cannulation
 Mechanical ventilation

14. Px. Due to barotrauma
 Boyles law: when the temperature is constant
volume is inversely proportional to pressure.
 Air trapped in the pleural bleb expands resulting
in rupture – aircrew ,scuba,sub-mariners,caisson
workers.
 Pts on positive pressure mechanical
ventilation,endotracheal tube misplacement,CPR.

15. Effect of px. On lung function
 Restrictive impairment of VC,FRC,TLC.
 Small reduction in diffusing capacity
 Initial hypoxaemia and subsequent return
to normoxaemia.
 Mediastinal displacement & compression –
fall in cardiac output- hypotension and
syncope.

16. CLINICAL FEATURES
Depends on the etiology: primary / secondary
type:closed / tension/open
Presence / absence of fluid
 Sharp unilateral chest pain.
 Shortness of breath
 Dry cough

17. Signs
 Diminished chest movements
 Hyperresonant/ resonant note
 Diminished or absent breath sounds
 Contralateral shift of mediastinum
 Displacement of upper border of hepatic dullness
caudally
 Crepitus sound over precordium(Hamman’s sign)
 Palpable crepitus of subcutaneous emphysema

18. Tension Px.
 Communication between the airway and pleural
space act as one way valve. As a result large
amount of trapped air accumulate in pleural
space. Intrapleural pressure may rise well above
the atmospheric pressure.
 Rapidly progressive SOB, Tachycardia
,hypotension ,cyanosis ,contralateral shift of
mediastinum.

19. Px. signs in ventilated patient
 Sudden onset of tachycardia & hypotension
 Increase in peak airway pressure
 Sudden decline in Oxygen saturation
 Patient appearing to fight the ventilater

20. Radiological features
Typical signs:
 Sharply defined deflated lung edge
separated from the chest wall by lucent
zone devoid of lung makings.
 Dense globular shadow at the hilum
 Contralateral shift of mediastinum

21.  A Px. is strongly suspected clinically but a pleural
line is not identified.the Px. can be detected by :
 A chest x ray in erect position in full
expiration, Rationale being that lung volume is
reduced while the volume of gas in the pleural
space is constant thus making it easier to detect.
 Lateral decubitus view with suspected side
upper most with a horizontal x ray beam (
cross table lateral view)Rationale air in the
pleural space rises to the highest point in
hemithorax the air lung interface becomes clearly
visible beneath the lateral chest wall.

22. Atypical signs
 A deep, finger like costophrenic sulcus laterally
 A visible anterior costophrenic recess seen as
oblique line .
 A transradiant band parallel to the diaphragm and
/ or mediastinum.
 Visualization of under surface of heart & of
cardiac fat pad as rounded opacity
 Depression of ipsilateral hemidiaphragm.
 Collection of air within the minor fissure.

23. Deep sulcus sign
 In ICU only supine films may be available
for interpretation.
 Px. may be indicated by :
1. Increased lucency on the ipsilateral
side due to anterior collection of gas.
2. A deep lateral costophneric angle
on the affected side i.e deep sulcus sign.

24. Differential diagnosis
Conditions asso. with chest pain & SOB:
 MI
 Pleuritis : infection / pulm. Infarction
 Perforated peptic ulcer
SOB with hyperresonant / resonant note:
 Gen. Empysema
 Large emphysematous bulla
 Large congenital lung cyst
 Diaphragmatic hernias

25. Management
Depends on
 Etiology
 Type of Px.
 Size of Px. Done by expressing the Px. as
a percentage of the hemithorax.
 Light index: % of Px.= 100(1- avg. d. lung^3
/ avg. d. hemithorax^3)

26. Treatment
option
Type of Pt. BTS/ACCP
1.Observation +
/ - sup. oxygen
Small prim.sp Px.
Asymptomatic
All pts sec. Sp Px. < 1 cm
3 to 6 hrs-rpt cxr-
no progression of
Px.- dischrage
Hospitalised,ACCP
3.Aspiration Sympt. primary Spont. Px.
Not recom. for sec. Px.
BTS guidelines
4.Tube
thoracostomy
All Pts large Px.
All pts fail asp.
all pts with sec. Sp Px.
ACCP
BTS
Treatment options

27. Treatment options Type of the patient BTS / ACCP
5.Tube thoracostomy with
chem. pleurodesis
If the pt is
unwilling/unable to
undergo the surgery
BTS rec. rate
< 20%
6.Thoracoscopy
VATS/Medical
Resection/stapling of blebs
pleurectomy ,pleural abrasion
instillation of sclerosing agent
If the lung remains
unexpanded / persistent
air leak > 3 days/ rec.
Px.
BTS /ACCP
,rec. rate <
5%
7.Thoracotomy
,parietal pleurectomy/abrasion,
bullectomy,resection of
blebs,apical pleurectomy
Unexpanded lung .for >
5 to 7 days
BTS/ACCP
Rec. rate < 1
%

28. Indications for ICTD
 Tension Px.
 Presence of dyspnoea
 Intermittent PPV
 Previous contralateral Px.
 Bilateral Pneumothoraces
 Presence of pleural fluid
 Large / complete Px.
 Failed manual aspiration

29. Indications for PP / abrasion in sp Px.
 Failed tube drianage (persistent Px.)
 Ipsilateral recurrence ( first / second)
 Contralateral occurrence (first)
 Bilateral simultaneous Px.
 Persistent pleural effusion
 Initial episode life-threatening
 Special risk groups e.g aircrew,divers etc..

30. Complications
 Failure to reexpand : 1.multiple leaks in
gen. emphysema., adhesions preventing a
BPF from closing, atelectasis from retained
secretions , pleural rind.
 Recurrence
 Haemo/pyo Px.
 Resp. failure
 Re-expansion pulm. edema