PneumothorPneumothoraxax in in ICUICU

Dr Ashok Jadon, MD Dr Ashok Jadon, MD DNBDNB

Sr. Consultant & HOD Sr. Consultant & HOD Dept. of AnaesthesiaDept. of AnaesthesiaTata Motors Hospital, Tata Motors Hospital,

JamshedpurJamshedpur

IntroductionIntroduction Pneumothorax; air Pneumothorax; air

in pleural spacein pleural space

Air can enter from Air can enter from the outside; injury the outside; injury penetrated the penetrated the chest wall chest wall

Air can enter from Air can enter from inside, if the lung inside, if the lung is torn or ruptured is torn or ruptured e.g. (pulmonary e.g. (pulmonary bleb).bleb).

Pneumothorax is the most common serious Pneumothorax is the most common serious pleural complication in the ICU pleural complication in the ICU

Pneumothorax may be difficult to diagnose Pneumothorax may be difficult to diagnose when their locations are atypical, when their locations are atypical, when the patient has underlying when the patient has underlying

cardiopulmonary disease cardiopulmonary disease altered mental statusaltered mental status

ICU pts : High Risk ICU pts : High Risk Group Group

Serious systemic disease Serious systemic disease Hemodynamically unstable; Invasive Hemodynamically unstable; Invasive

ProceduresProcedures Ventilator/ ResuscitationsVentilator/ Resuscitations Postoperative Patients; shifted from another Postoperative Patients; shifted from another

invasive environment invasive environment Trauma; admitted to ICUTrauma; admitted to ICU

Penetrating Injury of Chest/ AbdomenPenetrating Injury of Chest/ Abdomen # Rib# Rib ResuscitationResuscitation Central LineCentral Line

De Lassence et al Anesthesiology. 2006 De Lassence et al Anesthesiology. 2006

Jan;104(1):5-13.Jan;104(1):5-13.

Incidence 1.4% on day 5 and 3.0% on day Incidence 1.4% on day 5 and 3.0% on day 30. 30.

Risk factorsRisk factors History of adult immunodeficiency syndromeHistory of adult immunodeficiency syndrome Diagnosis of acute respiratory distress Diagnosis of acute respiratory distress

syndrome syndrome Cardiogenic pulmonary edema at admission Cardiogenic pulmonary edema at admission Central vein or pulmonary artery catheter Central vein or pulmonary artery catheter

insertion insertion Use of inotropic agents during the first 24 hUse of inotropic agents during the first 24 h

Pneumothorax in the intensive care unit: incidence & risk factors,

Close Associations Close Associations for high incidencefor high incidence

Disease; ARDSDisease; ARDS Ventilation; Incidence (4 to 15%).Ventilation; Incidence (4 to 15%). ProceduresProcedures

Thoracentesis, Thoracentesis, Central venous catheter placement,Central venous catheter placement, BronchoscopyBronchoscopy Pericardiocentesis Pericardiocentesis Tracheostomy Tracheostomy

Types/ EtiologyTypes/ Etiology

SpontaneousSpontaneous PrimaryPrimary SecondarySecondary

Iatrogenic / TraumaticIatrogenic / Traumatic Open/ CloseOpen/ Close Tension Pneumothorax

Spontaneous Spontaneous Pneumothorax Pneumothorax

This refers to a condition in which the This refers to a condition in which the lung collapses with no apparent injury lung collapses with no apparent injury or traumaor trauma Pulmonary blebsPulmonary blebs COPD; Emphysematous BullaeCOPD; Emphysematous Bullae AIDS/ Lung TumorAIDS/ Lung Tumor Infective or Infiltrative Lung Disease Infective or Infiltrative Lung Disease

Cigarette smokers & Recreational drug Cigarette smokers & Recreational drug users are at greater risk for users are at greater risk for spontaneous pneumothorax.spontaneous pneumothorax.

How Mechanical How Mechanical Ventilation Ventilation

Responsible for Responsible for Pneumothorax ?Pneumothorax ?

