The document discusses peri-operative pneumothorax, including its definition, epidemiology, classification, causes related to anesthesia, and features of tension pneumothorax. It then presents a case scenario of a 55-year-old male patient who developed respiratory distress after craniotomy and was found to have a pneumothorax. The diagnosis, investigations, management, and different treatment modalities for pneumothorax are reviewed.

1. CASE SCENARIO OF
PERI-OPERATIVE
PNEUMOTHORX
Presenter: Dr ZIKRULLAH
1

2. 2
What is Pneumothorax?
• Pneumothorax is defined as collection of gas
inappropriately located between visceral and
parietal pluera resulting in compression of lung.

3. Epidemiology?
• Annual incidence of pneumothorax :9 per 100,000
• Primary pneumothorax occurs most commonly in
tall thin men aged between 20 and 40.
• less common in women (M:F ~5:1)
• Cigarette or cannabis smoking is a major risk factor
for pneumothorax, increasing the risk by a factor of
22 in men and 9 in women.
3

4. CLASSIFICATION?
4

5. A.Clinical Types of
Pneumothorax
Pneumothorax
Closed
pneumothorax
Open
pneumothorax
Tension
pneumothorax
5

6. B.On basis of Etiology
Pneumothorax
Spontaneous
Primary
(PSP)
Secondary
(SSP)
Traumatic
Iatrogenic
Interventional
procedures.
Positive Pressure
ventilation
Non Iatrogenic
Penetrating
trauma
Blunt trauma.
6

7. Common Causes Anaesthesia
Related
CAUSES % OF TOTAL CASESPROCEDURES
i) Regional Nerve Blocks
1. Supraclavicular neve blocks
2. Intercostal
3. Intersclaene
4. Stellate Ganglion
5. Suprascapular
ii) Airway Instrumentation
iii) Barotrauma
iv) Central Line Placement
7

8. Tension Pneumothorax?
• Tension pneumothorax defined as condition when
intrapleural air accumulates progressively in such a
way as to exert positive pressure on mediastinal and
intrathoracic structures, leading to significant
impairment of respiration and/or blood
circulation
• It is a life-threatening occurrence requiring rapid
recognition and treatment as it leads to
cardiorespiratory arrest.
8

9. Tension Pneumothorax:
Medical Emergency
9

10. CASE
SCENARIO
10

11. Case Scenario
• 55yr male, known heavy smoker, was on irregular
treatment for hypertension since last 3years, diagnosed as
intraparenchymal bleed in left frontotemporal lobe was
undergone for craniotomy with clipping of MCA anuerysm.
Patient was shifted to ICU with ETT in situ after completion
of surgery. Intraoperative course was uneventful.
• Patient was extubated on the same day in evening after
weaning trial of T-piece, and was kept on O2 therapy with
hudson mask . On the next day at around 3.30 PM in the
afternoon patient developed respiratory distress and was
intubated again.
11

12. Vitals in ICU day 2(evening)
• PR :92-138/min
• BP :84-136/58-82 mmHg(on inf norad 2-6ml/hr)
• RR : 38/min SpO2 :84-96%
• CHEST : b/l air entry decreased ;rt>>>lt
• CVS :S1S2 audible
• CNS :E3 M5 V2, pupil- rt NSNR; lt constr. Sluggish rkn
• Cvp :12 cm H20 ; IVC : 1.9cm
12

13. • But inspite of nebulisation and assisted controlled
ventilation with 100% and his O2 saturation was only 88-
96% .
• Ventilatory settings showed high peak airway pressure.
13

14. ABG ON ICU DAY 1 (22/9/2017)
PARAMETERS BEFORE EXTUBATION AFTER EXTUBATION
pH 7.39 7.47
pCO2 35 36
p02 115 133
HCO3- 21.2 25.5
SpO2 98 99
Lactate 0.8 1.0
Na+ 146 143
K+ 3.0 3.1
Ca++ 0.93 1.04
Ventiltory settings on t piece @10l/min Hudson@6l/min
Hb/Hct 9.9/32 10.2/3514

