This document discusses pneumothorax, including causes, symptoms, diagnosis, and treatment. It defines pneumothorax as air in the pleural cavity, causing lung collapse. Common causes include spontaneous pneumothorax, trauma, and medical procedures. Symptoms range from minimal to severe dyspnea. Chest x-ray and CT scan are used to diagnose and estimate size. Treatment depends on severity but may include observation, needle aspiration, chest tube drainage, pleurodesis, or surgery. Recurrence risk varies from 36-83% without treatment to 0.6-2% after surgery.

1. PNEUMOTHORAX
Dr. Noorulhaque Shaikh
MBBS; DA; DNB(Anaesthesiology)
Fellow in Critical Care Medicine
SMBT Institute of Medical Sciences & Research Centre
Nashik

2. Presence of air in pleural cavity with
secondary lung collapse

7. Well-known inherited diseases
associated with pneumothorax
• Birt-Hogg-Dube syndrome
• Marfan's syndrome
• Homocystinuria
• Ehlers-Danlos syndrome
• Alpha1-antitrypsin deficiency

8. Diseases and conditions associated with
secondary spontaneous pneumothorax
Obstructive lung disease
• Chronic obstructive lung disease (COPD)
• Asthma
Interstitial lung disease
• Idiopathic pulmonary fibrosis (usual interstitial pneumonitis [UIP])
• Non-specific interstitial pneumonitis
• Eosinophillic granuloma
• Lymphangioleiomyomatosis
• Sarcoidosis
• Langerhans cell granulomatosis
• Radiation pneumonitis or fibrosis
• Histocytosis X

9. Infection
• P. jerovici pneumonia
• Tuberculosis
• Coccidioidomycosis
• Acute bacterial pneumonia (i.e.:
staphylococcus)
Malignancy
• Primary lung carcinoma
• Pulmonary metastasis (especially sarcomas)
• Complications of chemotherapy

10. Connective tissue disease
• Rheumatoid arthritis
• Ankylosing spondylitis
• Marfan’s syndrome
• Ehlers-Danlos syndrome
• Polymyositis/dermatomyositis
• Scleroderma

11. Other
• Catamenial pneumothorax
• Pulmonary infarction
• Pulmonary hemorrhage
• Pulmonary alveolar proteinosis
• Tuberous sclerosis
• Von Recklinghausen’s disease
• Wegener’s granulomatosis

12. Causes of iatrogenic pneumothorax
• Transthoracic needle aspiration biopsy ( 28%)
• Central venous catheter insertion(22%) ,
• Thoracentesis (12)
• Transbronchial biopsy(2-5%)
• Intercostal nerve block,
• Tracheostomy
• Positive pressure ventilation and ARDS in the
ICU

13. Causes of non iatrogenic
pneumothorax
• Trauma - Penetrating and nonpenetrating
injury
• Rib fracture
• High-risk occupation.

14. Pathogenesis and mechanisms
• 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: inherent outward pull of the chest
wall and inherent elastic recoil of the lung
• The negative pressure will be disappeared if any
communication develops

15. Pathogenesis and mechanisms
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 until the
communication is sealed.

16. Pathogenesis and mechanisms
When a communication
develops through the
chest wall between the
atmosphere and the
pleural space air will
enter the pleural space
until the pressure
gradient is eliminated or
the communication is
closed

17. Pathophysiology
Changes due to Pneumothorax:
Negative pressure eliminated
• The lung recoil-small lung-volume decrease
• V/Q decrease-shunt increase
Positive pressure causes-
• Compression of blood vessels and heart
• Decreased cardiac output
• Impaired venous return
• Hypotension
• Shock
Result in
• A decrease in vital capacity ,DLCo
• A decrease in PaO2

18. Clinical manifestation
Symptom :
• Depend on whether underlying pulmonary
disease or not
• Depend on the speed of pneumothorax occurred
• Depend on size of pneumothorax
• Depend on the level of intrapleual pressure
The patient with underlying pulmonary disease will
undergo severe dyspnea
The healthy person will have minimal symptoms
although having large volume of pneomothorax

