PULMONOLOGY PNEUMOTHORAX

1. PNEUMOTHORAX
Dr.JAKEER HUSSAIN
M.D,DNB

2. PNEUMOTHORAX--intro
Presence of air in da pleural cavity with secondary
collapse of surrounding lung.
occurs due2 loss of integrity of either visceral r parietal
pleura, r both.
 this term was used 1st in doctoral thesis,
french physician ITARD, in 1803.
 In 5centuryBC, greek physician practised
HIPPOCRATIC SUCCUSSION of da chest.

3. PNEUMOTHORAX
 Overdisten of norm lungs results in rupt of subpleu alveoli.
 Air dissect- bronchoalveolar sheath medially –
pneumomediastinum, subcutaneous emphysema,PTX.
 peripheral dissection of air = aircontaining space within r
below da visceral pleura.
 BULLA lined partly by thickened fibrotic pleura n partly by
fibrous tissue within lung. BLEB situated within da pleura.
 Periph bullae r blebs –distended n rupture in2 pleu space=
PNEUMOTHORAX.

5. PNEUMOTHORAX
MAIN PHYSIOLOGICAL EFFECTS
↓vital capacity of lung, ↓PaO2,
↓ TLC, FRC,diffusing capacity of lungs.
↓in PaO2,
impaired exercise tolerance
↓ in cardiac output
all these more in tension PTX.

8. PNEUMOTHORAX– X-rays

9. PNEUMOTHORAX—CT-Scan

10. PNEUMOTHORAX
CLASSIFICATION

11. PNEUMOTHORAX
SPONTANEOUS
TRAUMATIC

12. PNEUMOTHORAX
SPONTANEOUS
PRIMARY
SPONTANEOUS
SECONDARY
SPONTANEOUS
TRAUMATIC

13. PNEUMOTHORAX
SPONTANEOUS
PRIMARY
SPONTANEOUS
SECONDARY
SPONTANEOUS
TRAUMATIC
IATROGENIC
NON IATROGENIC

14. PNEUMOTHORAX
SPONTANEOUS
PRIMARY
SPONTANEOUS
SECONDARY
SPONTANEOUS
TRAUMATIC
IATROGENIC
ACCIDENTAL
ARTIFICIAL
NON-IATROGENIC

15. PRIMARY SPONTANEOUS PNEUMOTHORAX
PRIMARY SPONTANEOUS PNEUMOTHORAX:
PTX without preceding trauma & without underlying
clinical or radiologic evidence of lung disease.
 age 18 – 40 years . Incidence 7.4/m,, 1.2/f
 tall n thin pts,, apical blebs rupture.
 80-90% ass č smoking, x9 folds risk.
 changes in atm press, proximity to loud noise,
 sharp innerborder of 1st n 2nd rib.

16. PRIMARY SPONTANEOUS PNEUMOTHORAX
 familial association. 10%,
mutations in gene encoding folliculin (FLCN)
 BIRT HOGG DUBE Syndrome: beningn skin growth,
pulmonary cysts, & renal cancers.
 specific HLA-A2,B40, antitrypsin phenotypes M1,M2
 incresed levels of HYDROXYPROLINE.

17. SECONDARY SPONTANEOUS PNEUMOTHORAX
SECONDARY SPONTANEOUS PNEUMOTHORAX:
 occurs in pts č underlying pulmonary structural
pathology.
 air enters da pleural space via distended,damaged
or compromised alveoli.
 presents c serious clinical symptoms.

18. SECONDARY SPONTANEOUS PNEUMOTHORAX
SECONDARY SPONTANEOUS PNEUMOTHORAX:
 COPD or emphysema, ASTHMA.
 CYSTIC FIBROSIS. ILD
 BRONCHOGENIC or METASTATIC CARCINOMA
 COLLAGEN VASCULAR Ds incl MARFAN SYNDROME.
 PNEUMONIA (fungal,HIV,caseating)
 CATAMENIAL PNEUMOTHORAX.

