Pneumothorax

Objectives:
Definition of Pneumothorax

Classifications
Etiology Clinical features

Sign & Symptoms

Complications Investigations

Treatment
2

Pneumothorax

Definition: Air in pleural space, between the lung and the chest wall First coined as pneumothorax simple by Itard in 1803

Pneumothorax
collection of air within the pleural space
transforms the potential space into a real one may lead to various degrees of respiratory compromise

with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario
impairs respiratory function decreases venous return to the right-side of the heart

Pneumothorax
Classification
Spontaneous Pneumothorax
Primary Secondary

Traumatic Pneumothorax
Iatrogenic Non Iatrogenic
Open
Closed

Types of Spontaneous Pneumothorax

Primary spontaneous pneumothorax
in healthy persons with no apparent underlying lung abnormalities or underlying conditions Secondary spontaneous pneumothorax

Clinically apparent underlying lung disease

Types of Traumatic Pneumothorax

Traumatic Pneumothorax
Open
Chest wall is penetrated : outside air enters pleural space

Closed
Chest wall is intact Ex. Fractured rib

Etiology:
Simple spontaneous: rupture of subpleural blebs at the lung apex, This most commonly occurs in healthy, tall males between the ages of 20 to 40. - Secondary spontaneous:

These occur as a result of trauma or pre-existing pulmonary disease (eg TB, malignancy, emphysema, insterstitial fibrosis).
widespread emphysema is the most common cause of secondary pneumothorax.

Risk Factors:
Sex: male more than female Age: 20 40 years most likely Smoking Lung disease: specially emphysema A history of pneumothorax

Effect of smoking on PSP recurrence risk

Bense et. al. Chest 1987; 92:1009

No. of cigarettes/day

Relative Risk (men)

Relative Risk (women)

1-12
13-22 >22

7
21 102

4
14 68

Pneumothorax
Traumatic Ptx

Parenchymal Injury vs. Tracheobronchial vs. Esophageal

Blunt or Penetrating

Iatrogenic
central lines / thoracentesis / biopsy endotracheal tube placement (esp. dual-lumen tubes !) endoscopy / dilational techniques

Barotrauma
Ventilation / blast injury / Boerhaves syndrome

Operative

Pathogenesis of PSP
90% of cases at thoracoscopy or thoracotomy 80% of cases on CT showed subpleural blebs or bullae

Etiology of bullous changes in healthy:

airway inflammation from smoking lifetime risk in smoking men 12% vs. 0.1% non-smokers tall stature-subpleural blebs in apex

Pathogenesis of PSP (contd) Other causes

Marfans syndrome
Homocystinuria

Catamenial pneumothorax in thoracic endometriosis

Familial spontaneous pneumothorax: autosomal dorminant, recessive, polygenic and X-linked recessive inheritance

Pneumothorax
Primary Spontaneous Ptx
a disease of younger individuals (15 - 35 yrs of age)
males > females tall, slim body habitus cigarette smoking implicated usual cause: parenchymal blebs
apex of the upper lobe superior segment of the lower lobe

Genetic mutation and PSP

Gene for Familial cancer syndromechromosome17p11.2 Birt-Hogg-Dube syndrome: benign skin tumors and renal cancer: high PSP incidence-23% in one study Other mutations of FLCN-bullous lung disease and spontaneous pneumothorax only Autosomal dorminant inheritance of bullous lung disease with 100% penetrance in a Finnish family

Clinical Presentation

Primary spontaneous pneumothorax Usually occurs at rest Peak age is early 20s; rare after 40 Sudden onset of dyspnea and pleuritic chest pain Severity of sx related to size of pneumothorax

Secondary spontaneous pneumothorax More severe sx for same size of pneumothorax

Physical Findings

Decreased chest excursions Decreased breath sounds Hyperresonant percussion Subcutaneous emphysema

Pleural line on chest radiograph

Clinical Manifestations
1. Hyperresonance, diminished breath sound 2. Asymmetric chest expansion 3. Trachial deviation away from affected side 4. Mild to moderate discomfort dyspnea & chest

5. In tention pneumothorax one of air hunger, agitation, hypotension, and cyanosis

Sign & Symptoms:

Dyspnea
SOB if little amount of pleuritic air Rapid heart rate Rapid breathing Couph Pleuretic chest pain Sudden onset

Signs:
Inspection: - movement of the affected side - bulging of the affected side ( tension pneumothorax)

Palpation:

- movement (affected side) -Mediastinal shift opposite side - TVF (affected side)

 Percussion: Hyperresonance or tympanatic note (affected side)

Ausculation: -Air entry (affected side) - Vocal resonance (affected side) - Amphoric breathing may be heard - Coin test may be positive in tension pneumothorax

Complications
Spontaneous Pnemothorax:
Recurrence Persist air leak

Tension Pneumothorax:
Hypoxemia
Cardiac arrest Respiratory failure Shock

DDx
MI

PE
Pneumonia Asthma

Pleural effusion
Aortic dissection Pericarditis

Aortic aneurysm rupture

Invistigations

CXR
Ultrasound CT

Investigations:
C.X.R.:
-Lung separated from chest wall by a homogenous jet-black zone ,best seen over apex. Best seen in films taken during expiration. -Lung lies close to the mediastinum and may show the underlying disease. -In tension pneumothorax : Copula of diaphragm may be depressed and flattened. Mediastinum shifted to opposite side.

Wide intercostal spaces

Imaging
Plain Radiographs
Upright PA on inspiration
Detect other pathologies: pneumonia, cardiac, etc.

Partially collapsed lung Tension Pneumothorax

Trachea and mediastinum deviate contralaterally

Ipsilateral depressed hemidiaphragm

Chest CT
Not routine Only to assess the need for surgery (thoracotomy)

PNEUMOTHORAX
DIAGNOSIS: standard procedure is making chest x ray posteroanterior projection. Should upright position, may miss a pneumothorax in semisupine portable anteroposterior view. Lateral decubitus view if patient cant be upright. The percentage of collapse is underestimated. Artifact skin fold. CT, cost effective.

Pneumothorax
General Management

First: evacuate the air Second: address the underlying source Third: promote pleural symphysis

Choice of Treatment Options

Size of pneumothorax Symptoms Clinical stability: <24/min resp rate, HR >60-<120, normal BP, pulse ox >90%, can speak whole sentences in between breaths Recurrence risk, underlying conditions Patient occupation

Size of Pneumothorax
Small < 2cm between lung margin and chest wall (BTS) < 3 cm apex-to-cupola distance (ACCP) < 15% of the hemithorax (UpToDate) Large > 2 cm between lung margin and chest wall (BTS) > 3cm apex-to-cupola distance (ACCP) > 15% of hemithorax (UpToDate)

Treatment Recommendations based on Size

Small < 15% SP and stable patients: observation and supplemental oxygen to facilitate absorption of pleural air Large >15% Initial simple aspiration of the pleural space Tube thoracostomy if persistent airleak and no lung reexpansion

Tube Thoracostomy Indications

PSP that fails aspiration treatment
Recurrent spontaneous pneumothorax Presents with hemopneumothorax

Small chest tube in most (5.5 or 7.0 French)

Clamp chest tube when no bubbles emanate from a patent tube in 12 hours Remove after 24 hours if no clinical or xray evidence of recurrence

Pleurodesis Procedures
Chemical pleurodesis Intrapleural instillation of sclerosing agents

Tetracycline, doxycycline, talc, premedicate with midazolam and an opiate

Open or surgical pleurodesis

thoracoscopy vs. a limited or full thoracotomy

Indications: lung remains unexpanded after 3 days of chest tube, bronchopleural fistula, recurrence after chemical pleurodesis, bullae resection, patient occupation

Tx

Postgrad Med 2005;118(6) (online

Surgical indication:
i. Failure of closure of the tear after 48 hours of continous drainage ii. Intrapleural haemorrhage

iii. Bronchopleural fistula

iv. History of pneumothorax in the opposite side

PNEUMOTHORAX
Spontaneous rupture of esophagus present as ptx without gastrointestinal symptoms. Ptx accompanying pleural fluid, atelectasis. spontaneous pneumothorax with COPD especially with bullae formation is troublesome, tolerate poorly even small degree of collapse. Catamenial pneumothorax, occurred first three days of menses, nonovulatory states such as pregnancy and oral contraceptive use were not associated with pneumothorax.

