By

Dr.Krishnakanth Reddy.P PG 2nd year

Dept of Paediatrics

Accumulation of extra pulmonary air within the

pleural cavity

Most commonly from leakage of air from the lung

Pneumothorax can be associated with

Serous effusion (Hydropneumothorax)

Blood ( Hemopneumothorax)

Purulent effusion ( pyopneumothorax)

Bilateral: After lung transplantation

Mycoplasma pneumonia

Tuberculosis

Spontaneous pneumothorax

Traumatic pneumothorax

Iatrogenic pneumothorax

Catamenial pneumothorax

Primary/ idiopathic: without trauma or underlying

disease • Familial cases have mutations in the folliculin

gene(FCLN) • Birt Hogg Dube syndrome • Marfans syndrome Ehler Danlos syndrome

Secondary - Complication of an underlying disease without trauma eg: pneumonia,emphysema,COPD,

Traumatic pneumothorax ◦ External chest trauma

◦ Abdominal blunt or penetrating trauma

Iatrogenic pneumothorax

◦ Thoracocentesis

◦ Trans thoracic needle aspiration

◦ Diagnostic or therapeutic procedures

Catamenial pneumothorax

◦ Prior to menses

◦ associated with diaphragmatic defects & pleural

blebs

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

Inherent elastic recoil of the lung

The negative pressure will be disappeared if any

communication develops

When a communication develops through the chest wall

between the atmosphere and the pleural space air will enter

the pleural space until the pressure gradient is eliminated or

the communication is closed

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 ◦ Decrease in vital capacity ◦ Decrease in PaO 2

Abrupt onset

Symptoms proportional to Extent of lung collapse & Pre existing lung disease and Pressure gradient

Dyspnoea

Chest pain

Cyanosis

Respiratory distress

Chest Retractions – subcostal, intercostal, xiphoid

Deviation of trachea, heart towards unaffected side

Tympanic percussion note

Decreased / absent breath sounds

Chest X ray findings

Pleural line

No lung markings

The outer margin of visceral

pleura separated from the

parietal pleura by a lucent

gas space devoid of

pulmonary markings .

BTS (British thoracic society) The rim of air between the

pleura and the chest wall Small <1cm Moderate :1- 2cm Large >2cm

ACCP ( American college of chest

physicians) The apex-to-cupola distance Small <3cm Large ≥ 3cm

In difficult cases in whom the lungs are obscured by

overlying surgical emphysema

To differentiate a pneumothorax from suspected

bulla in complex cystic lung disease and congenital

lobar emphysema

Emphysema ( local or generalized)

Cystic formations

Diaphragmatic hernia

Compensatory overexpansion with contralateral

atelecatasis

Goals

promote lung expansion

To eliminate the pathogenesis

To prevent recurrence of pneumothorax

based on

Type of pneumothorax

Pathogenesis

Pneumothorax frequency

Extension of lung collapse

Severity of disease

Complication and concomitant underlying disease

Observation

Antibiotics

100% oxygen

Needle aspiration

Intercostal tube drainage

Chemical pleurodesis

Thoracoscopy

Surgical treatment

Treatment of the underlying pulmonary disease

should begin on admission and should be continued

throughout the course of treatment directed to the

lung pathology

Observation and no intervention ◦ If Small (<5%),moderate sized in an

otherwise normal child

INDICATIONS Secondary spontaneous pneumothorax Unstable pneumothorax Severe dyspnoea Lung collapse Open or tension pneumothoraces Frequent recurrent pneumothoraces If Simple aspiration or catheter aspiration drainage

is unsuccessful in controlling symptoms

Prerequisites : check for and correct bleeding

disorders

Position: The child is positioned supine or with the affected side up.

Site:The site of chest tube insertion is in the midclavicular line of second and third intercostal space or anterior axillary line of 5th and 6th intercostal space

Placement of underwater seal below the drain insertion site

Movement of water column

Vital data

Dressing to be changed daily

Monitor the insertion site for infection

Equal breath sounds

No hypoxemia

CXR to ensure expansion

No air leak

Trial tube clamping for 6 hrs

No drainage/accumulation of fluid in tube

Penetration of major organs Lung, stomach, spleen, liver,

heart and great vessels

Occur more commonly when a sharp metal trocar is

inappropriately applied

Pleural infection

Empyema

Surgical emphysema

Subcutaneous emphysema

Other interventions in treatment of pneumothorax

Indications

Persistent air leak Repeated pneumothorax Bilateral pneumothoraces Complicated with bullae Lung dysfunction Sclerosing agents -Tetracycline, Minocycline, Doxycline,

Talc, Erythromycin

Video-assisted thoracoscopic surgery (VATS) is a preferred

therapy for blebectomy, pleural stripping, pleural

brushing,decortication and instillation of sclerosing agents,

with somewhat less morbidity than occurs with traditional

open thoracotomy.

Indications

No response to conventional treatment

Persist air leak

Hemopneumothorax

Bilateral pneumothoraces

Thick pleura makes lung unable to re expansion

Multiple blebs or bullae

Pyopneumothorax, Hemopneumothorax

◦ Caused by aspiration or intercostal chest tube insertion ◦ Also results from necrotic pneumonia, lung abscess, or caseous pneumonia

Mediastinal and subcutaneous emphysema

Pneumomediastinum, Pneumocardium, , Pneumoperitoneum

Surgical emphysema

Pyopneumothorax (also known as infected

hydropneumothorax or empyemic hydropneumothorax)

is a pleural collection of pus and air.

It may be a variant of a thoracic empyema with air

containing components although the aetiology may be

different.

Clinical presentation

Chest pain

Fever

Cough

Dyspnoea

An air-fluid level

Loss of silhouette with the dome of diaphragm.

Presence of thick pleural lining strongly favours the pyopneumothorax

Ultrasound

Fine internal echoes in the pleural collection strongly suggests

infected fluid in appropriate clinical settings.

CT scan chest

CT will clearly depict the location of the collection as well as

thickening of pleura and underlying disease process (if any).

Differential diagnosis

Non-infected hydropneumothorax (no pleural thickening)

peripheral lung abscess

previous empyema with iatrogenic introduction of air (e.g.

drain insertion or diagnostic aspiration etc.)

Treatment of pyo-pneumothorax Large collections require intercostal drainage with

antibiotics.