BiotraumaBiotrauma

Barotrauma and Barotrauma and VolutraumaVolutrauma

AtelectraumaAtelectrauma

Barotrauma and Barotrauma and VolutraumaVolutrauma

Ventilator-induced lung injury by high Ventilator-induced lung injury by high levels of mechanical stress and strain levels of mechanical stress and strain that occur when that occur when high airway high airway pressurespressures( Barotrauma) and ( Barotrauma) and high high volumesvolumes (Volutrauma) are delivered . (Volutrauma) are delivered .

This stress and strain can disrupt This stress and strain can disrupt the pulmonary fibroelastic skeleton the pulmonary fibroelastic skeleton and trigger a secondary and trigger a secondary inflammatory response. inflammatory response.

AtelectraumaAtelectrauma Moderate degrees of stress and Moderate degrees of stress and

strain related to the cyclic opening strain related to the cyclic opening and closing of parts of the lung and closing of parts of the lung may directly induce the release of may directly induce the release of inflammatory mediators and inflammatory mediators and noxious proteinases.noxious proteinases.

Relationship between ventilatory Relationship between ventilatory settings and barotrauma in the settings and barotrauma in the

ARDSARDS incidence of barotrauma 0% to 49%, incidence of barotrauma 0% to 49%, High incidence correlated strongly High incidence correlated strongly

P(plat), above 35 cm H2O, P(plat), above 35 cm H2O, Compliance below 30 ml/cm H2O Compliance below 30 ml/cm H2O

Aspiration PneumoniaAspiration Pneumonia In a prospective study 38 percent of patients In a prospective study 38 percent of patients

developed pneumothorax and pneumo-developed pneumothorax and pneumo-mediastinum. mediastinum.

Mohamed Boussarsar Intensive Care Med. 2002 ;28 (4):406-13.

PneumothoraxPneumothoraxTraumatic/ Procedure Traumatic/ Procedure

related related Direct trauma to the chest wall from Direct trauma to the chest wall from

either blunt or penetrating trauma either blunt or penetrating trauma causes this conditioncauses this condition

Thoracentesis (54%)Thoracentesis (54%) Central vein/pulmonary artery Central vein/pulmonary artery

catheterization (40%)catheterization (40%) Bronchoscopy /transbronchial Bronchoscopy /transbronchial

lung biopsy (23%)lung biopsy (23%)

Pneumothorax;Pneumothorax;Central Venous LineCentral Venous Line

Internal jugular, Internal jugular, subclavian, or subclavian, or Femoral VeinFemoral Vein

There is no There is no difference in the difference in the rates of rates of pneumothorax for pneumothorax for internal jugular internal jugular versus subclavian versus subclavian vein placementvein placement

Ruesch S, Walder B, Tramer M. Complications of Central Venous Catheters: Internal Jugular versus Subclavian access-A Systematic Review. Crit Care Med. 2002;30:454-60.

Pneumothorax after insertion of central Pneumothorax after insertion of central venous catheters in the intensive care unit: venous catheters in the intensive care unit: association with month of year and week of association with month of year and week of

monthmonth Highest in July and August and in the first Highest in July and August and in the first

week of the month (beginning of intensive week of the month (beginning of intensive care unit (ICU) rotation). care unit (ICU) rotation).

The rate of PTX after insertion of CVCs is The rate of PTX after insertion of CVCs is greatest in the last week of the greatest in the last week of the month(2.7%) than during the first, second month(2.7%) than during the first, second or third weeks (1.7%, 1.8% and 1.4%, or third weeks (1.7%, 1.8% and 1.4%, respectively). respectively). Najib T Ayas-Quality and Safety in Health Care 2007;16:252-255

SymptomsSymptoms

Sharp, stabbing chest pain that Sharp, stabbing chest pain that worsens on breathing or with deep worsens on breathing or with deep inspiration. Pain often radiates to inspiration. Pain often radiates to the shoulder and or back the shoulder and or back

A dry, hacking cough may occur A dry, hacking cough may occur because of irritation of the because of irritation of the diaphragm. diaphragm.

