A 30-year-old male presented with complaints of breathlessness and cough with expectoration for one month. Chest X-ray and CT scan revealed left hydropneumothorax, right bullous disease/hydropneumothorax, and bilateral lower lobe bronchiectasis. Needle aspiration was performed to relieve the pneumothorax. Idiopathic spontaneous pneumothorax often recurs, with at least 20-30% experiencing recurrence within 5 years, usually within the first year. Distinguishing features between a skin fold and genuine pneumothorax on chest X-ray include lung markings extending beyond the fold and absence of a fine pleural line.

1. Prof .Dr.K.H.NOORUL AMEEN’S unit M6 Dr.G ARUN KUMAR IMAGE OF THE WEEK

2. 30 YEAR OLD MALE CAME TO OPD WITH COMPLAINTS OF BREATHLESSNESS 1 MONTH DURATION. NOW INCREASED FOR 2 DAYS H/O COUGH WITH EXPECTORATION 1 MONTH CHRONIC ALCOHOLIC AND SMOKER 15 YEARS

4. COLLAPSED LUNG COLLAPSED LUNG HYDRO PNEUMOTHORAX

5. CHEST X RAY PA VIEW ADEQUATE INSPIRATION CENTRING, PATIENT POSITION - NORMAL EXPOSURE/PENETRATION - ADEQUQTE TRACHEA POSITION - MIDLINE HEART AND MEDIASTINUM – NORMAL PLEURAL SPACE – HYDROPNEUMOTHORAX ON THE LEFT SIDE EVIDENCED BY THE CONVEX OUTSIDE BORDER OF LUNG WITH VISCERAL PLEURA AND AIR FLUID LEVEL ? BULLAE/ ?LOCULATED HYDROPNEUMOTHORAX SEEN ON RIGHT SIDE EVIDENCED BY CONVEX INWARDS MARGINS OF THEIR WALLS WITH AIR FLUID LEVEL COSTOPHRENIC ANGLES BLUNTED BILATERALLY CARDIOPHRENIC ANGLES FREE HILA DENSITY, POSITION, SHAPE - NORMAL SOFT TISSUES – NORMAL BONES- NORMAL Imp:LEFT HYDROPNEUMOTHORAX RIGHT BULLOUS DISEASE/HYDROPNEUMOTHORAX WITH ?PLEURAL THICKENING

6. CT CHEST AFTER 10 DAYS

7. CT CHEST AFTER 10 DAYS RIGHT HYDROPNEUMOTHORAX EMPHYSEMATOUS BULLAE IN B/L LOWER LOBE, RIGHT MIDDLE LOBE B/L LOWER LOBE BRONCHIECTASIS

8. BULLAE

9. TENSION PNEUMOTHORAX

10. Pneumothorax Pneumothorax is the presence of air in the pleural cavity . Spontaneous pneumothorax Primary Secondary Airways disease (COPD, cystic fibrosis, acute severe asthma) Infectious lung disease Interstitial lung disease (e.g. sarcoidosis) Connective tissue disease (e.g. rheumatoid arthritis, Marfan Malignancy (bronchial carcinoma or sarcoma) Thoracic endometriosis Traumatic pneumothorax Iatrogenic pneumothorax Transthoracic needle aspiration Subclavian vein puncture Thoracentesis and pleural biopsy Pericardiocentesis Barotrauma related to mech ventilation

11. Because the normal pleural space contains a small volume of fluid , blunting of the costophrenic angle by a short fluid level is commonly seen in a pneumothorax In a small pneumothorax this fluid level may be the most obvious radiological sign. A larger fluid collection usually signifies a complication and represents exudate, pus or blood, depending an the aetiology of the pneumothorax. Pleural thickening may cause blunting of the costophrenic angle, but is distinguished from pleural fluid by the fact that it occurs as a linear shadow ascending vertically and clinging to the ribs.

12. Peripheral shadowing on the right Loss of right lung volume Shadowing over the whole right lung due to circumferential pleural thickening

15. Pleural thickening Diffuse pleural thickening due to acute pleuritis : Pneumonia Tuberculosis Empyema Connective tissue disease Drugs (eg. practolol, methysergide) Fibrosing pleuritis Post radiotherapy Post-traumatic diffuse pleural thickening eg. haemothorax Post-surgery (particularly coronary artery bypass grafting Other diagnoses that may resemble diffuse pleural thickening : Pleural plaques, Mesothelioma ,Other pleural- based tumours Essentially all common causes of nodular pleural thickening are malignant and include: mesothelioma , Lymphoma , invasive thymoma ,metastatic pleural disease particularly from adenocarcinomas

16. Pleural thickening is best seen at the lung edges where the pleura runs tangentially to the x-ray beam. Visible pleural edge & Lung markings not visible beyond this edge Localized pleural thickening often occurs at the lung apices with increasing age, forming an apical cap . This may be uni- or bilateral and is usually of homogeneous, soft tissue density, usually less than 5 mm thick, with a well-defined inferior margin. It should be distinguished from a superior sulcus neoplasm The most useful signs in predicting the presence of malignancy are 1. Circumferential thickening 2. Nodularity 3. Thickening of greater than 1cm 4. Involvement of the mediastinal pleura.

17. Signs of tension pneumothorax Pleuritic chest pain Respiratory distress ( dyspnea, tachypnea, ability to speak only in short sentences or single words, agitation, sweating ) • Falling arterial oxygen saturation • Ipsilateral hyperexpansion, hypomobility, hyperresonance with decreased BS • Tachycardia • Hypotension • Tracheal deviation • Elevated jugular venous pressure

18. Needle aspiration of pneumothorax Identify the 3rd to 4th intercostal space in the midaxillary line Infiltrate with lidocaine Connect a 21 G (green) needle to a three-way tap and a 60 ml syringe With the patient semirecumbent, insert the needle into the pleural space. Withdraw air and expel it via the three-way tap Obtain a chest X-ray to confirm resolution of the pneumothorax If a Heimlich flutter valve , which allows one-way passage of gas, is attached to the catheter, a series of coughs or Valsalva maneuvers will allow almost complete evacuation of the remainder of the pneumothorax that is not under tension.

19. Reccurence Idiopathic spontaneous pneumothorax often recurs. At least 20% to 30% of patients with idiopathic spontaneous pneumothorax will experience an ipsilateral recurrent pneumothorax within the ensuing 5 years; most recurrences occur within a year after the initial event. Recurrences are more common in women and taller men and are reduced by smoking cessation. Ninety percent or more of recurrences are ipsilateral, despite the fact that the underlying abnormality (i.e., apical subpleural blebs) is bilateral in more than half the cases. Simultaneous bilateral idiopathic spontaneous pneumothoraces are fortunately infrequent, occurring in approximately 1% of cases; surprisingly, when they do occur, they are rarely fatal. After the first ipsilateral recurrence of a pneumothorax, subsequent recurrences become increasingly likely.

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26. Supine chest radiograph of an intubated patient. There is a skin fold projected over the right lung apex simulating a pneumothorax (arrows). Close inspection reveals lung markings extending beyond the skin fold, and no fine pleural line that should be visible with a genuine pneumothorax