This document provides an overview of pneumothorax (PNO), including its definition, causes, symptoms, diagnosis and complications. It discusses different types of PNO such as primary spontaneous PNO, secondary spontaneous PNO, traumatic PNO, tension PNO and PNO in patients with acute respiratory distress syndrome (ARDS). PNO is caused by air in the pleural space and can range from asymptomatic to life-threatening depending on the type and size. Imaging plays a key role in diagnosis. Complications include recurrence and tension PNO which can impair breathing and circulation.
Walif Chbeir: Medical Imaging of PneumoThorax (PNO)–2Walif Chbeir
Dr. Walif Chbeir outlines in detail the medical imaging practice and diagnostic approach of pneumothorax (also known as PNO). This is the second in a four-part piece on PNO by Chbeir.
Walif Chbeir: Medical Imaging of PneumoThorax (PNO)–3Walif Chbeir
Dr. Walif Chbeir outlines in detail the medical imaging practice and diagnostic approach of pneumothorax (also known as PNO). This is the third in a four-part piece on PNO by Chbeir.
Walif Chbeir: Medical Imaging of PneumoThorax (PNO)–2Walif Chbeir
Dr. Walif Chbeir outlines in detail the medical imaging practice and diagnostic approach of pneumothorax (also known as PNO). This is the second in a four-part piece on PNO by Chbeir.
Walif Chbeir: Medical Imaging of PneumoThorax (PNO)–3Walif Chbeir
Dr. Walif Chbeir outlines in detail the medical imaging practice and diagnostic approach of pneumothorax (also known as PNO). This is the third in a four-part piece on PNO by Chbeir.
Pneumothorax is one of the most common air leak syndromes that occurs more frequently in the neonatal period than in any other period of life and is a life-threatening condition associated with a high incidence of morbidity and mortality.
Presented by Dr. Rupom
Medical Imaging of Pneumothorax (PNO)-Walif ChbeirWalif Chbeir
Walif Chbeir's scholarly work on the medical imaging of PneumoThorax or PNO. Explores what PNO is, images are taken and analyzed and takeaways.
Thorough review of PNO Radiology : Etiologies, Symptoms and Signs, Complications, PhysioPathology, Imaging ( XRay, CT Scan, UltraSonography) Mimics, degree of Collapse and indication of Drainage, Tension PNO, Underlying parenchymal lung disease, PNO In critical care and ARDS, Ultrasonography: Indication, technique and signs of PNO. Management of PNO.
Pneumothorax is one of the most common air leak syndromes that occurs more frequently in the neonatal period than in any other period of life and is a life-threatening condition associated with a high incidence of morbidity and mortality.
Presented by Dr. Rupom
Medical Imaging of Pneumothorax (PNO)-Walif ChbeirWalif Chbeir
Walif Chbeir's scholarly work on the medical imaging of PneumoThorax or PNO. Explores what PNO is, images are taken and analyzed and takeaways.
Thorough review of PNO Radiology : Etiologies, Symptoms and Signs, Complications, PhysioPathology, Imaging ( XRay, CT Scan, UltraSonography) Mimics, degree of Collapse and indication of Drainage, Tension PNO, Underlying parenchymal lung disease, PNO In critical care and ARDS, Ultrasonography: Indication, technique and signs of PNO. Management of PNO.
Respiratory Disorders
Disease Condition Pneumothorax, Causes, Sign and Symptoms, Pathophysiology, Types, Assessment and Dignostic Test, Management
By HIREN GEHLOTH For Nursing Students Medical Surgical Nursing
LAUGH A LOT IT CLEARS THE LUNGS
TEACHING IS ONE PROFESSION THAT CREATE ALL OTHER PROFESSION
pnemothorax and its management mainly physiotherapy point of view.
Dr. Amrit parihar
IKDRC ITS college of physiotherapy, Ahmedabad
amritparihar94@yahoo.com
Society of Radiologists in Ultrasound Consensus Conference: The consensus panel developed recommendations for diagnosis and stratification of ICA stenosis. These recommendations were derived from analysis of numerous studies and do not represent the results of any one laboratory or study. For a particular laboratory setting, internal validation is encouraged when possible. This may yield alternative diagnostic criteria that can be used successfully at that facility. However, each laboratory should have a single set of diagnostic criteria that is applied uniformly.
