This document discusses pneumothorax, including its history, classification, signs and symptoms, diagnosis using imaging modalities like chest x-rays and CT scans, and various treatment options. Pneumothorax is the accumulation of air in the pleural space, usually caused by a tear or rupture in the lung tissue. Treatment depends on factors like the size and severity of the pneumothorax, its cause, and whether it is a first occurrence or recurrent. Options include observation, aspiration of air, insertion of a chest tube to drain air, chemical pleurodesis to fuse the lungs to the chest wall to prevent recurrence, and surgery in more severe or complicated cases.

1. Dr Nirav Dhinoja

2. Pneumothorax is the accumulation of
extrapulmonary air within the chest.
Most commonly from leakage of air from
within the lung.

3. Term “pneumothorax” was first coined by Itard in
1803.
Laennec described the clinical picture of
pneumothorax occurring in patients with
pulmonary tuberculosis in 1819.
Description of primary spontaneous pneumothorax
occurring in healthy people was provided by
Kjaergard in 1932

4. Pneumothorax
Spontaneous
Primary Secondary
Traumatic
Iatrogenic
Interventional
procedures.
Positive pressure
ventilation
Non iatrogenic
Penetrating
trauma
Blunt trauma.

6. 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 .

7. 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.

8. Negative pressure eliminated
◦ The lung recoil-small lung-volume decrease
◦ V/Q decrease-shunt increase
Positive pressure
◦ Compress blood vessels and heart
◦ Decreased cardiac output
◦ Impaired venous return
◦ Hypotension
◦ Shock
Result in
◦ A decrease in vital capacity
◦ A decrease in PaO2

9. 9
closed communicated tension
Rupture small large valve-like
sealed open in,not out
Pressure P or N atmosphere high
After
Aspiration N atmosphere high again

10. Abrupt onset.
Severity depends on :
◦ Extent of lung collapse.
◦ Amount of pre-existing lung disease.
Pain – severity of pain does not reflect extent
of collapse.
Dyspnea.
Cyanosis.

11. Tension pneumothorax
◦ Distressed with rapid labored respiration
◦ Cyanosis
◦ Marked tachycardia
◦ Profuse diaphoresis
Patient who suddenly deteriorate
clinically,should be suspected in the patient
with
◦ Mechanical ventilation
◦ Cardiopulmonary resuscitation

12. The side with pneumothorax is larger than the contralateral side.
Chest moves less during the respiratory cycle.
Tactile fremitus is absent.
The percussion note is hyperresonant.
The breath sounds are reduced or absent on the affected side.
The lower edge of the liver may be shifted inferiorly with a right-side
pneumothorax.
The trachea may be shifted toward the contralateral side if the
pneumothorax is large.

13. 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

14. Pneumothorax
in erect position
Pneumothorax
in supine position
Air in apicolateral pleural space Air in anteromedial pleural space.

15. Pneumothorax
Erect
Small
pneumothorax
Apical lucency
Visceral
pleural line
Large
pneumothorax
Apical lucency
(>2cm in width)
Visceral
pleural line
Tension
pneumothorax
Lung collapse
Mediastinal shift
Low flat
diaphragm
Supine
Deep
Costophrenic
sulcus
Lucent
Cardiophrenic
sulcus
Sharp
Mediastinal
contour
Double
diaphragm

20. It is very important to
differentiate the pleural line
of a pneumothorax from
that of a skinfold, clothing,
tubing, or chest wall artifact.
Artifact extends beyond the
thorax, or that lung
markings are visible beyond
the apparent pleural line.

21. CT scanning is done if accurate size
estimates are required.
It is only recommended to difficult cases such
as patients in whom the lungs are obscured
by overlying surgical emphysema.
To differentiate a pneumothorax from
suspected bulla in complex cystic lung
disease.

23. 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.

24. 24
Small, closed mildly symptomatic spontaneous
pneumothoraces.
Do not require hospital admission
It should be stressed to patient that they should be return
directly to hospital in the event of developing breathlessness.

25. 25
Small SSP of less than 1 cm depth or isolated apical
pneumothoraces in asymptomatic patients.
Hospitalisation is recommended in these cases.
All other cases will require active intervention ( aspiration or
chest drain insertion)

26. 26
Marked breathlessness in a patient with a small
(<2 cm) PSP may herald tension pneumothorax.
Observation alone is inappropriate and active
intervation is required.
If a patient is hospitalised for observation,
supplemental high flow (10 l/min) oxygen should
be given.

27. 27
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.

28. 28
The rate of resolution/reabsorption of spontaneous
pneumothoraces is 1.25 – 1.8% of volume of hemithorax
every 24 hours.
High flow oxygen therapy has been shown to result in a 4-
fold increase in the rate of pneumothorax reabsorption
during the periods of oxygen supplementation.

29. 29
It is recommended as first line treatment for all PSP requiring intervention.
It is less likely to succeed in secondary pneumothoraces and in this situation,it 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.