19. IATROGENIC PNEUMOTHORAX
IATROGENIC PNEUMOTHORAX:
medical procedures resulting in traumatic PTX.

20. IATROGENIC PNEUMOTHORAX
IATROGENIC PNEUMOTHORAX causes:
 Trans-thoracic needle aspiration procedures.
 Thoraco centesis
 CV Catheter insertion (sub,supraclavicular, IJV)
 Mechanical ventillation (peak airway pressure)
 Pleural & transbronchial lung biopsy.
 Tracheostomy.
 CPR (if ventillation becomes progressively more diff)

21. ARTIFICIAL IATROGENIC PTX
ARTIFICIAL IATROGENIC PNEUMOTHORAX:
 Deliberate intro of air inda pleural cavity,by needle.
 devised by FORLANI in 19th cent. MAXWELL BOX
 used 2 treat pulm TB, before da ATT.

22. TRAUMATIC PNEUMOTHORAX
TRAUMATIC PNEUMOTHORAX:
 stab r gunshot wounds
 blunt chest inj in RTAs
 explosions

23. TENSION PNEUMOTHORAX
TENSION PNEUMOTHORAX is present when
intrapleural pressure is greater than atmosp press
throughout expiration & often during inspiration.
 One way value machanism develops..
 TPTX can occur after anytype of PTX.
 m.c after traumatic PTX. C mech ventillation.
during CPR.

24. TENSION PNEUMOTHORAX
When the pleural pressure is positive
throughout respiratory cycle
“Ball-valve mechanism”
Injury to pleura creates a tissue flap
that opens on inspiration and closes
on expiration

25. TENSION PNEUMOTHORAX
SIGNS N SYMPTOMS
 severe dyspnea, tachycardia, profuse diaphoresis
 cyanosis, hypotension, exhibit distended neck viens
 tracheal deviation,subcutaneous emphysema,
 unilateral chest hyperinflation. Widend IC spaces.
 ABG – severe hypoximia, resp acidosis.
 chest X-ray – mediastinal shift to opp.

26. Rx - TENSION PNEUMOTHORAX
• High flow O2.
• clinical confirmation of PTX- needle aspir 2nd IC
• Immeadiate tube thoracostomy.

27. SIGNS & SYMPTOMS

28. Clinicalfeatures-Symptoms
Sharp,stabbing unilateral chest pain
exacerbates by deep inspiration,
postural change
 shortness of breath
mild in PS-PTX, severity on size
in SS-PTX , dyspnea not on size.
 cough dry –irritation of da diaphragm.
generalised malaise.

29. SIGNS
PERCUSSION
hyper resonance on affected side.
AUSCULTATION
diminished breath sounds
decreased vocal resonance
COIN sound
scratch sign.

30. PTX in mech ventillated pt
 sudden onset of tachy, hypotension
 increase in peak airway pressure
 sudden decline in o2 sat.
 distressed pt appers to fight c da
ventillator.
 if pt on pressure control mode n
paralysed, ABG shows resp acidosis. As
pt cant increase his resp rate.

31. Title
ECG pt of tension PTX,
STseg elevation in II, III, Avf, V4-6,
c neg cardiac enzymes. Reversible after
chest tube.

32. Radiological signs – X ray
 A linear shadow of visceral pleura
with lack of lung markings peripheral to
the shadow
 Sharply defined lung edge convex
outwards.
 supine chest X-ray deep sulcus sign.
very dark n deep costophrenic angle.

33. PNEUMOTHORAX – Xray

34. PNEUMOTHORAX X-ray supine.

35. Radiological signs –CT scan
in PSPTX pts CT detects multiple blebs n bullae.
More sensitive for hemithorax, pulm contusion
Distinguish btw a large bulla and a PTX &
underlying emphysema or emphysemalike
changes.
Calculate exact size of PTX, esp smallPTX
can detect occult pneumothorax.

