This PowerPoint presentation provides an in-depth overview of pneumothorax, a medical condition that occurs when air leaks into the pleural cavity, causing the lung to collapse. The presentation covers the causes, symptoms, and diagnostic procedures for pneumothorax, including chest x-rays and CT scans. The presentation also discusses the various treatment options available for pneumothorax, such as thoracentesis, chest tube insertion, and surgery. The benefits and risks of each treatment are also explained in detail, providing the audience with a comprehensive understanding of the condition and its management. In addition, the presentation includes several case studies and real-life examples to help illustrate the impact of pneumothorax on patients and the importance of early diagnosis and treatment. It is an ideal resource for medical professionals, students, and anyone interested in learning more about this common medical condition. Overall, this PowerPoint presentation provides a valuable resource for understanding pneumothorax, its causes, symptoms, and treatment options, helping to improve patient outcomes and quality of care.

1. Pneumothorax

2. Introduction
• Air in the pleural space
• Bilateral in about 2% cases
• Types:
• Spontaneous pneumothorax: occur without antecedent trauma or
other obvious cause
• Primary spontaneous: occur in otherwise healthy individuals
• Secondary spontaneous: complication of underlying lung disease e.g., COPD
• Traumatic pneumothoraces: direct or indirect trauma to the chest
• Iatrogenic pneumothorax- after a diagnostic/therapeutic maneuver

3. Types of spontaneous pneumothorax
• Closed
• Open
• Tension

4. Epidemiology: 1° pneumothorax
• Annual incidence is around 9 per 100,000
• Most commonly in tall thin men aged between 20 and 40
• Less common in women (♂:♀ 5: 1)
• Cigarette or cannabis smoking: a major risk factor increase by factor
of 22 in men & 9 in women.
• Rupture of subpleural emphysematous blebs that are usually located
in the apices of the lung
• More common in patients with Marfan’s syndrome &homocystinuria

5. 2 ° spontaneous pneumothorax
• Underlying diseases include: COPD (60% of cases), asthma, ILD,
necrotizing pneumonia, TB, PCP, CF, Langerhan cells histiocytes(LCH),
LAM, oesophageal rupture, lung cancer, catamenial pneumothorax,
and pulmonary infarction
• Pneumothorax may be the first presentation of the underlying
disease.

6. Clinical features
• Classically presents with acute onset of pleuritic chest pain and/or
breathlessness
• Breathlessness is often minimal in young patients and is more severe
in 2° pneumothorax
• Signs: size & physiological reserve
• tachycardia, ↑RR, mediastinal shift, hyperinflation, reduced expansion,
hyperresonant percussion note, & quiet breath sounds on that side
• These are frequently absent in small pneumothoraces
• Hamman’s sign: a ‘click’ with the heart sounds, due to movement of
pleural surfaces with Lt pneumothorax

7. Clinical features
• May feel ‘bubbles’ and ‘crackles’ under the skin and neck if there is
subcutaneous emphysema
• In mechanically ventilated patients: acute clinical deterioration &
hypoxia or increasing inflation pressures.

8. Investigations
• CXR is the diagnostic test in most cases, revealing a visible lung edge and absent lung markings
peripherally.
• May also show features of underlying lung disease, but difficult to assess in the presence of a
large pneumothorax
• Blunting of the ipsilateral costophrenic angle due to low-volume bleeding into the pleural space is
seen
• Width of the rim of air surrounding the lung on CXR
• small (rim of air measured at level of hilum ≤2cm) and large (>2cm)
• 2cm rim of air approximately equates to a 50% pneumothorax in volume
• Tiny pneumothoraces not apparent on CXR PA may be visible on lateral chest/ decubitus films
• CT chest may be required
• to differentiate pneumothorax from bullous disease and
• in diagnosing unsuspected pneumothorax following trauma and to see evidence of underlying lung disease
• ABGs frequently show hypoxia and sometimes hypercapnia in 2° pneumothorax.

9. CXR-PA

10. CT images

11. Supine films/AP films
• Look for a sharply delineated heart
border, hemidiaphragm and
costophrenic angle depression
(‘deep sulcus sign’), and increased
lucency on the affected side

12. Prognosis- 1° pneumothorax
• Untreated, pneumothoraces without an ongoing air leak resolve at
rate of ~2% of volume of hemithorax every 24h
• Average of 30% (range 16–54% in studies) recur, most within 2yrs.
• Increased incidence of recurrence
• Continued smoking
• each subsequent pneumothorax
• around 30% after the 1st, 40% after 2nd & >50% after the 3rd

13. Prognosis- 2° pneumothorax
• Mortality is 10%
• Recurrence higher than 1° pneumothorax: 39–47% and is associated
with age, pulmonary fibrosis, and emphysema
• Higher recurrence rates may be as high as 80% in patients with LCH or
LAM.