Tension PneumothoraxTension Pneumothorax When the pleural When the pleural

pressure is positive pressure is positive throughout throughout respiratory cycle respiratory cycle

““Ball-valve Ball-valve mechanism”mechanism”

Injury to pleura Injury to pleura creates a creates a tissue tissue flapflap that opens on that opens on inspiration and inspiration and closes on closes on expirationexpiration

EpidemiologyEpidemiology Kolef reviewed 464 ICU patientsKolef reviewed 464 ICU patients

28 (6%) developed pneumothorax28 (6%) developed pneumothorax 9 patients missed the initial diagnosis 9 patients missed the initial diagnosis 3 (33%) developed tension pneumothorax3 (33%) developed tension pneumothorax In diagnosed 19 patients only 1 (5%) In diagnosed 19 patients only 1 (5%)

develop pneumothorax develop pneumothorax Tocino & coworkers Tocino & coworkers

Missed pneumothorax 34/112 (30%)Missed pneumothorax 34/112 (30%) 16/34 patients developed tension 16/34 patients developed tension

pneumothoraxpneumothorax

Clinical pictureClinical picture

DistressedDistressed Rapid labored Rapid labored

breathingbreathing CyanosisCyanosis Profuse Profuse

diaphoresisdiaphoresis Marked Marked

tachycardiatachycardia HypotensionHypotension

Decreased breath Decreased breath soundssounds

Hyper resonance Hyper resonance on percussionon percussion

Etiology of symptomsEtiology of symptoms

HypoxiaHypoxia Decreased PaO2Decreased PaO2 Perfusion of atelectatic lungPerfusion of atelectatic lung

Decrease venous return Decrease venous return increase intrathoracic pressureincrease intrathoracic pressure Decreased CO & SVDecreased CO & SV

InvestigationsInvestigationsA

A

A

A

A

Hallmark: air between two pleural Hallmark: air between two pleural spacesspaces

Why they are missed? Why they are missed? Unfortunately, it is difficult to make a

radiographic diagnosis of a pneumothorax on portable x-ray films taken in the ICU setting.

X-ray Upright-air in ApexX-ray Upright-air in Apex X-ray In ICU; supine , semi supine X-ray In ICU; supine , semi supine In addition, concurrent lung disease

may lead to different distributions of free air in the pleural space than in patients with relatively normal lungs.

Distribution of airDistribution of air

38%

26%

22%

11%3%

anterio-medial

subpulmonic

apicolateral

posterio-medial

others

Always look for….

Subtle radiographic signs of pneumothorax

Relative hyperlucency over the upper abdominal quadrants

Deep costophrenic angle (the deep sulcus sign)

Role of Ultrasound in Role of Ultrasound in DiagnosisDiagnosis

Disappearance of "lung sliding" was observed in Disappearance of "lung sliding" was observed in 100% 100%

In this series, sensitivity was 95.3%, specificity In this series, sensitivity was 95.3%, specificity 91.1%, and negative predictive value 100% 91.1%, and negative predictive value 100% (p<0.001).(p<0.001).

Conclusions:Conclusions: Ultrasound was a sensitive test Ultrasound was a sensitive test for detection of pneumothorax, although for detection of pneumothorax, although false-positive cases were noted. The false-positive cases were noted. The principal value of this test was that it could principal value of this test was that it could immediately exclude anterior pneumothorax.immediately exclude anterior pneumothorax.

CT ThoraxCT Thorax

Pneumothorax Pneumothorax Prevention during CVCsPrevention during CVCs

Remove patient from ventilator Remove patient from ventilator before advancing the needle. before advancing the needle.

Choose the right side rather than Choose the right side rather than left, left,

Avoid multiple attempts when Avoid multiple attempts when possiblepossible

Check post procedure x-ray, Check post procedure x-ray,

Ultrasound Guided CVCsUltrasound Guided CVCs

Success with Success with ultrasound ultrasound guidance was guidance was 100%, compared 100%, compared with 88% when with 88% when ultrasound was not ultrasound was not used. used.

incidence of incidence of carotid puncture carotid puncture was reduced from was reduced from 8.3% to 1.7%.8.3% to 1.7%.