Medical imaging practice, diagnosis, symptoms and treatment for Cerebral Cavernous Malformation, written, edited and reviewed by Dr Walif Chbeir. Images can be found on WalifChbeir.net.
Normal Labral Variant Figures II - Walif ChbeirWalif Chbeir
The second portion of the figures from the Normal Labral Variants piece from Dr. Walif Chbeir. Other similar reports can be accessed via Walif Chbeir's slideshare account.
Doppler of Lower Limb Arteries. Technical Aspects.Walif Chbeir
Technique of Doppler of LLA Description: General Rules, Role and place of Real-Time Gray-Scale Imaging, Duplex Doppler Sonography, Color Doppler sonography and of Power Doppler sonography. Scanning Technique is described as well as Interpretation and Reporting.
Ankle-Brachial Index (ABI) --Walif ChbeirWalif Chbeir
The anklebrachial pressure index (ABPI) or anklebrachial index (ABI) is the ratio of the blood pressure at the ankle to the higher of the brachial systolic blood pressures, which is the best estimate of central systolic blood pressure.
It is a noninvasive, simple, valid, reliable and cot effective test wich is used to detect lower extremity peripheral arterial disease (PAD), to measure the severity of atherosclerosis in the legs but is also an independent predictor of mortality, as it reflects the burden of atherosclerosis (5,16,17). However, alone it is not appropriate to detect PAD (Peripheral Arterial Disease) because of possibility of false-negative findings and does not give enough directions for revascularisation in term of localization and characterization.
Lower extremity peripheral arterial disease (PAD) is a frequent, chronic, progressive vascular disease and associated with significant morbidity and mortality.
ABI It is a noninvasive, cost effective and reliable test used to detect lower extremity peripheral arterial disease (PAD), to measure the severity of atherosclerosis in the legs but is also an independent predictor of cardiovascular events and mortality. However, alone this test is not appropriate to investigate PAD because of possibility of false-negative findings and does not give enough directions for revascularisation in term of localization and characterization.
Few contreIndications must be considered, especially in the setting of distal bypass.
Standardization of the technic is recommended as in AHA Scientific Statement.
Walif Chbeir provides an in-depth look at labral variants and the analysis of CT and MRI scans on patients.
In this article, we discuss, describe and illustrate the normal anatomic variants of the glenoid labrum, the Biceps labral complex and of the gleno-humeral Ligaments as well as their differenciation of some labral tears with wich they could be easily confused. From this perspective, Resonance Magnetic Imaging Pitfalls are also described.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Walif Chbeir: Medical Imaging of PneumoThorax (PNO)–1
1. Edited March02,2016
Medical Imaging of PneumoThorax (PNO1)
Dr WALIF CHBEIR
* We searched Medline and google for articles relating to Pneumothorax with focus on
imaging appearances and diagnostic approach.
* Key Words: - Pneumothorax/etiology. - Pneumothorax/radiography.
- Pneumothorax/ultrasonography. - Pneumothorax/diagnosis. - Acute respiratory distress
syndrome (ARDS) - Tension Pneumothorax - intensive care unit (ICU)- mechanical
ventilation. - critical care
* No financial relationships with commercial entities to disclose.
I- Definition
PNO is air in the pleural space causing partial or complete lung collapse.
II-Etiology
* Primary spontaneous pneumothorax (PSP) occurs in patients without underlying
pulmonary disease. It is thought to be due to spontaneous rupture of subpleural apical blebs or
bullae that result from smoking or that are inherited.
* Secondary spontaneous pneumothorax (SSP) It most often results from rupture of a bleb
or bulla in patients with underlying pulmonary disease. SSP is more serious than PSP because it
occurs in patients whose underlying lung disease decreases their pulmonary reserve.
--Most common: - Chronic obstructive pulmonary disease
2. - Asthma
- Cystic fibrosis
- Pneumonia: Pneumocystis jirovecii infection / Tuberculosis / Bacterial
pneumonia.( Cavitary or Necrotizing) .
