- The document discusses pneumothorax, describing its classification, pathogenesis, clinical presentation, diagnosis, and treatment options. - Key points include that tension pneumothorax can cause rapid deterioration and requires immediate treatment, while spontaneous pneumothorax is classified as primary or secondary depending on underlying lung health. - Treatment involves observation for small primary pneumothoraces or procedures like aspiration, chest tube placement, or surgery depending on the size and symptoms.

1. PNEUMOTHORAX MBBS.weebly.com

2. Introduction Laennec described the clinical picture of pneumothorax in 1819 The modern description of primary spontaneous pneumothorax occurring in otherwise healthy people was provided by Kjaergard in 1932 Primary pneumothorax remains a significant global problem The incidence is 18-28/100 000 per year for men and 1.2-6/100 000 per year for women

3. Introduction Secondary pneumothorax is associated with underlying lung disease, whereas primary pneumothorax is not Hospital admission rates for combined primary and secondary pneumothorax are reported in the UK at between 5.8/10 000 per year for women and 16.7/10 000 per year for men Mortality rates in the UK were 0.62/million for men between 1991 and 1995

4. Contents What is pneumothorax Pathogenesis and mechanisms Pathophysiology Clinical typing Clinical manifestation Diagnosis and differentiate diagnosis Treatment

5. What is Pneumothorax

6. Classification of pneumothorax Types Spontaneous having an unknown cause or occurring as a consequence of the nature course of a disease process, such as COPD, tuberculosis Traumatic following any penetrating or non-penetrating chest trauma, with or without bronchial rupture Iatrogenic occurring as the results of diagnostic or therapeutic medical procedure. Intentional or a complication

7. Spontaneous pneumothoraces are subclassified as: Primary spontaneous pneumothorax (PSP) Healthy people, most young people Secondary spontaneous pneumothorax (SSP) Underlying diseases Chronic obstructive pulmonary disease (COPD), pulmonary tuberculosis Clinical typing of pneumothorax

8. Pathogenesis and mechanisms In normal people, the pressure in pleural space is negative during the entire respiratory cycle Two opposite forces result in negative pressure in pleural space: inherent outward pull of the chest wall and inherent elastic recoil of the lung The negative pressure will be disappeared if any communication develops

9. When a communication develops between an alveolus or other intrapulmonary air space and pleural space air will flow into the pleural space until there is no longer a pressure difference or until the communication is sealed Pathogenesis and mechanisms

10. Pathogenesis and mechanisms When a communication develops through the chest wall between the atmosphere and the pleural space air will enter the pleural space until the pressure gradient is eliminated or the communication is closed

11. Pneumothorax: Negative pressure eliminated The lung recoil-small lung-volume decrease V/Q decrease-shunt increase Positive pressure Compress blood vessels and heart decreased cardiac output Impaired venous return Hypotension Shock Result in A decrease in vital capacity A decrease in PaO 2 Pathophysiology

12. Thoracoscopic studies Blebs Air filled spaces between the lung parenchyma and the visceral pleura Pathophysiology Shows a similar cystic space, completely surrounded by pl pleura

13. Bullae Air filled spaces within the lung parenchyma itself Pathophysiology Lung parenchyma Surrounded by fibrous tissue

14. Blebs The patient, a 22-year-old male, was admitted to hospital, complaining of left chest pain and palpitations.

15. Blebs and bullae are also known as emphysema-like changes (ELCs) The probable cause of pneumothorax is rupture of an apical bleb or bulla Because the compliance of blebs or bullae in the apices is lower compared with that of similar lesions situated in the lower parts of the lungs Pathophysiology

16. It is often hard to assess whether bullae are the site of leakage, and where the site of rupture of the visceral pleura is Smoking causes a 9-fold increase in the relative risk of a pneumothorax in females A 22-fold increase in male smokers With a dose-response relationship between the number of cigarettes smoked per day and occurrence of PSP Pathophysiology

17. PSP SSP

18. Clinical typing of pneumothorax Closed communicated tension Rupture small large valve-like sealed open in not out Pressure P or N atmosphere high After Aspiration N atmosphere high again

19. Clinical manifestation Symptom Depend on whether underlying pulmonary disease or not Depend on the speed of pneumothorax occurred Depend on size of pneumothorax Depend on the level of intrapleual pressure The patient with underlying pulmonary disease will undergo severe dyspnea The healthy person will have minimal symptoms although having large volume of pneomothorax

20. 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 Clinical manifestation

21. Tension pneumothorax risk factors Receiving positive-pressure mechanical ventilation During cardiopulmonary resuscitation Undergoing hyperbaric oxygen therapy Evolving during the course of spontaneous pneumothorax Clinical manifestation

