Cardiothoracic Surgery Pneumothorax
CLASSIFICATION <ul><li>Primary spontaneous </li></ul><ul><li>Secondary spontaneous </li></ul><ul><li>Traumatic </li></ul><...
Primary spontaneous <ul><li>Tall thin people </li></ul><ul><li>Age; 20-30 years old </li></ul><ul><li>Smokers- occurrence ...
Secondary spontaneous <ul><li>Underlying pulmonary pathology </li></ul><ul><li>Most commonly seen in COPD patients </li></...
Traumatic pneumothorax <ul><li>Penetrating versus blunt chest trauma </li></ul>
Tension pneumothorax <ul><li>Surgical emergency </li></ul><ul><li>Definition-a build up of positive pressure within the he...
Examination <ul><li>Decreased or absent breath sounds on affected side </li></ul><ul><li>Hyperresonance </li></ul><ul><li>...
Mediastinal shift <ul><li>Pressure on unaffected lung interferes with gas exchange leading to hypoxaemia </li></ul><ul><li...
Investigations <ul><li>Chest X ray- should never be performed when suspecting  tension pneumothorax </li></ul><ul><li>ABG-...
Management of spontaneous pneumothorax <ul><li>Observation with follow up X-ray </li></ul><ul><li>Tube thoracostomy </li><...
Management of tension pneumothorax <ul><li>Immediately insert a large bore cannula into 2nd intercostal space in midclavic...
Insertion of chest drain <ul><li>NB remember surgical principles ie aseptic technique </li></ul><ul><ul><li>Paint with Bet...
Insertion of chest drain <ul><li>Sharp dissection of skin </li></ul><ul><li>Blunt dissection through the remaining tissue ...
Insertion of chest drain <ul><li>Remove the trocar and the tube is carefully and securely positioned using a purse string ...
Definitive surgical management <ul><li>Indications </li></ul><ul><ul><li>Recurrent pneumothorax for any reason </li></ul><...
Definitive surgical management <ul><li>Surgical options </li></ul><ul><ul><li>Pleurodesis- tube thoracostomy with preferre...
 
 
 
 
 
 
 
Classification <ul><li>Primary spontaneous </li></ul><ul><li>Secondary spontaneous </li></ul><ul><li>Traumatic </li></ul><...
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Fwd: Cardiothoracic surgery Bambury

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From: UCD Graduate '09 None <ucdgrad09@gmail.com&gt;
Date: 2009/2/25
Subject: Cardiothoracic surgery Bambury
To: ucdgrad09@gmail.com

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Fwd: Cardiothoracic surgery Bambury