- ARDS
-- Less common: - About 0.5% of pneumothoraces are associated with lung metastases, of
which 89% are caused by sarcomas, with osteogenic sarcoma being the most common
- Langerhans cell histiocytosis
- Lymphangioleiomyomatosis/tuberous sclerosis .
- Sarcoidosis.
- Connective tissue disorders: Ankylosing spondylitis , Ehlers-Danlos
syndrome, Marfan syndrome, Polymyositis and dermatomyositis, RA, Systemic sclerosis.
- Catamenial pneumothorax: is a rare form of SSP that occurs within 48
h of the onset of menstruation in premenopausal women and sometimes in postmenopausal
women taking estrogen . The cause is intrathoracic endometriosis, possibly due to migration of
peritoneal endometrial tissue through diaphragmatic defects or embolization through pelvic
veins.
* Traumatic pneumothorax is a common complication of penetrating or blunt chest injuries.
- In patients with penetrating wounds that traverse the mediastinum,or with severe blunt
trauma, pneumothorax may be caused by disruption of the tracheobronchial tree. Air from
the pneumothorax may enter the soft tissues of the chest and/or neck (subcutaneous
emphysema), or mediastinum (pneumomediastinum).
- Iatrogenic pneumothorax is caused by medical interventions, including transthoracic
needle aspiration and Biopsy, thoracentesis, Thoracotomy, central venous catheter placement,
mechanical ventilation and barotrauma, and cardiopulmonary resuscitation. Also: Surgical
procedures in the thorax, head, or neck. and Abdominal procedures using bowel or peritoneal
distension.
III- Symptoms and Signs ( + PhysioPatho)
* Small pneumothoraces are occasionally asymptomatic.
* Symptoms of pneumothorax typically include pleuritic chest pain and shortness of breath.
- Dyspnea may be sudden or gradual in onset depending on the rate of development and size of
the pneumothorax.
3. - Pain can simulate pericarditis, pneumonia, pleuritis, pulmonary embolism, musculoskeletal
injury (when referred to the shoulder), or an intra-abdominal process (when referred to the
abdomen). Pain can also simulate cardiac ischemia, although typically the pain of cardiac
ischemia is not pleuritic.
- Physical findings classically consist of absent tactile fremitus, hyperresonance to percussion,
and decreased breath sounds on the affected side. If the pneumothorax is large, the affected
side may be enlarged with the trachea visibly shifted to the opposite side. With tension
pneumothorax, hypotension can occur.
. Importantly, the volume of the pneumothorax can show limited correlation with the
intensity of the symptoms experienced by the victim, and physical signs may not be apparent if
the pneumothorax is relatively small.
* Primary Spontaneous Pneumothorax (PSP) :
- Classically in tall, thin, asthenic men. Most patients are between 20 and 40 years of age, and
the male-to-female ratio is approximately 5 to 1. It is thought to be due to spontaneous rupture
of subpleural apical blebs or bullae that result from smoking or that are inherited. It generally
occurs at rest, although some cases occur during activities involving reaching or stretching. PSP
also occurs during diving and high-altitude flying .
- It usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the
usual predominant presenting features. People who are affected by PSPs are often unaware of
potential danger and may wait several days before seeking medical attention. PSPs more
commonly occur during changes in atmospheric pressure, explaining to some extent why
episodes of pneumothorax may happen in clusters. It is rare for PSPs to cause tension
pneumothoraces.
* Secondary Spontaneous Pneumothorax: Symptoms in SSPs tend to be more severe than
in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the
affected lungs. Hypoxemia is usually present and may be observed as cyanosis. Hypercapnia
is sometimes encountered; this may cause confusion and if very severe may result in comas.
The sudden onset of breathlessness in someone with COP), cystic fibrosis, or other serious lung
diseases should therefore prompt investigations to identify the possibility of a pneumothorax.
* Traumatic pneumothorax (TP) Traumatic pneumothoraces have been found to occur in up
to half of all cases of chest trauma, with only rib fractures being more common in this group.
The pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge
particularly if mechanical ventilation is required. They are also encountered in patients already
receiving mechanical ventilation for some other reason.