19. • Chest pain-prickling-like, cutting-like
• Dyspnea
• Dry cough

20. Tension pneumothorax
risk factors:
• Receiving positive-pressure mechanical
ventilation
• During cardiopulmonary resuscitation
• Undergoing hyperbaric oxygen therapy
• Evolving during the course of spontaneous
pneumothorax

22. Clinical manifestation
• Tension pneumothorax
-Distressed with rapid labored respiration
-Cyanosis
-Marked tachycardia
-Profuse diaphoresis
• Patient who suddenly deteriorate clinically,
be suspected if the patient with
-Mechanical ventilation
-Cardiopulmonary resuscitation

23. General examination
Depend on size of pneumothorax
• Tachypnoea
• Tachycardia
• Raised JVP
• Cyanosis
• Subcutaneous emphysema

24. Physical examination
 The breath sounds are reduced or absent on the
affected side
 The trachea may be shifted toward the
contralateral side if the pneumothorax is large
 Tactile fremitus is absent
 The percussion note is hyperesonant
 The lower edge of the liver may be shifted
inferiorly with a right-side pneumothorax
 Hamman’s sign (pneumomediastinum)

25. Radiological
manifestations

26. Imaging- Plane chest X-ray film
Establishing the diagnosis
The characteristics of
pneumothorax
 Pleural line
 No lung markings in
pneumothorax
 The outer margin of
visceral pleura separated
from the parietal pleura
by a lucent gas space
devoid of pulmonary
vessels

28. If suspected clinically
 Xray in full expiration
 In lateral decubitus position
Very small pneumothorax also can be detected

30. Pneumothorax signs
• Deep Costophrenic Sulcus Sign

33. Double diaphragm sign
subpulmonic pneumothorax

34. Estimation of pneumothorax volume
• 1. Light equation
Pneumothorax％＝
（1－L3/HT3）x 100
Lung (L)
Hemithorax (HT)

35. 2.Rhea method= on Xray there is 10%
pneumothorax for every 1 cm of intrapleural
distance.
3.Collin’s index
• % pneumothorax = 4.2 + [4.7 X (A + B + C))

37. BTS guideline
Lung margin to chest wall
 small<2cm
 large≥2cm
ACCP guideline
Lung apex to chest top
 Small <3cm
 large≥3cm

52. Treatment
• Goals
– To promote lung expansion
– To eliminate the pathogenesis
– To decrease pneumothorax recurrence
• Treatment options according to
– Classification of pneumothorax
– Pathogenesis
– Pneumothorax frequency
– The extension of lung collapse
– Severity of disease
– Complication and concomitant underlying diseases

53. TREATMENT MODALITIES
• Observation
• Supplemental oxygen
• Simple aspiration
• Tube thoracostomy with or without instillation of
sclerosing agent
• Medical thoracoscopy with the insufflation of talc
• Video assisted thoracoscopy with stappling of
blebs.

55. Observation
• Observation alone is advised for small, closed
mildly symptomatic spontaneous
pneumothoraces
• Patients with small PSP and minimal symptoms
do not require hospital admission.
• However, it should be stressed before discharge
that they should return directly to hospital in the
event of developing breathlessness No heavy
physical exertion.
• Most patients in this group who fail this
treatment have secondary pneumothoraces

56. Observation - SSP
• Observation only is recommend in patients
with small SSP of less than 1 cm depth or
isolated apical pneumothoraces in
asymptomatic patients

57. • Marked breathlessness in a patient with a
small (<2 cm) PSP may be forerunner of
tension pneumothorax
• Observation alone is inappropriate and active
intervention is required
• If a patient is hospitalized for observation,
supplemental high flow (10 l/min) oxygen
should be given where feasible

58. • Inhalation of high concentration of oxygen
may reduce the total pressure of gases in
pleural capillaries by reducing the partial
pressure of nitrogen
• This should increase the pressure gradient
between the pleural capillaries and the pleural
cavity
• Thereby increasing absorption of air from the
pleural cavity

