Pathophysiology: intrapleural pressure exceeds atm. pressure in lung during expiration (check-valve mechanism) When collection of gas is constantly enlarging, resulting compression of mediastinal structures it can be life-threatening and is known as a tension pneumothorax.
Tension hydropneumothorax: air-fluid level in pleural space on erect CXR
Additionally, respiration causes the right hemi diaphragm to contract against the liver, known as the “piston effect,” which potentially allows for endometrial implantation and/or migration across the diaphragm.
Left sided implants: direct seeding of endometrial tissue along with venous drainage.
Finally, although congenital diaphragmatic hernias are far more common on the left side, congenital diaphragmatic defects, particularly fenestrations, are known to occur more commonly on the right, leading to the right-sided predominance of TES
Hormonal : high levels of prostaglandin from thoracic endometrial implants cause vascular and bronchiolar vasoconstriction, leading to ischemic injury and ultimately causing alveolar rupture
lung becomes smaller and volume of pleural air is unchanged .. Hence more conspicuous
normal lung ---interface with pleura shows lung sliding with vertical comet tails running down from the pleural surface.
In pneumothorax, this sliding is absent and so are the comet tail artifacts from the pleura. This is due to air in between the parietal and visceral pleura, preventing lung from sliding.
Visualising the junction between sliding lung and absent sliding is known as the lung point sign and is near 100% specific for pneumothorax Not found in all pneumothorax cases (sensitivity is around 65%) especially large pneumothoraces where the lung is collapsed and there is globally absent sliding.
Most catamenial pneumothoraces are small and self resolving. Partial diaphragmatic resection and/or exeresis of visceral pleural implants, as well as talc pleurodesis,
Catamenial Pneumothorax (mahesh)
Dr. Mahesh Chaudhary
Name: Momtaz Sultana
Age: 34 years
Occupation: School Teacher
1. Sudden onset of chest pain on the left side for 2 days.
2. Shortness of breath for 2 days.
3. Dry cough for 2 days.
No history of fever, hemoptysis, hematemesis or trauma.
She has history of episodes of similar symptoms at every
30-40 days duration for last 4 years.
The SOB & chest pain were always followed by menstruation.
Married for last 10 years
No history of pregnancy: G0P0
Irregular cycle (30-40 days) with dysmenorrhea
Associated with chest pain, SOB and backache
Primary spontaneous (80%)
rupture of subpleural blebs
Age: 20-40 years;
M:F = 8:1
Young tall stature men
Mostly in smokers
Secondary spontaneous (20%)
Connective tissue disorder
[Greek: kata , = according to; men= month]
Types of Pneumothorax
Open : chest wound
air move in & out of pleural space during respiration
Closed : intact thoracic cage
no air movement
Valvular: enter during inspiration & doesn't exit
Tension : (clinical diagnosis)
higher in barotrauma
pneumothorax >25% requires
chest tube drainage
Air resorb from the pleural space
at a rate of approximately 1.5% /
Catamenial Pneumothorax (CP)
CP is deﬁned as recurrent pneumothorax (at least two episodes)
occurring between the day before and within 72 hours after the
onset of menstruation.
Incidence of 3-6 % among all the pneumothoraxes in women.
Involves right-side (85-95%) or can be left-sided or bilateral.
Associated with diaphragmatic perforations and/or thoracic
TES is the presence of endometrial tissue in or around
the lung & consists of 4 distinct clinical entities:
1. Catamenial pneumothorax (CP),
2. Catamenial hemothorax,
3. Hemoptysis &
4. Pulmonary nodules or implants.
Thoracic endometriosis syndrome (TES)
Physiologically, peritoneal fluid moves in a clockwise
fashion from the pelvis along the right paracolic
gutter to the subphrenic space.
Endometrial tissue located within the peritoneum
likely follows the same directional flow, landing more
commonly on the right hemi diaphragm.
Once there, the falciform ligament prevents further
travel of tissue to the left.
Theories for CP
Ingression of air via diaphragmatic fenestrations
from the vagina to the peritoneum
Hormonal: Rupture of pre-existing pleural blebs/
alveoli during menstruation by increase in PG-F2.
Sloughing of Pleural or parenchymal endometrial
implants in the lung.
1. X-ray chest PA view
2. CT scan of Chest
3. Hormone level of gonadotropin hormones
4. Video-Assisted Thoracoscopic Surgery (VATS)
Visceral pleural edge seen as a very thin, sharp white line
No lung markings are seen peripheral to this line
Peripheral space is radiolucent compared to adjacent lung
The lung may completely collapse
Mediastinum shift (+)– if tension pneumothorax is present
Expiratory chest radiograph
Identifies even small pneumothoraces not visible in CXR
Differentiates bullous disease from intrapleural air
CT guided drain in complicated or inaccessible pneumothorax:
Posterior location or tethered lung
Asymptomatic small rim pneumothorax (<2 cm): no treatment with
follow up radiology to confirm resolution
Pneumothorax with mild symptoms (no underlying lung condition):
needle aspiration in the first instance
pneumothorax in a patient with background chronic lung disease or
significant symptoms: intercostal drain insertion (small drain using the
Hormonal therapy (GnRH analogue)
Repair of diaphragmatic defects with an artificial mesh
Treatment are usually medical in conjunct to surgical alleviation of the