4. - Many patients also have a hemothorax (hemopneumothorax).
- In patients with penetrating wounds that traverse the mediastinum or with severe blunt trauma,
pneumothorax may be caused by disruption of the tracheobronchial tree.
- Air from the pneumothorax may enter the soft tissues of the chest and/or neck (subcutaneous
emphysema), or mediastinum (pneumomediastinum).
- Patients commonly have pleuritic chest pain, dyspnea, tachypnea, and tachycardia.
- Breath sounds may be diminished and the affected hemithorax hyperresonant to
percussion—mainly with larger pneumothoraces. However, these findings are not always
present and may be hard to detect in a noisy resuscitation setting.
- Subcutaneous emphysema causes a crackle or crunch when palpated; findings may be
localized to a small area or involve a large portion of the chest wall and/or extend to the neck;
extensive involvement suggests disruption of the tracheobronchial tree.
- Air in the mediastinum may produce a characteristic crunching sound synchronous with the
heartbeat (Hamman sign or Hamman crunch), but this finding is not always present and also is
occasionally caused by injury to the esophagus.
* Open pneumothorax
- Some patients with traumatic pneumothorax have an unsealed opening in the chest wall.
when the opening is sufficiently large, the ventillation on the affected side is eliminated
respiratory mechanics are impaired and the inability to ventilate the lungs causes respiratory
distress and respiratory failure.
* Tension pneumothorax ( TP) is accumulation of air in the pleural space under pressure,
compressing the lungs and decreasing venous return to the heart. Although multiple definitions
exist, a tension pneumothorax is generally considered to be present when a pneumothorax leads
to significant impairment of respiration and/or blood circulation.
- Tension pneumothorax develops when a lung or chest wall injury is such that it allows air
into the pleural space but not out of it (a one-way valve). As a result, air accumulates and
compresses the lung, eventually shifting the mediastinum, compressing the contralateral
lung, and increasing intrathoracic pressure enough to decrease venous return to the heart,
causing shock. These effects can develop rapidly, particularly in patients undergoing
positive pressure ventilation.
5. - Causes include patients receiving positive-pressure ventilation (most commonly) with
mechanical ventilation or particularly during resuscitation, failed central venous cannulation,
simple (uncomplicated) pneumothorax with lung injury that fails to seal following penetrating
or blunt chest trauma and in patients with lung disease.
- Symptoms and signs initially are those of simple pneumothorax, tachypnea and increased
heart rate . As intrathoracic pressure increases, patients develop hypotension, tracheal
deviation, neck vein distention and respiratory distress. The affected hemithorax is
hyperresonant to percussion with reduced expansion and often feels somewhat distended,
tense, and poorly compressible to palpation. Rarely, there may be cyanosis, altered level of
consciousness.
- Recent studies have shown that the development of tension features may not always be as
rapid as previously thought. Deviation of the trachea to one side and the presence of raised
jugular venous pressure (distended neck veins) are not reliable as clinical signs.
- In case of Tension pneumothorax occuring in someone who is receiving mechanical
ventilation, it may be difficult to spot as the person is typically receiving sedation; it is often
noted because of a sudden deterioration in condition.
- This is a medical emergency and may require immediate treatment without further
investigations. Without appropriate treatment, the impaired venous return can cause systemic
hypotension and respiratory and cardiac arrest (pulseless electrical activity) within minutes.
* Acute respiratory distress syndrome, critically ill adults and pneumothorax:
- pneumothorax is common in ventilated critically ill patients . Approximately 50% of patients
with ARDS who require mechanical ventilation will develop a pneumothorax during their
treatment. The ARDS damages the lung parenchyma, and the high intrathoracic pressures
resulting from mechanical ventilation of stiff lungs contributes to rupture of the diseased lung
tissue.
- In patients with minimal pulmonary reserve, even a small pneumothorax can have adverse
hemodynamic effects or cause tension that rapidly induces cardiovascular collapse and death.
- Many factors may precipitate the occurrence of pneumothorax in ARDS, such as the
mechanical ventilation settings, the clinical severity of ARDS and the underlying pulmonary
pathology (like preexisting emphysema).
