pneumothorax : its classifications , types etc

1. PNEUMOTHORAX

2. PNEUMOTHORAX is the presence of air in the
pleural space.

3. can be
a) Spontaneous
b) Result of iatrogenic injury
c) Trauma to the lung or chest wall

4. Classification
1. Spontaneous
# Primary
- No evidence of overt lung disease
- occurs in males aged 15-30
- air escapes from the lung into the pleural
space through rupture of a small emphysematous
bulla or pleural bleb
- smoking, tall stature & the presence of apical subpleural
blebs are additional risk factors

5. #Secondary
- underlying lung disease
- occurs mainly in males above 55 yrs
- most commonly COPD & TB
- also seen in asthma, lung abscess, pul infarcts,
bronchogenic carcinoma, all forms of fibrotic &
cystic lung disease

6. 2. Traumatic
- iatrogenic ( foll thoracic surgeryor biopsy)
- chest wall injury

8. TYPES
1. Closed spontaneous pneumothorax
2. Open spontaneous pneumothorax
3. Tension pneumothorax

9. Closed type
 Communication b/n airway and the pleural space
seals off as the lung deflates
 Mean pleural pressure remains negative
 Spontaneous reabsorption of air & re-expansion of
lung occur over a few days or weeks
 Infection uncommon

10. Open type
 Communication b/n pleura & bronchus doesn’t
seals off (Bronchopleural fistula)
 Intra pleural pressure = atm. Pressure
 Collapsed lung, no re expansion
 Transmission of infection from the airways into
the pleural space through fistula common
(empyema)

11. Tension type
 Communication b/n the airway & the pleural
space acts as a one-way valve
 Allowing air to enter the pleural space during
inspiration but not to escape on expiration
 Large amt of air accumulates progressively in the
pleural space
 Intrapleural pressure increases above atm

12.  Pressure causes mediastinal shift towards the
opposite side
 with compression of the opposite lung
 & impairment of systemic venous return
 Causing cardiovascular compromise

14.  Occasionally tension pneumothorax may
occur without mediastinal shift, if malignant
ds or scarring has splinted the mediastinum

15. Clinical features
 Sudden onset of unliateral pleuritic chest pain
 Breathlessness
[In pts with a small pneumothorax, physical
examination may be normal ]

16. General examination
Cyanosis
Rapid thready pulse
Signs of peripheral circulatory failure in
severe cases

17. Inspection & palpation
 Dyspnoea
 Accessory muscles of respiration
 Shift of trachea
 Shift of mediastinum to opposite side
 Fullness of chest on the affected side
 Diminished chest movements

18.  Marked diminished vocal fremitus on
affected side
 Reduction in total chest expansion
 Increase in size of affected hemithorax
 Diminished expansion of the affected
hemithorax

19. Percussion
 Hyper-resonant on affected
pneumothorax.
 Right sided pneumothorax-liver dullness is
obliterated and cardiac dullness is shifted
to the opposite side

20. Auscultation
 Diminished to absent breath sounds
 Absence of adventitious sounds
 Diminished vocal resonance
 Bronchopleural fistula-amphoric broncial
breathing.

22. Investigations
Chest x ray
Shows : increased radiolucency, with absence of
bronchovascular markings
 extend of mediastinal shift.
pleural fluid ,if present .
underlying pulmonary disease .


 (costophrenic angles are clear)
[care must be taken to differentiate b/n a large pre-existing bulla &
a pneumothorax to avoid misdirected attempts at aspiration]

24. CT
Helps to differentiate between large pre
existing emphysematous bullae and
pneumothorax .

25. TREATMENT

26. Primary pneumothorax
 If the lung edge is < 2cm from the chest wall
and patient is not breathless
↓
Resolves normally with out intervention

27.  If the patient
is having
↓ severe symptoms
Percutaneous needle aspiration
↓
If it fails , intercostal tube drainage is done

28. PERCUTANEOUS NEEDLE ASPIRATION OF AIR

29. Intercostal
drainage

30. Secondary pneumothorax
Even a small secondary pneumothorax may
cause respiratory failure, so all such patients require
↓
Intercostal tube drainage
[Intercostal drains are inserted in the 4 ,5 or 6th th th
intercostal space in the midaxillary line ,connected
to an under waterseal]

31.  Clamping of the drain is potentially dangerous
 Should be removed 24hrs after the lung has fully
reinflated and bubbling stopped .
 Continued bubbling after 5 -7 days is an indication
for surgery .
 All patients should receive supplemental oxygen

32.  If intercostal tube drainage fails
↓
Thoracoscopy (VATS ) or thoracotomy with
stapling of blebs and pleural abrasion is indicated

33.  If surgery is contraindicated, pleurodesis
should be done .
↓
Intrapleural injection of sclerosing agent

34. Tension pneumothorax
 It is a medical emergency.
 A large bore needle is inserted into pleural
space through 2nd intercostal space.
 Needle should be left in place until a
thoracostomy tube can be inserted.

35. Traumatic pneumothorax
 Supplemental oxygen or aspiration done.
 Tube thoracostomy , if not improves.
 If hemo pneumothorax is present, 1 chest
tube should be placed in the superior part to
evacuate air, other should be placed in the
inferior part to remove blood.

36. Recurrent spontaneous
pneumothorax
 Surgical pleurodesis is recommended in all
patients following a 2
if ipsilateral)
nd pneumothorax(even

37. thank you