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- 1. Pneumothorax By Dr. MD ABDULLAHSALEEM 1
- 2. What is pneumothorax 2 Pneumothorax is defined as presence of air or gas in the pleural space (OR) air between the lung and chest wall, in other term, air between the visceral pleura and the parietal pleura
- 3. Mechanism 3 ⚫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 .
- 4. ⚫When a communication develops betweenan 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 4
- 5. Pathophysiology 5 Negative pressure eliminated Thelung recoil-& lung-volume decrease V/Q low –anatomic shunt hypoxia Positive pressure ◦ Compress blood vessels and heart ◦ Decreased cardiac output ◦ Impaired venous return ◦ Hypotension Result in ◦ A decrease in vital capacity ◦ A decrease in PaO2
- 6. CLASSIFICATION OF PNEUMOTHORAX Pneumothorax Spontaneous PrimarySecondary Traumatic Iatrogenic Interventional procedures. Positive pressure ventilation Non iatrogenic Penetrating trauma Blunt trauma. 6
- 7. Primary spontaneous pneumothorax ⚫It occursin young healthy individuals without underlying lung disease. ⚫ It is due to rupture of apical sub-pleural bleb or bullae Predisposing factors: Smoking. Tall, thin male. Airway inflammation (distal) Structural abnormalities of bronchial tree Genetic contribution 7
- 8. Secondary spontaneous pneumothorax: It isseen in pt with underlying lung disease. INFECTION: Tb Acute bacteria pneumonia Copd Obstructive lung disease ILD Fibrosis Eosinophilic granuloma Sarcoidosis Lymphangioleiomyomatosis.. Malignancy: Primary lung carcinoma Complication of chemotherpy Connective tissue disease Scleroderma Marfans syndrome Catamenial pneumothorax Pulmonary infract Wegegner’s granulomatosis… 8
- 9. Clinical manifestation 9 Dyspnea Chest pain( pleuritic) Uncommon manifestation Cough Hemoptysis Orthopnea Cyanosis Mod tachycardia
- 10. Traumatic pneumothorax 10 Accidental trauma:(non-iatrogenic) Blunttrauma: with fracture ribs. Penetrating trauma: stab wound or shot gun injury. Iatrogenic : Positive pressure ventilation: Alveolar rupture interstitial emphysema pneumothorax. Interventional procedures: Biopsy, thoraco-centesis, CVP line,trachestomy etc..
- 11. clinical type ofPNX Pneumothorax Closed pneumothorax Open pneumothorax Tension pneumothorax 11
- 12. Closed pneumothorax Open pneumothorax Tension pneumothorax The pleural tear Issealed The pleural tear is open The pleural tear act as a ball & valve mechanism The pleural cavity pressure is < the atmospheric pressure The pleural cavity pressure is = the atmospheric pressure The pleural cavity pressure is > the atmospheric pressure 12
- 13. Clinical manifestation 13 ⚫Tension pneumothorax ◦Distressed with rapid labored respiration ◦ Cyanosis ◦ Marked tachycardia ⚫Patient who suddenly deteriorate clinically, be suspected in the patient with ◦ Mechanical ventilation ◦ Cardiopulmonary resuscitation
- 14. Physical examination 14 ◦ Dependon size of pneumothorax ◦ The vital signs usually normal ◦ Unilateral Chest movements ◦ The trachea may be shifted toward the contralateral side if the pneumothorax is large ◦ Tactile fremitus is absent ◦ The percussion note is hypersonant ◦ 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
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- 16. Radiological manifestation cxray inerect position cxray in supine position 16
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- 22. Quantification of thesize The simple method to estimate the size Small, a visible rim of < 2 cm between the lung margin and the chest wall Large, a visible rim of ≥2 cm between the lung margin and chest Light index Measure transverse Diameters of lung and Compare it with diameter hemithorax wall 22 2 Hemithorax (HT) Lung (L) 2
- 23. CT scanning 23 It isrecommended in 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
- 24. CT can diagnoseeasily pneumothroax 24
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- 26. MANAGMENT 26 Goals ◦ Topromote lung expansion ◦ To eliminate the pathogenesis ◦ To decrease pneumothorax recurrence Treatment options according to ◦ Classification of pneumothorax ◦ Pathogenesis ◦ The extension of lung collapse ◦ Severity of disease ◦ Complication and concomitant underlying diseases
- 27. TREATMENT OPTIONS FORPSP AND SSP Observation O2 treatment Simple aspiration Small catheter aspiration Chest tube drainage Thoracoscopy (VAT with blebtomy & 27 VAT with pleurectomy) Open (axillary) thoracotomy
- 28. Observation - PSP 28 ⚫Small,closed mildly symptomatic spontaneous pneumothorax. ⚫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.