22. Tension pneumothorax

23. Tension pneumothorax Distressed with rapid labored respiration Cyanosis Marked tachycardia Profuse diaphoresis Patient who suddenly deteriorate clinically, be suspected if the patient with Mechanical ventilation Cardiopulmonary resuscitation Clinical manifestation

24. Physical examination Depend on size of pneumothorax Depend on whether pleural effusions or not The vital signs usually normal The side with pneumothorax is larger than the contralateral side Chest moves less during the respiratory cycle Clinical manifestation

25. Physical examination Tactile fremitus is absent The percussion note is hypersonant The 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 Clinical manifestation

26. Clinical stability Stable patients RR: <24/min HR: 60-120/min BP: normal SO 2 : >90% (room air) Patient can speak in whole sentences between breaths All above present Unstable patients Not fulfilling the definition of stable Evaluate the severity and make decision for treatment

27. Imaging- Plane chest X-ray film Establishing the diagnosis The characteristics of pneumothorax Pleural line No lung markings in pneumothorax The outer margin of visceral pleura separated from the parietal pleura by a lucent gas space devoid of pulmonary vessels

28. Plane chest X-ray film In erect patients, pleural gas collects over the apex, and the space between the lung and chest wall is most notable there In the supine position, gas migrates along the broad ventral surface of lung, making detection on a frontal radiograph difficult

29. Plane chest X-ray film It is very important to differentiate the pleural line of a pneumothorax from that of a skinfold, clothing, tubing, or chest wall artifact Careful inspection of the film may show that the artifact extends beyond the thorax, or that lung markings are visible beyond the apparent pleural line

30. Plane chest X-ray film In the absence of underlying lung disease, the pleural line of a pneumothorax usually parallels the shape of chest wall Artifactual densities generally do not parallel the course of the chest wall over their entire length

31. Plane chest X-ray film Quantification of the size The size of a pneumothorax, in terms of volume, is 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

32. BTS The rim of air between the pleura and the chest wall Small <1cm Moderate :1- 2cm Large >2cm ACCP The apex-to-cupola distance Small <3cm Large ≥ 3cm Estimation of pneumothorax volume

33. Since the volume of a pneumothorax approximates to the ratio of the cube of the lung diameter to the hemithorax diameter A pneumothorax of 1 cm on the PA chest radiograph occupies about 27% of the hemithorax volume Lung is 9 cm, hemithorax is 10 cm in diameter Equation Volume of pneumothorax = (HT 3 – L 3 ) ÷ HT 3 = (10 3 – 9 3 ) ÷ 10 3 = (1000 – 729) ÷1000 = 0.27 Plane chest X-ray film Hemithorax (HT) Lung (L)

34. A pneumothorax of 2 cm on the PA chest radiograph occupies about 49% of the hemithorax volume Lung is 8 cm, hemithorax is 10 cm in diameter Equation Volume of pneumothorax = (HT 3 – L 3 ) ÷ HT 3 = (10 3 – 8 3 ) ÷ 10 3 = (1000 – 512) ÷1000 = 0.49 Plane chest X-ray film Hemithorax (HT) Lung (L)

35. CT scanning CT scanning is the most robust 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

36. CT scanning bullae pneumothorax

37. CT scanning bullae pneumothorax pneumothorax

38. CT scanning pneumothorax

39. CT scanning Small pneumothorax Subcutaneous emphysema

41. Diagnosis and Differentiation PSP Young, thin, tall man Clinical history (chest pain) and physical examination Chest radiograph SSP (COPD and Asthma) Repeated wheezing episode Dyspnea gradually progress In the course of disease, if patients Onset of severe dyspnea, cold sweat, dysphoria No response to bronchial dilators, antibiotics Consider pneumothorax Chest X-ray radiograph to confirm the diagnosis

42. Goals To promote lung expansion To eliminate the pathogenesis To decrease pneumothorax recurrence Treatment options according to Classification of pneumothorax Pathogenesis Pneumothorax frequency The extension of lung collapse Severity of disease Complication and concomitant underlying diseases Treatment

43. Observation - PSP Observation along is advised for small, closed mildly symptomatic spontaneous pneumothoraces Patients with small PSP and minimal symptoms do not require hospital admission However, it should be stressed before discharge that they should be return directly to hospital in the event of developing breathlessness Most patients in this group who fail this treatment have secondary pneumothoraces

44. Observation along is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothoraces in asymptomatic patients Hospitalisation is recommended in these cases All other cases will require active intervention ( aspiration or chest drain insertion) Observation - SSP

45. Observation along is inappropriate and active intervation is required Marked breathlessness in a patient with a small (<2 cm) PSP may herald tension pneumothorax If a patient is hospitalised for observation, supplemental high flow (10 l/min) oxygen should be given where feasible Observation - PSP or SSP