30. Repeated aspiration is reasonable for primary pneumothorax
when the first aspiration has been unsuccessful.
A volume of < 2.5 L has been aspirated on the first attempt.
The aspiration can be used by needle or catheter.

31. 31
Making a small incision
Using a forceps to extend the hole
Inserting a catheter into pleural cavity
Fix the catheter and cover with gauze

32. 32
INDICATIONS
◦ Unstable pneumothorax
◦ Severe dyspnea
◦ Large lung collapse
◦ Open or tension pneumothoraces
◦ Frequent recurrent pneumothoraces
◦ Simple aspiration or catheter aspiration drainage is
unsuccessful in controlling symptoms

33. 33
Position of intercostal tube
The chest tube should be positioned in the
uppermost part of the pleural space, where
residual air accumulates
This procedure permits the air in the pleural
space to be evacuated rapidly

34. 34
The site of chest
tube insertion is in
the midclavicular
line of 2nd and 3rd
intercostal or
anterior axillary line
of 5th and 6th
intercostal space.

35. 35

36. 36
Making a small skin
incision slightly
larger than the
diameter of the
chest tube

37. 37
Introduction of 18-
gauge needle into
the pleural space

38. 38
Insertion of wire
with “J” end into the
pleural space

39. 39
With guidewire in
space, the tract is
enlarged by
advancing
progressively larger
dilators over the
wire guide

40. 40
Introduction the
chest tube
inserter/chest tube
assembly over the
guidewire

41. 41
The guidewire and
chest tube inserter
have been removed,
leaving the chest
tube positioned with
the pleural space

42. 42
Insertion of trocar into the pleural space.

43. 43
Insertion of the chest tube through the trocar

44. 44
The physician’s
index finger is used
to enlarge the
opening and to
explore the pleural
space

45. 45
Placement of chest
tube intrapleurally
using large
hemostat

46. 46
No bubble released
◦ The lung reexpansion
◦ The chest tube is obstructed by secretion or blood clot
◦ The chest tube shift to chest wall, the hole of the chest tube is
located in the chest wall
If the lung reexpansion, removing the chest tube 24
hours after reexpansion.
Otherwise, the chest tube will be inserted again or
regulated the position.

47. 47
Penetration of major organs
◦ Lung, stomach, spleen, liver, heart and great
vessels
◦ It occurs more commonly when a sharp metal trocar
is inappropriately applied
Pleural infection
◦ Empyema, the rate of 1%
Surgical emphysema
◦ Subcutaneous emphysema

48. 48
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

49. 49
Sclerosing agents
◦ Tetracycline
◦ Minocycline
◦ Doxycline
◦ Talc
◦ Erythromycin
The instillation of sclerosing agents into the pleural
space should lead to an aseptic inflammation with
dense adhesions.

50. 50
Methods
◦ Via chest tube or by surgical mean
◦ Administration of intrapleural local anaesthesia, 200 – 400 mg lidocaine intrapleurally
injection
◦ Agents diluted by 60 – 100 ml saline
◦ Injected to pleural space
◦ Clamp the tube 1 – 2 hours
◦ Drainage again
◦ Observed by chest X-ray film, if air of pleural space is absorption, remove the chest tube
◦ If pneumothorax still exist, repeated pleurodesis.

51. 51
Side effct
◦ Chest pain
◦ Fever
◦ Dyspnea
◦ Acute respiratory distress syndrome
◦ Acute respiratory failure

52. 52
Indication
◦ No response to medical treatment
◦ Persist air leak
◦ Hemopneumothorax
◦ Bilateral pneumothoraces
◦ Recurrent pneumothorax
◦ Tension pneumothorax failed to dainage
◦ Thicken pleura makes lung unable to reexpansion
◦ Multiple blebs or bullae

53. 53
Pyopneumothorax
◦ Caused by aspiration or intercostal chest tube insertion
(iatrogenic)
◦ Also results from necrotic pneumonia, lung abscess, or
caseous pneumonia
Hydropneumothorax.
Hemopneumotorax
◦ Bleeding in pleural space.
◦ Common cause is rupture of vessels in adhesions.
◦ When lung reexpansion, bleeding will stop.
◦ When bleeding persists, surgical ligation will be needed.

54. 54
Mediastinal and subcutaneous emphysema
◦ Alveoli rupture, the air enter into pulmonary
interstitial, and then goes into mediastinal and
subcutaneous tissues.
◦ After aspiration or intercostal chest tube insertion,
the air enters the subcutaneous by the needle hole
or incision – surgical emphysema
◦ Physical exam – crepitus is present.

55. 55
Subcutaneous
emphysema

56. 56
Treatment
◦ Automatic absorption when pneumothorax is gone
◦ Inhalation of high concentration of oxygen
◦ Making a small incision in suprasternal pit for
draining the air from mediastinal and subcutaneous
tissues.