36. X-ray --------- CT-scan

37. ??? PNEUMOTHORAX ,,, ?side

38. PNEUMOTHORAX – Lt.side

39. Occult PTX: A PTX identified on a CT
scan dat was not seen on a preceeding
supine chest Xray AP view

40. Radiological signs - usg
USG used as bedside technique to detect PTX
used in unstable pts, who cant b shift outside
for xrays., ct scan.
acute care setting as a readily available bedside
tool, especially in ICU and emergency
departments

41. Differential diagnosis
ACS
ARDS
ASTHMA,COPD,EMPHYSEMA
CHF, Pulm oedema
Esophagal perforation,tear,rupture
Foreign bodies, trachea
Mediastenitis
Myocarditis, MI,Pericarditis,

42. Differential diagnosis
Pleural effusion
Pneumonia aspiration, bacterial, viral,
 pulmonary embolism.

43. Quantification
LIGHTS METHOD
Pneumothorax %
Size of PTX: ratio of lung diameter cubed
to hemithorax diameter cubed

44. Quantification

45. Quantification

46. RHEA METHOD:
it uses a nomogram,
that relates da average
intrapleural distance to
the pneumothorax size.
On this nomogram there
is 10% pneumothorax
for every cm of
intrapleural distance.

47. Quantification
 BTS guidelines…
Distance btw pleura n chestwall…
less than 1cm – small
1-2 cm - moderate
greater than 2 – large.

48. Quantification
 ACCP-measuring distance from da apex
of lung to the top margin of da
visceral pleura (thoracic cupola). On xray
small PTX – less than 3cm.
large PTX – greater than 3cm.

49. TREATMENT

50. MANAGEMENT
Of PNEUMOTHORAX

51. treatment
Aim of treatment of primary spont PTX
 to rid da pleural space of its air
 achieve closure of da leak.
 either prevent r reduce this risk.
 to decrease da likelihood of a recurrance.

52. treatment
 Observation
 supplemental oxygen
 simple aspiration
 tube thoraco-stomy č/čout sclerosing agent
 medical thoraco-scopy č da insufflation of talc
 video assisted thoraco-scopy č staplin of blebs
Instillation of sclerosing agent or pleural abrasion
Open thoraco-tomy

53. treatment
The choice of therapy depends on:
 clinical status of da pt
Cause of da pneumothorax
Evidence of concomitant lung ds
Prior history of pneumothorax, r risk of recurrence
Availability of specific therapeutic options
experience n prefered techniques of da physician

54. OBSERVATION
OBSERVATION
Rate of spontaneous reabsorbtion is slow,
Kircher n Swartzel- 1.25% of vol was absor every 24 h
so PTX occup 15% of hemithorax take 12 days
recomended only for pts č PTX less than 15%
asymptomatic, unilateral.

55. O2 Supplementation
SUPPLEMENTAL O2
admin of o2 accelerates da rate of pleural air
absorption .
Northfield- rate of absorp on ↑ 4 mes č 02
O2 high conc recomended for hosp pts..

56. O2 Supplementation
Rate of gas reabsorption depends on:
 press gradient for da gases
btw pleu space to venous blood
 diffusion properties of da gases
 area of contact btw pleural gas n pleura
 permeability of da pleural surface…
(thickend,fibro c pleura will absorb ↓normal pleura)

57. SIMPLE ASPIRATION
ASPIRATION
initial Rx of pts if PTX > 15%
16 G needle – ( 2nd IC ,M.C.line), (4-5th IC, M.A.line)
use a 3 way,
This procedure is done in emergency in tension ptx ,
to relive pressure. As emergency decompression.

59. SIMPLE ASPIRATION
When no more air can be aspirated or the patient suddenly
coughs, the lung most likely has reexpanded
Remove the catheter, and massage the insertion site with
sterile gauze to seal the channel into the pleural space .
Devanand et all- metaanalysis –simple aspiration is
adv than ICD – shorter hospitalization.
Noppen – recurr rate c aspiration is 19%

60. SIMPLE ASPIRATION

61. TUBE THORACOSTOMY
TUBE THORACOSTOMY
Air in pleural space canbe rapidly evacuated.
positioned in da uppermost part of pleural space.
mc site is 2nd IC space in Mid-Clavicular line.
now- 4,5th IC space btw ant n post axillary lines.

