Dr Nirav Dhinoja

Pneumothorax is the accumulation of extrapulmonary air within the chest.

Most commonly from leakage of air from within the lung.

Term “pneumothorax” was first coined by Itard in

1803.

Laennec described the clinical picture of

pneumothorax occurring in patients with

pulmonary tuberculosis in 1819.

Description of primary spontaneous pneumothorax

occurring in healthy people was provided by

Kjaergard in 1932

Pneumothorax

Spontaneous

Primary Secondary

Traumatic

Iatrogenic

Interventional

procedures.

Positive pressure

ventilation

Non iatrogenic

Penetrating

traumaBlunt trauma.

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 and inherent elastic recoil of the lung.

The negative pressure will be disappeared if any communication develops .

When a communication develops between an 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 until the communication is sealed.

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 ◦ A decrease in vital capacity ◦ A decrease in PaO2

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closed communicated tension

Rupture small large valve-like

sealed open in,not out

Pressure P or N atmosphere high

After

Aspiration N atmosphere high again

Abrupt onset.

Severity depends on :◦ Extent of lung collapse.

◦ Amount of pre-existing lung disease.

Pain – severity of pain does not reflect extent of collapse.

Dyspnea.

Cyanosis.

Tension pneumothorax◦ Distressed with rapid labored respiration

◦ Cyanosis

◦ Marked tachycardia

◦ Profuse diaphoresis

Patient who suddenly deteriorate clinically,should be suspected in the patient with◦ Mechanical ventilation

◦ Cardiopulmonary resuscitation

The side with pneumothorax is larger than the contralateral side.

Chest moves less during the respiratory cycle.

Tactile fremitus is absent.

The percussion note is hyperresonant.

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.

The trachea may be shifted toward the contralateral side if the

pneumothorax is large.

The characteristics of pneumothorax◦ Pleural line◦ No lung markings in

pneumothorax

The outer margin of visceral pleura separated from the parietal pleura by a lucent gas space devoid of pulmonary vessels

Pneumothorax

in erect position

Pneumothorax

in supine position

Air in apicolateral pleural space Air in anteromedial pleural space.

Pneumothorax

Erect

Smallpneumothorax

Apical lucency

Visceral pleural line

Largepneumothorax

Apical lucency(>2cm in width)

Visceral pleural line

Tensionpneumothorax

Lung collapse

Mediastinal shift

Low flat diaphragm

Supine

DeepCostophrenic

sulcus

LucentCardiophrenic

sulcus

Sharp Mediastinal

contour

Double diaphragm

It is very important to differentiate the pleural line of a pneumothorax from that of a skinfold, clothing, tubing, or chest wall artifact.

Artifact extends beyond the thorax, or that lung markings are visible beyond the apparent pleural line.

CT scanning is done if accurate size estimates are required.It is only recommended to 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.

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.

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Small, closed mildly symptomatic spontaneous

pneumothoraces.

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.

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Small SSP of less than 1 cm depth or isolated apical

pneumothoraces in asymptomatic patients.

Hospitalisation is recommended in these cases.

All other cases will require active intervention ( aspiration or

chest drain insertion)

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Marked breathlessness in a patient with a small (<2 cm) PSP may herald tension pneumothorax.

Observation alone is inappropriate and active intervation is required.

If a patient is hospitalised for observation, supplemental high flow (10 l/min) oxygen should be given.

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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.

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The rate of resolution/reabsorption of spontaneous

pneumothoraces is 1.25 – 1.8% of volume of hemithorax

every 24 hours.

High flow oxygen therapy has been shown to result in a 4-

fold increase in the rate of pneumothorax reabsorption

during the periods of oxygen supplementation.

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It is recommended as first line treatment for all PSP requiring intervention.

It is less likely to succeed in secondary pneumothoraces and in this situation,it 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.

Repeated aspiration is reasonable 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.

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Fix the catheter and cover with gauze

Making a small incisionUsing a forceps to extend the holeInserting a catheter into pleural cavity

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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

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Position of intercostal tube

The chest tube should be positioned in the uppermost part of the pleural space, where residual air accumulates

This procedure permits the air in the pleural space to be evacuated rapidly

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The site of chest tube insertion is in the midclavicularline of 2nd and 3rd

intercostal or anterior axillary line of 5th and 6th

intercostal space.

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Making a small skin incision slightly larger than the diameter of the chest tube

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Introduction of 18-gauge needle into the pleural space

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Insertion of wire with “J” end into the pleural space

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With guidewire in space, the tract is enlarged by advancing progressively larger dilators over the wire guide

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Introduction the chest tube inserter/chest tube assembly over the guidewire

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The guidewire and chest tube inserter have been removed, leaving the chest tube positioned with the pleural space

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Insertion of trocar into the pleural space.

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Insertion of the chest tube through the trocar

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The physician’s index finger is used to enlarge the opening and to explore the pleural space

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Placement of chest tube intrapleurally using large hemostat

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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.

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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

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Goals ◦ To prevent pneumothorax recurrence ◦ To produce inflammation of pleura and adhesions

Indications◦ Persist air leak and repeated pneumothorax◦ Bilateral pneumothoraces◦ Complicated with bullae◦ Lung dysfunction, not tolerate to operation

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Sclerosing agents◦ Tetracycline◦ Minocycline◦ Doxycline◦ Talc ◦ Erythromycin

The instillation of sclerosing agents into the pleural space should lead to an aseptic inflammation with dense adhesions.

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Methods

◦ Via chest tube or by surgical mean

◦ Administration of intrapleural local anaesthesia, 200 – 400 mg lidocaine intrapleurally

injection

◦ Agents diluted by 60 – 100 ml saline

◦ Injected to pleural space

◦ Clamp the tube 1 – 2 hours

◦ 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.

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Side effct◦ Chest pain

◦ Fever

◦ Dyspnea

◦ Acute respiratory distress syndrome

◦ Acute respiratory failure

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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

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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 reexpansion, bleeding will stop.◦ When bleeding persists, surgical ligation will be needed.

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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 – surgical emphysema

◦ Physical exam – crepitus is present.

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Subcutaneous emphysema

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Treatment ◦ Automatic absorption when pneumothorax is gone

◦ Inhalation of high concentration of oxygen

◦ Making a small incision in suprasternal pit for draining the air from mediastinal and subcutaneous tissues.