59. • The rate of resolution/reabsorption of
spontaneous pneumothoraces is 1.25 – 1.8%
of volume of hemithorax every 24 hours
• The addition of high flow oxygen therapy has
been shown to result in a 4-fold increase in
the rate of peumothorax reabsorption during
the periods of oxygen supplementation

60. Simple aspiration
• Simple aspiration is recommended as first line
treatment for all PSP requiring intervention
• Simple aspiration is less likely to succeed in
secondary pneumothoraces and in this situation,
is only recommended as an initial treatment in
small (<2 cm) pneumothoraces in minimally
breathless patients under the age of 50 years
• Patients with secondary pneumothoraces treated
successfully with simple aspiration should be
admitted to hospital and observed for at least 24
hours before discharge

61. Repeated catheter aspiration
• Repeated aspiration is reasonable for primary
pneumothorax when the first aspiration has
been unsuccessful
• A volume of < 3 L can be aspirated on the first
attempt,provided pts condition is stable
• The aspiration can be done by needle or
catheter

62. Intercostal tube drainage
• INDICATIONS
– Tension pneumothorax
– Severe dyspnea
– Intermittent positive pressure ventilation
– Previous contralateral pneumothorax
– B/L pneumothorax
– Presence of pleural fluid
– Large or complete pneumothoraces
– Frequent recurrent pneumothoraces
– Simple aspiration or catheter aspiration drainage is
unsuccessful in controlling symptoms

63. Drainage system

64. One bottle system
• Consists of one bottle that serves as both a
collection container and a water seal
• The chest tube is connected to a rigid straw
inserted through a stopper into a sterile bottle
• Enough sterile saline solution is instilled into the
bottle so that the tip of the rigid straw is about 2
cm below the surface of the saline solution
• The bottle’s stopper must have a vent to prevent
pressure from building up when air or fluid
coming from the pleural space enters the bottle

65. Three bottle system consists of
Collection bottle – for collecting pleural fluid
Water seal bottle – for regulating pressure
Suction control bottle – connect to the negative
pressure pump, for suction of the air of pleural space,
pres level: -10 - -20 cm H2O

66. Heimlich valve
• A flutter valve (also known as the Heimlich
valve) is a one-way valve
• It is most commonly used to help remove air
from a pneumothorax.
• Advantages : no need for under water seal
ambulation

68. Chemical pleurodesis
Goals
• To prevent pneumothorax recurrence
• To produce inflammation of pleura and adhesions
Indications
• Persist air leak and repeated pneumothorax
• Bilateral pneumothoraces
• Complicated with bullae
• Lung dysfunction, not tolerate to operation

69. Chemical pleurodesis
• Sclerosing agents
– Tetracycline
– Talc
• The instillation of sclerosing agents into the pleural
space should lead to an aseptic inflammation with
dense adhesions, leading ultimately to pleural
adhesion

70. Surgical treatment
• Indication
– No response to medical treatment
– Persist air leak
– Hemopneumothorax
– Bilateral pneumothoraces
– Recurrent pneumothorax
– Tension pneumothorax failed to drainage
– Thicken pleura makes lung unable to reexpansion
– Multiple blebs or bullae

71. • Medical thoracoscopy
• VATS –bullectomy
stapling
pleural abration
laser/electro cautrey
pleurectomy
• Open thoracotomy

72. Bronchopleural fistula
1) FOB: glue, gel foams, endobronchial valves
autulogus blood
2) VATS: pleurodesis, stapling, segmentectomy,
lobectomy

73. Risk of recurrence
Without treatment
• 1st year-36%
• 2nd year-62%
• 3rd year-83%

74. With treatment
• Observation - 30-40%
• Aspiration – 25-40%
• Chest tube- 25-30%
• Pleurodesis (tetracycline)- 20-25%
(talc) 7-15%
• Surgical 0.6-2%