62. TUBE THORACOSTOMY
Indications for ICD in SPTX
 tension pneumothorax
 presence of dyspnea
 Intermittent positive pressure ventillation
 Prev contralateral pneumothorax
 b/l pneumothoraces, or large pneumothorax
 Presence of pleural fluid
 failed manual aspiration

63. TUBE THORACOSTOMY
Placement of ICD irritate pleura – partial pleurodesis
thus ↓ recurrence of PTX.
treat c small tubes 14F as insertion less traumatic.
if lung not expanded in 48hrs –large tubes be placed

64. TUBE THORACOSTOMY
TT C Instillation of SCLEROSING AGENTS:
Injec n sclerosin agents ↓recurrence rates of PTX
It create intense inflam reaction – obliterate pl space.
Agents – quinacrine, talc slurry, olive oil, bleomycin
silver nitrate, tetracycline.
best are – TALC SLURRY, TETRACYCLINE derivatives.
injected as soon as lung has reexpanded.

65. TUBE THORACOSTOMY
TALC SLURRY: 5 – 10 gms in 250ml of saline intrapleurally
very effective as a slurry via chest tube
talc poudrage during thoracoscopy.
meta analysis shows success rate of 91%.
can be performed easily at bedside.
inhomogeniety in distru – loculation n incomple symphysis.
↑incidence of ARDS, size of talc particles (↓15mm),
dose(↑5g) ass c higher incidence of ARDS.

66. TUBE THORACOSTOMY
TETRACYCLINES.
Minocycline – 600mg in 50-100ml of saline.
Doxycycline – 500 mg in 50 -100ml of saline.
very effective, c less recurrence rate.
injected as lung re expanded, n position da pt so dat
tetracycline comes incontact c apical pleura
very painful intrapleural injection.

67. MEDICAL THORACO SCOPY
MEDICAL THORACO SCOPY:
performed ↓local anesthesia, r c conscious sedation.
cost effective than drianage alone.
Tschopp et all –recurrance rate is 7.5%
MT c talc recurrance rate is 5%.
in MT blebs were not treated.

68. VATS
VATS performed ↓ GA. c double lumen ET tube.
c single lung ventillation – collapse of operated lung.
AIM to treat bullous ds responsible for PTX
to create pleurodesis.
bullae r treated c an endoscopic stapling device.
very less recurrence rate than electrocoagulation, r
ligation c Roeder loop

69. VATS

70. OPEN THORACO TOMY
THORACOTOMY – ultimate n most eff therapy fot PTX
allows examination of lung for da site of an air leak
lysis of prev adhesions – (loculated PTX)
enables release of fibrotic peel
pleura is scarified, ---↓↓recurance rate.
recurrance rate is < 2%.
thoracotomy recom only after failed thoracoscopy.

71. OPEN THORACO TOMY
potential risk ass c GA,
increased costs, significant pt discomfort.
more severe c lateral r post lateral thoracotomy
c muscle division n rib spreading.
nowadays smaller incisions –muscle sparing thoracotomies
mini axillary thoracotomy performed.
open thoracotomy still remains valuable option for
complicated cases

72. recommendations
If PTX small, pt asymptomatic – OBSERVATION
If pt near hospital – high flow O2 supplementation.
If PTX >15% - aspiration – if successful- discharge pt.
if unsuccessful – plan thoraco scopy
if both medical n VATS avail – VATS prefered (blebs)
if rec PTX- thoracoscopy – in pilots, divers - fatal PTX
if no thoracoscopy - tube thoracostomy c doxy.

73. Rx of SS-PTX
PTX in pts c lung ds is life threatening.
aim is to get rid of air in pleural space, ↓recurrence.
ASPIRATION is NOT recommended.
every pt – hospitalised, plan TUBE THOROCO STOMY.
in SS PTX, tube thoracostomy less effecttive, than PS PTX
delayed lung expansion n persistant air leaks.
in COPD meantime 5days for lung expansion.
in 20% SS PTX pts air leak lasts for 7 days,

74. Rx of SS-PTX
After lung expansion – prevent recurrence of PTX.
VATS (stapling of blebs,pleu abrasion) as recurence rate < 5%.
medical thoracoscopy c talc insufflation.
mini thoracotomy good alternative to thoracoscopy.
BTS guidelines: Open thoracotomy & repair.
thoracoscopy reserved for pts c poor lung funct, not fit.
intrapleural inj of doxy through chest tube ↓50 to 30%.
(only if above procedures not available.)