  1. 1. Cardiothoracic Surgery Pneumothorax
  2. 2. CLASSIFICATION <ul><li>Primary spontaneous </li></ul><ul><li>Secondary spontaneous </li></ul><ul><li>Traumatic </li></ul><ul><li>Tension </li></ul><ul><li>Definition- injury to the lung resulting in release of air into the intrapleural space(between the parietal and visceral pleura) </li></ul>
  3. 3. Primary spontaneous <ul><li>Tall thin people </li></ul><ul><li>Age; 20-30 years old </li></ul><ul><li>Smokers- occurrence increases directly with the number of cigarettes smoked per day </li></ul><ul><li>Familial </li></ul><ul><li>Presentation </li></ul><ul><ul><li>Sudden onset SOB </li></ul></ul><ul><ul><li>Associated with chest pain </li></ul></ul>
  4. 4. Secondary spontaneous <ul><li>Underlying pulmonary pathology </li></ul><ul><li>Most commonly seen in COPD patients </li></ul><ul><li>Other causes include </li></ul><ul><ul><li>Sarcoidosis </li></ul></ul><ul><ul><li>Tuberculosis </li></ul></ul><ul><ul><li>Cystic fibrosis </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Idiopathic pulmonary fibrosis </li></ul></ul>
  5. 5. Traumatic pneumothorax <ul><li>Penetrating versus blunt chest trauma </li></ul>
  6. 6. Tension pneumothorax <ul><li>Surgical emergency </li></ul><ul><li>Definition-a build up of positive pressure within the hemithorax-mediastinal shift. </li></ul><ul><li>One way valve mechanism- air enters alveoli but can’t escape as the lung tissue collapses around the hole in the pleura. </li></ul>
  7. 7. Examination <ul><li>Decreased or absent breath sounds on affected side </li></ul><ul><li>Hyperresonance </li></ul><ul><li>Decreased tactile fremitus </li></ul><ul><li>Hypotension </li></ul><ul><li>Tachycardia>130 </li></ul><ul><li>Tachypnoea </li></ul><ul><li>Cyanosis </li></ul><ul><li>Distended jugular venous pulsation </li></ul><ul><li>Tracheal deviation to contralateral side </li></ul>
  8. 8. Mediastinal shift <ul><li>Pressure on unaffected lung interferes with gas exchange leading to hypoxaemia </li></ul><ul><li>Pressure on the heart reduces venous return to the heart reducing cardiac output. </li></ul><ul><li>Leads to cardiorespiratory failure </li></ul>
  9. 9. Investigations <ul><li>Chest X ray- should never be performed when suspecting tension pneumothorax </li></ul><ul><li>ABG-hypoxaemia </li></ul><ul><li>Imaging to distinguish Bullae at apex from pnemothotax- in emergency setting U/S or CT if not an emergency </li></ul>
  10. 10. Management of spontaneous pneumothorax <ul><li>Observation with follow up X-ray </li></ul><ul><li>Tube thoracostomy </li></ul>
  11. 11. Management of tension pneumothorax <ul><li>Immediately insert a large bore cannula into 2nd intercostal space in midclavicular line </li></ul><ul><li>Hissing sound will be heard </li></ul><ul><li>Follow by inserting a chest drain </li></ul>
  12. 12. Insertion of chest drain <ul><li>NB remember surgical principles ie aseptic technique </li></ul><ul><ul><li>Paint with Bethadine </li></ul></ul><ul><ul><li>Drape the surrounding area </li></ul></ul><ul><ul><li>Triangle of safety is </li></ul></ul><ul><ul><ul><li>1) anterior to the midaxillary line </li></ul></ul></ul><ul><ul><ul><li>2) above the level of the nipple </li></ul></ul></ul><ul><ul><ul><li>3)below and lateral to the pec major </li></ul></ul></ul><ul><ul><li>5th intercostal space in midaxillary line </li></ul></ul>
  13. 13. Insertion of chest drain <ul><li>Sharp dissection of skin </li></ul><ul><li>Blunt dissection through the remaining tissue as far as the parietal pleura </li></ul><ul><li>The tract should be just above the lower rib to avoid the neurovascular bundle aiming toward the apex. </li></ul><ul><li>Insert finger into cavity and use this to guide the trocar </li></ul>
  14. 14. Insertion of chest drain <ul><li>Remove the trocar and the tube is carefully and securely positioned using a purse string suture. </li></ul><ul><li>Tube is then connected to an underwater seal and bubbling of the water is observed. </li></ul><ul><li>Request a chest x ray to determine correct positioning of the tube and reinflation of the lung </li></ul>
  15. 15. Definitive surgical management <ul><li>Indications </li></ul><ul><ul><li>Recurrent pneumothorax for any reason </li></ul></ul><ul><ul><li>Patients with </li></ul></ul><ul><ul><li>high risk occupations eg pilots, divers. </li></ul></ul>
  16. 16. Definitive surgical management <ul><li>Surgical options </li></ul><ul><ul><li>Pleurodesis- tube thoracostomy with preferred agent being talc </li></ul></ul><ul><ul><li>Thorocotomy with pleurectomy </li></ul></ul><ul><ul><li>VATS- video assisted thorascopic surgical biopsy with talc insufflation </li></ul></ul>
  17. 24. Classification <ul><li>Primary spontaneous </li></ul><ul><li>Secondary spontaneous </li></ul><ul><li>Traumatic </li></ul><ul><li>Tension </li></ul>

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