46. Inhalation of high concentration of oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen This should increase the pressure gradient between the pleural capillaries and the pleural cavity Thereby increasing absorption of air from the pleural cavity Observation - PSP or SSP

47. The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25 – 1.8% of volume of hemithorax every 24 hours The addition of high flow oxygen therapy has been shown to result in a 4-fold increase in the rate of peumothorax reabsorption during the periods of oxygen supplementation Observation - PSP or SSP

48. Aspiration Simple aspiration is recommended as first line treatment for all PSP requiring intervention Simple aspiration is less likely to succeed in secondary pneumothoraces and in this situation, is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients under the age of 50 years Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge

49. Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful and a volume of < 2.5 L has been aspirated on the first attempt Aspiration

50. Catheter aspiration Catheter aspiration of pneumothorax can be used where the equipment and experience is available

51. Intercostal tube drainage Fix the catheter and cover with gauze Making a small incision

52. Intercostal tube drainage

53. INDICATIONS SSP 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 Intercostal tube drainage

54. Position of intercostal tube The chest tube should be positioned in the uppermost part of the pleural space, where residual air accumulates This procedure permits the air in the pleural space to be evacuated rapidly Intercostal tube drainage

55. The site of chest tube insertion is in the midclavicular line of second and third intercostal or anterior axillary line of fifth and sixth intercostal Intercostal tube drainage

56. Observation of drainage No bubble released The lung reexpansion 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 If the lung reexpansion, removing the chest tube 24 hours after reexpansion Otherwise, the chest tube will be inserted again or regulated the position

57. Complications of intercostal tube drainage Penetration of major organs Lung, stomach, spleen, liver, heart and great vessels Occur more commonly when a sharp metal trocar is inappropriately applied Pleural infection Empyema, the rate of 1% Surgical emphysema Subcutaneous emphysema

58. Chemical pleurodesis Goals Prevention of pneumothorax recurrence To produce inflammation of pleura and adhesions Indications Persist air leak and repeated pneumothorax Bilateral pneumothoraces Complicated with bullae Lung dysfunction, not tolerate to operation

59. Chemical pleurodesis Sclerosing agents Tetracycline Minocycline Doxycline Talc Erythromycin The instillation of sclerosing agents into the pleural space should lead to an aseptic inflammation with dense adhesions, leading ultimately to pleural symphysis

60. 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 Chemical pleurodesis

61. Side effect Chest pain Fever Dyspnea Acute respiratory distress syndrome Acute respiratory failure Chemical pleurodesis

62. Thoracoscopy Medical thoracoscopy VATS: video-assisted thoracoscopic surgery

63. Surgical treatment Indication No response to medical treatment Persist air leak Hemopneumothorax Bilateral pneumothoraces Recurrent pneumothorax Tension pneumothorax failed to dainage Thicken pleura makes lung unable to reexpansion Multiple blebs or bullae

64. Complications of pneumothorax Pyopneumothorax Caused by aspiration or intercostal chest tube insertion Also results from necrotic pneumonia, lung abscess, or caseous pneumonia Chest X-ray shows hydropneumothorax The pleural effusion is purulent Antibiotics and intercostal drainage Surgical mean

65. Hemopneumotorax Bleeding in pleural space Common cause is rupture of vessels in adhesions When lung reexpansion, bleeding will stop When bleeding persists, surgical ligation will be needed Infusion Complications

66. Complications

67. Complications

68. 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 Physical exam – crepitus is present Complications

69. Complications Pneumomediastinum Pneumocardium Pneumoperitoneum Surgical emphysema

70. Complications Subcutaneous emphysema

71. Complications Treatment 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

72. Recurrent Rates 30-50% recurrence after observation or tube thoracostomy. Attempts: thoracoscopy, surgery, pleurodesis.

73. Case 1 Female, 20 Chest pain 3 hours, and suddenly deteriorate dyspnea Cyanosis Marked tachycardia Profuse diaphoresis

74. Questions The diagnosis is A. pneumothorax B. cardiac infarction C. pulmonary embolism D. Asthma episode The type of pneumothorax is A. closed B. open C. tension D. hemothorax

75. Questions Which treatment is the first step A. oxygen inhalation B. bronchial dilators C. aspiration D. chest tube drainage

76. Case 2 Male, 70 Dyspnea 24 hours No chest pain COPD history 20 ys Cyanosis Marked tachycardia

77. Questions The diagnosis is A. AECOPD B. asthma episode C. primary pneumx D. SSP Which treatment prefer A. oxygen therapy B. aspiration C. chest tube D. surgical procedure

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