- 29. Observation - SSP 29 ⚫Observationalong is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothorax in asymptomatic patients ⚫Hospitalization is recommended in these cases ⚫All other cases will require active intervention ( aspiration or chest drain insertion)
- 30. ⚫Marked breathlessness ina patient with a small (<2 cm) PSP may develop tension pneumothorax ⚫Observation is inappropriate and active intervation is required ⚫If a patient is hospitalised for observation, supplemental high flow (10 l/min) oxygen should be given where feasible Observation - PSP or SSP 30
- 31. O2 TREATMENT-- PSPor SSP ⚫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 31
- 32. ⚫The rate ofresolution/reabsorption of spontaneous pneumothorax 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 32
- 33. Simple aspiration 33 ⚫ Simpleaspiration 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
- 34. ⚫Repeated aspiration isreasonable 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 34 Catheter aspiration
- 35. Intercostal tube drainage ⚫INDICATIONS ◦ Unstable pneumothorax ◦ Severe dyspnea ◦ Large lung collapse ◦ Open or tension pneumothorax ◦ Recurrent pneumothorax ◦ Simple aspiration or catheter aspiration drainage is unsuccessful in controlling symptoms 35
- 36. 36 36 ⚫ The siteof chest tube insertion is in the midclavicular line of second and third intercostal ⚫ or anterior axillary line of fifth and sixth intercostal Intercostal tube drainage
- 37. 37 37 Intercostal tubedrainage Fix the catheter and cover with gauze Making a small incision Using a forceps to extend the hole Inserting a catheter into pleural cavity
- 38. Trocar tube thoracostomy ⚫Insertionof trocar into the pleural space. 38
- 39. Trocar tube thoracostomy ⚫Insertionof the chest tube through the trocar 39
- 40. 4 Operative tube thoracostomy Thephysician’s index finger is used to enlarge the opening and to explore the pleural space Placement of chest tube Intrapleurally using large hemostat
- 41. Observation of drainage 41 ⚫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.
- 42. Complications of intercostaltube drainage 42 ⚫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
- 43. Chemical pleurodesis 43 ⚫Goals ◦ Toprevent pneumothorax recurrence ◦ To produce inflammation of pleura and adhesions ⚫Indications ◦ Persist air leak and repeated pneumothorax ◦ Bilateral pneumothorax ◦ Complicated with bullae ◦ Lung dysfunction, not tolerate to operation
- 44. Chemical pleurodesis ⚫ Sclerosingagents ◦ Tetracycline ◦ Doxycline ◦ Talc ◦ Erythromycin ⚫ The instillation of sclerosing agents into the pleural space lead to an aseptic inflammation with dense adhesions. 44
- 45. ⚫ Methods ◦ Viachest tube or by surgical mean ◦ Administration of intrapleural local anaesthesia, 200 – 300 mg lidocaine intrapleurally injection ◦ Agents diluted by 60 – 100 ml saline ◦ Injected to pleural space ◦ Clamp the tube 4hours ◦ 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. Chemical pleurodesis 45
- 46. 46 ⚫Side effct ◦ Chestpain ◦ Fever ◦ Dyspnea ◦ Acute respiratory distress syndrome ◦ Acute respiratory failure Chemical pleurodesis 46
- 47. Surgical treatment 47 ⚫Indications ◦ Noresponse 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
- 48. Thoracoscopy- VATs 48 ⚫It isbeing increasly used in ot with recurrent psp-ssp ⚫Recent studies show VATsit may be the procedure of choice and it has very less complication when compare to other open surgery ⚫Pleural belbs causes pneumothorax which can be treated by a method called endostapling or suturefollowed by pleurodosis
- 49. Axillary (open) thoracotomy ⚫Transaxillary minithoracotomy is preferred .when VAT s isnot available ⚫ Open thotacotomy with suturing of blebs and pleural abrasion is done ⚫ Recurrence ⚫ High risk professions ⚫ B/L or tension pneumothorax INDICATIONS 49
- 50. 50 Complications of pneumothorax ⚫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 re-expansion, bleeding will stop. ◦ When bleeding persists, surgical ligation will be needed.
- 51. ⚫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 – sur ◦ Physical exam gical emphysema – crepitus is present. 51 Subcutaneous emphysema
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