15. ABG ON ICU DAY 2 (23/9/2017)
PARAMETERS BEFORE INTUBATION
(4:30 PM)
AFTER INTUBATION
(7:10 PM)
pH 7.49 7.29
pCO2 35 46
p02 51 152
HCO3- 26.7 22.1
SpO2 89 95
Lactate 1.7 1.1
Na+ 145 149
K+ 3.0 3.0
Ca++ 1.08 0.86
Ventiltory settings on hudson @8l/min VCV(480/12/0.7) peep-5
Hb/Hct 10.5/34 11.2/3215

16. PRE-OP X RAY CHEST
16

17. X RAY CHEST
(23/9/2017morning)
17

18. USG CHEST-M MODE
RIGHT CHEST LEFT CHEST
18

19. X RAY CHEST
23/9/2017 (POST
INTERVENTION) 24/9/2017
19

20. DIFFERENTIAL
DIAGNOSIS ?
20

21. DIFFERENTIAL DIAGNOSIS
• Pnuemothorax
• Bronchospasm
• Laryngospasm
• Endobronchial Intubation
• Pulmonary Embolism
• Pulmonary edema
• Cardiac Tamponade
521

22. DIAGNOSIS---????
SPONTANEOUS PNUEMOTHORAX
POINTS IN FAVOUR OF DIAGNOSIS :
PAST
HISTORY
SYMPTOMS
& SIGNS
AUSCULTATORY
FINDINGS
RADIOLOGICAL
EXAMINATION
22

23. MANAGEMENT
23
Clinical exam.
investigations
Treatment

24. 1.CLINICAL FEATURES
OF
PNUEMOTHORAX ?
24

25. SYMPTOMS & SIGNS
• Classically presents with:
1. Acute onset of pleuritic chest pain ,and/or
2. Breathlessness is often minimal in young patients
and is more severe in secondary spontaneous
pneumothorax
• Uncommon manifestation--
cough,hemoptysis,orthopnea
[In pts with a small pneumothorax, physical
examination may be normal ]25

26. General examination
•Cyanosis
•Rapid thready pulse
•Signs of peripheral circulatory failure in severe
cases
26

27. Inspection & palpation
Dyspnoea
Use of accessory muscles for respiration
Shift of trachea
Shift of mediastinum to opposite side
Fullness of chest on the affected side
Diminished chest movements on affected side
27

28. Marked diminished vocal fremitus on affected side
May feel ‘bubbles’ and ‘crackles’ under the skin of
the torso and neck if there is subcutaneous
emphysema.
28

29. Percussion
• Hyper-resonant on affected pneumothorax.
• Right sided pneumothorax-liver dullness is
obliterated and cardiac dullness is shifted to the
opposite side
29

30. Auscultation
• Diminished to absent breath sounds, frequently
absent in small pneumothorax.
• Absence of adventitious sounds
• Diminished vocal resonance
• Bronchopleural fistula-amphoric broncial breathing.
• Hamman’s sign refers to a ‘click’ on auscultation
in time with the heart sounds, due to movement
of pleural surfaces with a left-sided
pneumothorax 30

31. Hypoxemia & Hypercapnia
Hypoxemia is common
collapsed and poorly ventilated portions of lung
continue to receive significant perfusion  V/Q
mismatch
Hypercapnia is unusual
 underlying lung function is relatively normal and
adequate alveolar ventilation can be maintained
by the contralateral lung
31

32. Investigations?
• ABGs frequently show hypoxia[arterial oxygen
tension (PaO2) being less than 80 mm Hg] and
sometimes hypercapnia in secondary
pneumothorax.
• PFT -- are weakly sensitive measures of the
presence or size of pneumothorax and are not
recommended .
32

33. RADIOLOGICAL
MANIFESTATION:
a.chest x-ray
b. ct scan chest
c.usg chest
33

34. CHEST X-RAY?
34

35. Pneumothorax
in erect position
Pneumothorax
in supine position
Air in apicolateral pleural
space
Air in anteromedial pleural
space.
35

36. Pneumothorax
Erect
Small
pneumothorax
Apical
lucency(<2cm
in width)
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
Sharp
Mediastinal
contour
Double
diaphragm
36

