Medicine: PNX management. Must know things for MBBS.

1. PNEUMOTHORAX
Sabin Banmala
5097
15/22/2020

2. Case Scenario:
25/22/2020

3. 35/22/2020

4. • What is PNEUMOTHORAX?
• What is its pathophysiology?
• ETIOLOGY?
• C/F?
• Investigation?
• Treatment?
45/22/2020

5. • Pneumothorax is defined as presence of air in the pleural
space
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6. 65/22/2020

7. Primary spontaneous pneumothorax
• Occurs in young individuals without any underlying lung disease
• Risk factors
Smoking
Tall thin male
Presence of apical sub pleural blebs
75/22/2020

8. Secondary Spontaneous Pneumothorax
• COPD
• TB
• Asthma
• Lung abscess
• Pulmonary infarcts
• Lung cancer
• Fibrotic and cystic diseases
85/22/2020

9. Pathophysiology and Mechanism
• 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(outward pull
of the chest wall and elastic recoil of
the lung)
• The negative pressure will be
disappeared if any communication
develops .
95/22/2020

10. 5/22/2020 10

11. Pathophysiology and Mechanism
• 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 the
communication is sealed
• When a communication develops through chest wall between
atmosphere and pleural space, air will flow into the pleural space
until there is no longer a pressure difference or the communication is
sealed
5/22/2020 11

12. Pathophysiology and Mechanism in PSP
• Probable cause is rupture of apical bleb or bulla
• Because the compliance of blebs or bulla in apices is lower compared
with that of similar lesions situated in the lower parts of lungs
• Smoking increases 9x risk in female and 22x in male smokers
5/22/2020 12

13. Pathophysiology and Mechanism
5/22/2020 13

14. Pathophysiology
Negative pressure eliminated
The lung recoil-& lung-volume decrease
V/Q low –anatomic shunt
Hypoxia
Positive pressure(Tension PNX)
Compress blood vessels and heart
Decreased cardiac output
Impaired venous return
Hypotension
Result
A decrease in vital capacity
A decrease in PaO2 145/22/2020

15. 155/22/2020

16. Closed Pneumothorax Open Pneumothorax Tension Pneumothorax
Pleural tear is sealed Pleural tear is open Pleural tear acts as one way
valve(ball and valve mechanism)
Pleural pressure < atmospheric
pressure
Pleural pressure = atmospheric
pressure
Pleural pressure > atmospheric
pressure
165/22/2020

17. C/F
Symptoms
• Breathlessness
• Unilateral pleuritic chest pain of sudden onset
Signs
Vitals
• Closed and Open- Normal
• Tension Pnx-Marked tachycardia, hypotension, rapid pulses, raised jvp
cyanosis
• Fever + if secondary infection occur
175/22/2020

18. Systemic examinatiom
Inspection
• Dysnea with accessary muscle use
• Tracheal shift(trials sign)
• Diminished chest movement in affected side
Palpation
• Trachea and mediastinum shifted to opposite side
• Tactile fremitus absent
• Diminished chest expansion of diminished side
185/22/2020

19. Percussion
• Hyper resonant note on affected side
• Liver dullness shifted inferiorly- right sided PNX
• Cardiac dullness shifted to opposite side- Left sided PNX
Auscultation
• Breath sound absent or reduced
195/22/2020

20. Investigation
• Chest X-R
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25. 255/22/2020

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29. 295/22/2020

30. 305/22/2020

31. CT Scan
• It is recommended in difficult cases such as patients in whom the
lungs are obscured by overlying surgical emphysema
• To differentiate a pneumothorax from suspected bullous disease
315/22/2020

32. 325/22/2020

33. 335/22/2020

34. 345/22/2020

35. 355/22/2020

36. Treatment
Goal
• To promote lung expansion
• To eliminate the pathogenesis/cause
• To decrease pneumothorax recurrence
365/22/2020

37. Treatment Options
1. Supplemental Oxygen
2. Simple needle aspiration
3. Catheter aspiration
4. Intercostal tube drainage with under water seal
5. Surgery
375/22/2020

38. Treatment options depends on
• Classification of pneumothorax
• Pathogenesis
• The extension of lung collapse(small or large Pnx)
• Severity of disease
• Complication and concomitant underlying diseases
385/22/2020

39. Supplemental Oxygen
• Inhalation of high concentration oxygen at the rate of 10L/min
• Increases the rate of reabsorption of air from pleural space
• Because it reduces the total pressure of gases in pleural capillaries by
reducing partial pressure of Nitrogen
395/22/2020

40. Simple needle aspiration
Indication
• PSP with significant breathlessness and/or size > 2cm
• SSP with pt age<50 and even with small pnx(size<2cm)
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41. Catheter aspiration
• PSP when 1st aspiration is unsuccessful
• Or volume of <2.5L aspirated in 1st aspiration
415/22/2020

42. Intercostal tube drainage
425/22/2020

43. Intercostal tube drainage
• inserted in the fourth, fifth or sixth intercostal space in the mid-
axillary line, connected to an underwater seal or one-way Heimlich
valve secured firmly to the chest wall.
• Clamping of an intercostal drain is potentially dangerous and rarely
indicated
• drain removed the morning after the lung has fully re-inflated and
bubbling has stopped.
• Continued bubbling after 5–7 days is an indication or surgery.
• If bubbling in the drainage bottle stops before full re-inflation, the
tube is either blocked or kinked or displaced
435/22/2020

44. Surgical pleurodesis
Indication
• 2nd ipsilateral PNX (Recurrent PNX)
• Continued bubbling after 5-7 days of ICTD
• B/L PNX
• Professions at risk (divers, pilot) even after 1st PNX
Techniques
• Open thoracotomy: partial pleurectomy/ pleural abrasion
• VATS(Video assisted thoracic surgery): partial pleurectomy/ pleural abrasion
445/22/2020

45. 455/22/2020

46. 5/22/2020 46

47. Tension PNX
• Life threatening condition
• Pressure in the pleural space > atmospheric pressure throughout the
respiration
• PP-Traumatic, Positive airway pressure
C/F-
Symptoms:
• rapidly progressive SOB, chest pain
475/22/2020

48. Signs
• Tachypnea
• tachycardia,
• Hypotension
• Cyanosis
• Raised jvp
485/22/2020

49. CXR
• Mediastinal shift
• Flattening of the hemidiaphragm
• Lung collapse.
495/22/2020

50. Management
• Give high flow 0xygen
• Percutaneous needle aspiration-hissing air confirms diagnosis
• Insert intercostal tube drainage
505/22/2020

51. • What is PNEUMOTHORAX?
• What is its pathophysiology?
• ETIOLOGY?
• C/F?
• Investigation?
• Treatment?
515/22/2020

52. • Thank you
525/22/2020