6. - Up to 96% of patients who develop pneumothorax while receiving ventilation will progress
to tension pneumothorax because the machine blows air out of the hole in the lung into the
pleural space with positive pressure.
- Tension pneumothorax occurs when intrapleural pressure exceeds atmospheric pressure.
Tension pneumothorax is a clinical diagnosis, not a radiographic diagnosis, because the
respiratory and hemodynamic consequences of tension pneumothorax do not have radiographic
equivalents in many circumstances.
. Radiographic signs of tension (mediastinal shift, inversion of diaphragm,
enlargement of affected hemithorax) can occur in the absence of adverse physiologic effects,
and the physiologic effects of pleural tension may be present without radiographic signs of
tension. In ARDS, the diseased noncompliant lung may not collapse in the presence of a
pneumothorax, and the controralateral lung may be too stiff to allow mediastinal shift. Thus,
tension pneumothorax in ARDS can present as a loculated paracardiac or subpulmonic air
collection with little or no mediastinal shift and only slight changes of the cardiac contour.
++++
. Also, In patients with severe ARDS and pleural adhesions, most if not all of cardinal
clinical signs of Tension PNO (sudden increase in ventilation pressures, severely reduced
breath sounds on the affected side, jugular venous distention, and the dreaded mediastinal shift)
that results in cardiovascular collapse will be absent. The lung may be so diseased, stiff and
noncompliant that it does not fully collapse when air trapped in the pleural space presses on it.
If only a small portion of the lung is externally compressed, the mediastinum will not be
affected Therefore, radiographic evidence of extrapulmonary air collections becomes even
more important in this group of critically ill patients.
. Adherence of inflamed pleura to the chest wall ( parietal pl) may confine a
pneumothorax to a loculated portion of the pleural space around the site of the air leak.
Even daily chest radiographs can miss small loculated pneumothoraces. Two studies reported
by Chon and colleagues (cf num ref) reported that in critically ill, mechanically ventilated
adults, 33% to 50% of "missed" pneumothoraces (that is, pneumothoraces too small or subtle to
be seen on the radiograph until retrospective review) progressed to tension. Even small areas of
compression on the lung can have a significant impact on pulmonary function when the lungs
are so dysfunctional to begin with.
- The most repeatable finding of PNO in patients with severe ARDS was a subtle drop in
oxygenation measurements. Patients showed an improvement in PaO2 within 24 hours of
chest tube insertion and pneumothorax resolution.
7. . Loculated pneumothorax provides only subtle clinical clues. The only clinical evidence
may be deteriorating oxygenation without another obvious cause.
. The early and accurate diagnosis of pneumothorax in ARDS patients is mandatory
since this complication carries an increased mortality. Furthermore, small pneumothoraces in
these patients can cause severe hemodynamic or pulmonary compromise. This is the reason
why pneumothorax must always be suspected in any patient with ARDS who experiences an
acute worsening in respiratory function, accompanied with dyspnea and hypoxemia, which is
usually unresponded to oxygen therapy.
. Although non-specific, the association of respiratory and haemodynamic signs found
with a tension pneumothorax are a medical emergency. Severe haemodynamic compromise
will require urgent needle decompression of the pneumothorax before its diagnosis being
confirmed radiologically. Fortunately this situation is uncommon and there is frequently time
for radiological investigations to help establish the diagnosis of a simple pneumothorax.
* Complications of PNO
- In most reported series, the rate of recurrence of spontaneous pneumothorax on the same side
is as much as 30%.
- On the contralateral side, the rate of recurrence is approximately 10%.
- Other complications include the following: Reexpansion pulmonary edema . Bronchopleural
fistula Occurs in 35% of patients, Pneumomediastinum and pneumopericardium and Tension
pneumothorax. Tension PNO may occur after spontaneous pneumothorax, although it is more
common after traumatic pneumothorax or with mechanical ventilation.
* In summary: A simple unilateral pneumothorax, even when large, is well tolerated by most
patients unless they have significant underlying pulmonary disease. However, tension
pneumothorax can cause severe hypotension, and open pneumothorax can compromise
ventilation.