37. Small pneumothorax(apical
lucency)
37

38. Large pneumothorax
38

39. Tension Pneumothorax
39

40. Visceral pleural line
40

41. Signs of
pneumothorax in
supine position
41

42. 1.Deep costophrenic
sulcus
42

43. 2.Sharp mediastinal
contour
43

44. 3.Double diaphragm sign
(subpulmonic pneumothorax)
44

45. CT Thorax
45

46. USG in pneumothorax
• Classical belief lung not optimal for U/S.
• Ultrasound found to be more sensitive than
CXR in diagnosis of pneumothorax.
• Disappearance of "lung sliding" was observed in
100%
• sensitivity was 95.3%, specificity 91.1%, and
negative predictive value 100% (p<0.001).
46

47. U/S signs of pneumothorax?
• Loss of lung sliding.
• Loss of comet tails.
• loss of seashore sign (M mode).
• Stratosphere sign or bar code sign(M mode).
47

48. 48
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
Treatment

49. TREATMENT–DIFFERENT
MODALITIES?
1. Observation +/- supplemental oxygen
2. Simple aspiration/catheter aspiration
3. Immediate large bore needle insertion(in case of tension
pnuemothorax)
4. Intercostal tube drainage/Heimlich flutter valve drainage
5. Surgical intervention
49

50. 1. OBSERVATION
50

51. 51
Observation - PSP
• for small, closed mildly symptomatic spontaneous
pneumothorax(<2cm)--- OBSERVATION is advised
• hospital admission not recquired
• Marked breathlessness in a patient with a small (<2 cm)
PSP may herald tension pneumothorax
• Observation along is inappropriate and active intervation is
required in case of tension pnuemothorax

52. 52
• Recommend in patients with small SSP Of
a)less than 1 cm depth or
b)isolated apical pneumothorax in asymptomatic patients
• Hospitalisation is recommended in these cases
• All other cases will require active intervention ( aspiration
or chest drain insertion)
Observation - SSP

53. 2. ASPIRATION
53

54. 54
Simple aspiration
Simple aspiration is recommended as first line treatment
for all PSP requiring intervention
Simple aspiration is less likely to succeed in secondary
pneumothorax and is only recommended as an initial
treatment in small (<2 cm) pneumothorax in minimally
breathless patients under the age of 50 years
Do not aspirate >1.5L of air, as this suggests a large air leak
and aspiration is likely to fail

55. 3. NEEDLE
DECOMPRESSION?
55

56. T.P. --Immediate Needle
Decompression
Needle Thoracostomy in 2nd I.C.S in
M.C.L.
Chest tube insertion in 5th I.C.S in M.A.L.
56

57. 4. INTERCOSTAL
TUBE
DRAINAGE
57

58. 58
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
Intercostal tube drainage?

59. 59
Intercostal tube drainage

60. Chest drainage
• Heimlich flutter
valves (or thoracic
vents) are an
alternative to
underwater bottle
drainage
• They allow patient
mobilization and
sometimes
outpatient
management of
pneumothorax. 60

61. SURGICAL
MANAGEMENT
61

62. 62
Surgical T/t– Indications?
• 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

63. Surgical
management
• Surgical treatments
aim to repair the
apical hole or bleb
and close the pleural
space.
1. Video Assisted
Thoracic Surgery
63

64. Surgical
management
2. Open Thoracotomy
Same range of operative interventions
undertaken as for VATS but associated with
longer recovery (with marginally lower
recurrence rates)
3. Transaxillary mini-thoracotomy64

65. Further Management
• Outpatient follow-up .Repeat CXR to ensure resolution of
pneumothorax and normal appearance of underlying lungs
• Discuss risk of recurrence,emphasize smoking cessation, if
appropriate
• Ascent to altitude with a pneumothorax is potentially
hazardous. Guidelines recommend that patients should not fly
for at least 1 week from the resolution of spontaneous
pneumothorax on CXR. This time interval is arbitrary, however,
and patients should understand that there is a high initial risk of
recurrence that falls with time, and they may wish to avoid
flying for a longer period, e.g. 1 year
• Advise never to dive in the future, unless patient has undergone
a definitive surgical procedure.65

66. COMPLICATIONS?
66

67. Complications of pneumothorax
Recurrence of spontaneous pneumothorax
Tension pneumothorax
Hydropneumothorax
Encysted pneumothorax
Failure of expansion of the collapsed lung
Re-expansion pulmonary edema
Broncho-pleural fistula
Pneumomediastinum67

68. SUMMARY
68

69. 69

70. 70

71. Thank
you….
71