75. TENSION PNEUMOTHORAX
• present when the intrapleural pressure
exceeds atmospheric pressure throughout
expiration and often during inspiration as well
• Most tension pneumothoraces occur in
patients who are receiving positive-pressure
ventilation either from mechanical ventilation
or during resuscitation

76. Pathophysiology
• The combination of a decreased cardiac
output due to impaired venous return and
marked hypoxemia.

77. Clinical manifestation
• The patient appears distressed with rapid labored
respirations, cyanosis, and usually profuse
diaphoresis, hypotension, and marked
tachycardia. Arterial blood gases reveal marked
hypoxemia and, sometimes, respiratory acidosis.
The physical findings are those of any large
pneumothorax, but in addition, the involved
hemithorax is larger than the contralateral
hemithorax with the interspaces widened. The
trachea is usually shifted toward the contralateral
side.

78. management
• Valuable time should not be wasted on
radiologic studies
• Clinical situation and the physical findings are
usually sufficient to establish the diagnosis.
• given a high concentration of supplemental
oxygen to combat the hypoxia.
• Needle thoracotomy.
• Immediate insertion of a large chest tube.

79. Complications of pneumothorax
 Recurrence of spontaneous pneumothorax
 Heamopneumothorax
 Pyopneumothorax
 Respiratory failure
 Failure of expansion of the collapsed lung
 Re-expansion pulmonary edema
 Pneumomediastinum
 Complications of management

80. BTS Pleural Disease Guideline 2010
A Quick Reference Guide
MANAGEMENT OF SPONTANEOUS
PNEUMOTHORAX
Andrew MacDuff, Anthony Arnold, John Harvey

81. Management of PSP
► Patients with PSP or SSP and significant breathlessness associated
with any size of pneumothorax, should undergo active intervention.
► Chest drains are usually required for patients with tension or
bilateral pneumothorax, who should be admitted to hospital.
► Observation is the treatment of choice for small PSP, without
significant breathlessness.
► Selected, asymptomatic patients with a large PSP may be
managed by observation alone.
► Patients with small PSP, without breathlessness, should be
considered for discharge with early outpatient review. These
patients should also receive clear written advice to return in the
event of worsening breathlessness

82. Needle aspiration or chest drain?
► Needle (14–16G) aspiration (NA) is as effective as large bore
(>20Fr) chest drains, and may be associated with reduced
hospitalisation and length of stay.
► NA should not be repeated, unless there were technical
difficulties.
► Following failed NA, small bore (<14Fr) chest drain insertion is
recommended.
► Large bore chest drains are not needed for pneumothorax.
Suction
► Suction should not be routinely employed.
► High volume low pressure suction systems are recommended

83. Management of SSP
► All patients with SSP should be admitted to hospital
for at least 24 hours, and receive supplemental oxygen
► Most patients will require the insertion of a small-bore
chest drain.
Patients with SSP but unfit for surgery
► Medical pleurodesis may be appropriate for
inoperable patients.
► Patients with SSP can be considered for ambulatory
management with a Heimlich valve

84. Discharge and follow-up
► Patients should be advised to return to hospital
if increasing breathlessness develops.
► All patients should be followed up by respiratory
physicians until full resolution.
► Air travel should be avoided until full resolution.
► Diving should be permanently avoided unless
the patient has undergone bilateral surgical
pleurectomy and has normal lung function and
chest CT scan postoperatively

85. Medical chemical pleurodesis
► Chemical pleurodesis can control difficult or
recurrent pneumothoraces but, since surgical
options are more effective, it should only be
used if a patient is either unwilling or unable
to undergo surgery

86. Surgical strategies: open thoracotomy
or VATS?
► Open thoracotomy and pleurectomy remain
the procedure with the lowest recurrence rate
(approximately 1%) for difficult or recurrent
pneumothoraces.
► Video-assisted thoracoscopic surgery (VATS)
with pleurectomy and pleural abrasion is
better tolerated, but has a higher recurrence
rate of approximately 5%.