TreatmentTreatment Small pneumothoraxSmall pneumothorax

Resolve over days to weeksResolve over days to weeks Supplemental oxygen and Supplemental oxygen and

observationobservation Spontaneous pneumothoraxSpontaneous pneumothorax

Asymptomatic –f/u with serial CXRAsymptomatic –f/u with serial CXR Symptomatic –chest tubeSymptomatic –chest tube Recurrent pneumothorax – CT to Recurrent pneumothorax – CT to

evaluate need for thoracotomyevaluate need for thoracotomy

Tension pneumothorax; Tension pneumothorax; Treatment Treatment

Pneumothorax can be life-threatening. Pneumothorax can be life-threatening. The immediate treatment is tube The immediate treatment is tube

thoracostomy, or the insertion of a thoracostomy, or the insertion of a chest tube. chest tube.

Chest tubes are generally inserted Chest tubes are generally inserted using local anesthesia. using local anesthesia.

The chest tube is left in place until the The chest tube is left in place until the lung leak seals on its own; this usually lung leak seals on its own; this usually occurs within two to five days.occurs within two to five days.

Thoracostomy (Chest Thoracostomy (Chest tube) tube)

Pulmonary blebsPulmonary blebs Pulmonary blebs can Pulmonary blebs can

be resected, be resected, preventing future preventing future pneumothorax. pneumothorax.

Thoracoscopic Thoracoscopic surgical procedure. surgical procedure.

A stapling device is A stapling device is inserted into the inserted into the chest during, and the chest during, and the segment of lung with segment of lung with blebs is stapled across blebs is stapled across and then removedand then removed

complications of air of pleural parenchyma

Sub-pleural air cysts; Secondary infections in the cysts,

Pseudomonas sepsis & death. Systemic Gas Embolism

It is possible for extra-alveolar air to enter the systemic circulation if there is a bronchovenous communication and an adequate pressure gradient.

PrognosisPrognosis

Paucity of clinical data Paucity of clinical data describing the prognostic factors describing the prognostic factors associated with patient outcomesassociated with patient outcomes

PrognosisPrognosis Seven patients (12%) had to undergo Seven patients (12%) had to undergo

external suction and pleurodesis for external suction and pleurodesis for persistent air leaks. persistent air leaks.

Five patients still had air leaks, and the Five patients still had air leaks, and the chest tube was not removed during their chest tube was not removed during their ICU stay. ICU stay.

The mean duration of ICU stay was 24 ± The mean duration of ICU stay was 24 ± 19 days (median, 17.5 days). 19 days (median, 17.5 days).

The mean duration of chest tube drainage The mean duration of chest tube drainage was 10 ± 11 days (median, 6 days). was 10 ± 11 days (median, 6 days).

The mortality rate for patients with The mortality rate for patients with pneumothorax was 68%. pneumothorax was 68%.

Prognosis contd..Prognosis contd..

Patients with procedure-related Patients with procedure-related pneumothorax had a lower risk of pneumothorax had a lower risk of mortality. mortality.

Patients who had tension Patients who had tension pneumothorax and concurrent septic pneumothorax and concurrent septic shock had a higher risk of mortality. shock had a higher risk of mortality.

pneumothorax due to barotrauma, pneumothorax due to barotrauma, tension pneumothorax, and concurrent tension pneumothorax, and concurrent septic shock were significantly and septic shock were significantly and independently associated with death. independently associated with death.

ConclusionConclusion

Twist in Tale..Twist in Tale..

CXR with recurrent right-sidedpneumothorax, despite thoracostomy tube in place

CT scan with giant bullae and anterior pneumothorax after insertion of a second thoracostomy tube

MessageMessage

Put Chest Drain; Be HappyPut Chest Drain; Be Happy But, Be Observant and Do But, Be Observant and Do

Follow -Up Follow -Up Not only Till Patient Go Not only Till Patient Go

Home Home Later on too.Later on too.

Thank Thank YouYou