14. Management
• Considerable variation amongst clinicians regarding optimal
management
• General management points
• Observation
• All hospitalized patients should receive high-flow (10 L/min) inspired O2
(unless CO2 retention is a problem)
• Drainage- aspiration, chest tube

15. General management
• Primary or secondary (evidence of lung disease clinically or age >50 with
significant smoking history)
• Degree of breathlessness and hypoxia,
• severe breathlessness out of proportion to pneumothorax size on a prior CXR may be
a feature of impending tension pneumothorax
• Evidence of hemodynamic compromise
• Presence and severity of any underlying lung disease, and,
• To a lesser extent, CXR pneumothorax size
• 2° pneumothorax has a significant mortality (10%) & requires aggressive
management
• Treatment of the underlying disease.

16. Measurement of size

17. Further management-aspiration
• Aseptic technique
• halt the procedure if painful or if the patient coughs excessively
• do not aspirate >1.5L of air; a large air leak and aspiration is likely to fail
• Successful aspiration
• if the lung is fully or nearly re-expanded on CXR and patient feels
symptomatically better with improved physiology
• If initial aspiration of a 1° pneumothorax fails, a chest drain is likely to
be required if benefits outweigh risks

18. Further management- chest tube drainage
• Associated with significant morbidity and even mortality, and not required
in the majority of patients with 1° spontaneous pneumothorax
• Small (12–14F) drains are sufficient in most cases
• Larger if 2° pneumothorax with large air leak, severe subcutaneous
emphysema, or in mechanically ventilated patients
• Never clamp a bubbling chest drain (risk of tension pneumothorax)
• Clamping after no air leak
• No swing in water level
• kinked (check underneath dressing as tube enters skin)
• blocked, clamped, or incorrectly positioned- check CXR

19. Other option
• Heimlich flutter valves (or thoracic vents)

20. Persistent air leak
• Arbitrarily defined as continued bubbling of air 48h after insertion
• Causes:
• Bronchopleural fistula
• A hole lies outside
• Management:
• Consider drain suction (–10 to –20 cmH2O)
• Autologous blood patch
• Insertion of large-bore drain, and/or
• Thoracic surgical referral

21. Surgical referral
• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Bilateral spontaneous pneumothorax
• Persistent air leak or failure of lung to re-expand (3–5 days of
drainage)
• Spontaneous haemothorax
• Professions at risk (e.g. pilots, divers) after first pneumothorax
• Options
• VATS
• Open thoracotomy

22. Pleurodosis
• Agents:
• talc slurry and the tetracycline derivatives
• Blood
• Betadine

23. Tension Pneumothorax
• Pneumothorax acts as a one-way valve, with air entering the pleural
space on each inspiration and unable to escape on expiration
• Progressive increase in pleural pressure compresses both lungs and
mediastinum and inhibits venous return to the heart, leading to
hypotension and potentially cardiac arrest
• Not related to pneumothorax size, & tension can occur with very
small pneumothoraces if air trapping in the lung from obstructive
lung disease

24. Clinical features
• Typically presents with acute respiratory distress, agitation
• Hypotension, raised JVP,
• Tracheal deviation away from the pneumothorax side,
• Reduced breath sound on affected side
• May present with cardiac arrest (pulseless electrical activity) or with
acute deterioration in ventilated patients

25. Management of a tension pneumothorax
• If strong clinical suspicion, give high-flow O2 and insert large-bore
cannula into second intercostal space in mid-clavicular line on side of
pneumothorax
• Do not wait for a CXR if patient seriously compromised or cardiac
arrest has occurred
• Hiss of escaping air confirms diagnosis- aspirate air until the patient is
less distressed, & then insert chest drain in safe triangle, leaving
cannula in place until finished & underwater seal is

26. Iatrogenic pneumothorax
• Causes: TBB, transthoracic needle lung biopsy, subclavian line
insertion, mechanical ventilation, pleural aspiration, pleural biopsy,
external cardiac massage, and percutaneous liver biopsy
• Presentation may be delayed, even several days
• Most cases do not require intervention and improve with
observation, although aspiration is sometimes required
• ICD is seldom needed except in mechanically ventilated patients, who
will require an intercostal drain in the majority of cases.

27. Traumatic pneumothorax
• Up to half may not be clinically apparent or visible on CXR
• CT chest is required for diagnosis
• Majority of patients require intercostal drain
• VATS early if persistent air leak.

28. Catamenial pneumothorax
• Pneumothorax occurring between the day before and within 72 hours
after onset of menses
• Usually recurrent
• Pathogenesis is unknown; pleural endometriosis or transfer of air into
pleural spaces through a diaphragmatic defect from the peritoneal
cavity at menstruation
• Treatment options: VATS, pleurodesis, ovulation-suppressing drugs.

29. Surgical emphysema
• Occurs as air tracks below skin under pressure from the pleural space
• May result from large air leaks, particularly in the presence of underlying
lung disease such as COPD
• Chest drain is blocked or displaced so that holes lie subcutaneously
• Harmless in majority of cases although rarely may result in significant
respiratory compromise from upper airway compression
• Treatment:
• High-flow (10L/min) oxygen (unless CO2 retention a problem)
• Ensure the drain is patent (swinging, bubbling)
• If the airway is compromised, consider anaesthetizing and incising areas of affected
skin, and ‘milking’ out subcutaneous air

30. Discharge
• 6 weeks no fly rule
• Outpatient follow up
• Emphasize on recurrence

31. BTS treatment algorithm for
spontaneous pneumothorax 2010.