PNEUMOTHORAX
Lung cancer with pneumothorax only 0.03 to 0.05%. Lymphangioleiomyomatosis seen in young women. Acquired pneumothorax is most often iatrogenic, chest tube dysfunction. Barotraumas pneumothorax is patient receving positive-pressure ventilation--treated by intervention rather than observation, indication for tube thoracostomy.

PNEUMOTHORAX

Small fluid collections frequently encountered if pneumothorax over 24 hours.

The fluid always clear. Large effusion often bloody and suggest a torn vascular adhesion, may require immediate operation to control bleeding.

PNEUMOTHORAX

Important to exclude a giant bullae in differential diagnosis because the tube drainage if such bullae is unrewarding.
Patient with pneumothorax should not be encouraged to travel by air.

PNEUMOTHORAX
1.5% of the air is reabsorbed over each 24 hours. Tube thoracostomy for pneumothorax over 30% or for patient with heart disease or COPD. Tube place at anterior and mid-axillary line, less muscle tissue has to be traversed. Anterior tube through second intercostal space, provide excellent apical air clearance but avoided in women.

PNEUMOTHORAX
Various agents for induce pleural symphysis: siver nitrate, talc, hypertonic glucose, urea, oil, nitrogen mustard, various antibiotics. Intrapleural tetracycline instillation could reduce the incidence of recurrence but difficulty to obtain. Talc should be reserved for malignant effusion, not benign pneumothorax.

PNEUMOTHORAX
Open operation by limited lateral or axillary incision with bleb excision and pleural abrasion or limited apical pleurectomy--- excellent result, low recurrence.

Video-assisted thoracic surgery VATS.

The recurrence rate is more high in VATS than other minithoracotomy.

PNEUMOTHORAX
Complete parietal pleurectomy should be reserved for open treatment failure, for postpneumonectomy patient with first pneumothorax and for old patient usually with COPD. Bilateral pneumothorax could be treated for bilateral via median sternotomy.

PNEUMOTHORAX

Goal of surgical treatment is to find the offending bleb, remove it, encourage adhesion formation but not too dense an adhesion.
If no bleb is found, the apex of the upper lobe should be staple off.

PNEUMOTHORAX
Surgical treatment of AIDS patient: usually persistent air leak. Thoracoscope approach with fibrin glue derivative. YAG laser, Heimlich valves. Persistent air leak who is poor operative risk,could be treated by using closed by pneumoperitoneum. Conclusion: If surgical treatment is going to be necessary the sooner it is performed, the sooner that patient can resume a routine life style.

Tension Pneumothorax

Tension Pneumothorax
Ball-valve mechanism Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration

Tension PTHX
= air in the pleural space, which pressure exceeds the atmospheric pressure throughout expiration (inspiration).

CAUSES any type of PTHX:

1. 2. 3. 4. 5. with mechanical ventilation / NIPPV during cardiopulmonary resuscitation in divers in air travel in spontaneously breathing person at constant pressures (airway, environment)

6.

improper chest tube handling

Tension PTHX

mediastinal shift hyperinflation

collapsed lung

low hemidiaphragm

2. Tension PTHX
Pathophysiology:
impaired venous return and decreased cardiac output V/Q mismatch - profound hypoxia

Clinical manifestations:
sudden deterioration dyspnoe, cyanosis, tachicardia, profuse sweating hypotension, low O2 saturation, distended neck veins subcutaneous emphysema, unilateral hyperinflation respiratory acidosis, hypoxemia sudden increse in plateau and peak pressures (volume type vent.) sudden drop of tidal volumes (pressure type vent.)

2. Tension PTHX
TH: medical emergency clinical diagnosis do not wait for CXR 100% O2 observation, auscultation, percussion needle & syringe with saline 2nd anterior ICS

bubbles? replace with large - bore needle

prepare for tube thoracostomy

Risk of Recurrence
Range 25 - >50%; 54% within first 4 years in one study
Risk factors for recurrence in PSP
smoking tall stature female gender low body weight

Risk factors for recurrence in SSP

age over 60 years pulmonary fibrosis emphysema