75. CATAMENIAL PNEUMOTHORAX
Recurrent PTX in women in 30 -40 s during periods
with incidence 3 – 6%, occurs within 48- 72hrs.
c/o chestpain, dyspnea.
ass c mental n physical stress.
90% on rt side, but b/l, lt side PTX also occurs.
diaphragm defects,
Ectopic endometriosis in subpleural area.

76. CATAMENIAL PNEUMOTHORAX
Medical rx
Supress da ectopic endometrium using ocps
supress ovulation,, danazol.
GnRH agonists used 2 supress CP,,,Lupron
Surgical rx
Thoracoscopy-closure of diaph def, stapling blebs, pleural
abrasions, -- diaphragm mesh (bagan)
Hysterectomy c b/l oopherectomy induce surg menopause

77. PTX 2 CYSTIC FIBROSIS
SSPTX is frequently seen in pts c CYSTIC FIBROSIS.
Incidence is 6%, c mean age of 1st episode 21.9 yr
Freq seen in pts c severe resp impairement, ↑age.
FEV1 < 40% seen in 75% of pts c PTX.
↑press, vol in alveoli due2 mucous pluggin n inflam of prox
airways leadin to rupture inda pleural space.
Rx to prevent recurrence..
initially stabalised c tube thoracostomy .

78. PTX 2 CYSTIC FIBROSIS
thoracoscopy if persistant air leak, lung not expands
for 3 days after tube thoracostomy.
As many pts require lung transplantation,
procedure of choice is VATS c staplin of blebs, &
pleural abrasion.

79. PTX 2 Lymphangio leiomyomatosis
LAM rare condition, char by peribronchial,
perivascular,& perilymphatic proliferation of
abnormal smooth muscle cells.
affects women of child bearing age. Incidence 66%.
presents c progressive dyspnea, chylothorax,
recurrent SPTX, hemoptysis….
Rx VATS,c stapling of blebs, n pleural abrasion.

80. COMPLICATIONS
TENSION PNEUMOTHORAX
BRONCHO – PLEURAL FISTULA
Re expansion PULM OEDEMA
HEMO THORAX
PYO THORAX.

81. Title

82. BRONCHO PLEURAL FISTULA
BRONCHOPLEURAL FISTULA. Rare but serious.
a communication btw pleural space n bronchial tree.
usually airleak seals within 24-48 hrs.
only 3- 5% have persistant air leak.
pts c COPD, cystic fibrosis- ↑risk of persistant BPF.

83. BRONCHO PLEURAL FISTULA
ACCP guidelines recommend – if leak for 4 days, pt
should be evaluated for Sx, to close airleak n
perform pleurodesis to prevent recurrence.
THORACO SCOPY preff - to prevent recurrence.
Pts not fit for Sx - BPF localised by bronchoscopic
baloon cath occlusion, n injected to seal airleak.
fibrin glue, liquid bioadhesive, sterile gelatin sponge,
lead shot, & autologous blood patch.

84. Title

85. Re expansion pulmonary oedema
REEXPANSION PULM EDEMA: rare , potentially fatal
condition that occur after rapid reexpansion of collapsed
lung. Usually in long standing PTX.
usually unilateral.
due to ↑permeability of pulm capillaries that r damaged
by mechanical stress during re expansion of lung.
reperfusion inj due 2 free radicals, decreased surfactant.
ischemic reperfusion inj, airway obstruc on, ↓lymp flow.

86. Re expansion pulmonary oedema
REPE depends on duration(3days), severity of PTX,
method (suction) &rate of expansion.
 symptoms- severe cough, chest pain.within an hr.
hypoximia,tachypnea,tachycardia, hypotension.
last for 24 – 48 hrs only.
 Rx supportive, c high flow O2.
try to prevent. (c no negative pressure.)

87. Title