Urgent pleural disordersAleš Rozman

University Clinic of Respiratory Diseases and Allergy,

GOLNIK, Slovenia

Portorož – 8th May 2009

Pleural emergencies:

• haemorrhage

- haemothorax

• elevated pleural pressure

- tension pneumothorax

- massive pleural effusion

1. Haemothorax= pleural fluid with Ht > 50% blood Ht

CAUSES:• chest trauma: penetrating / non – penetrating

(lung blood vessels, chest wall, diaphragm, pleural adhesions, mediastinum, large vessels, abdomen)

• iatrogenic(pleural biopsy, subclavian or jugular CVC placement, thoracentesis, transthoracic or transbronchial NA, esophageal variceal TH,...)

• nonthraumatic(pleural malignancy, anticoagulant TH, spontaneous rupture of vessel (AO aneurism), bleeding disorder, thoracic endometriosis,...)

1. Haemothorax

DG:

• CXR

• chest CT – for all patients with severe chest trauma

• thoracentesis

transudate

haemothorax with higher attenuation (> 35 HU)

1. Haemothorax

TH:

• immediate tube thoracostomy1. evacuation of blood2. stop bleeding by apposition of pleural surfaces3. evaluation of blood loss4. may decrease incidence of empiema or fibrothorax5. autotransfusion possible

• thoracotomy (cca 15%)1. immediate drainage of > 20 ml/kg of blood2. persistent bleeding > 200 ml/h3. cardiac tamponade, vascular injury, pleural contamination,

major air leaks,...

•TH of shock, blood and fluid replacement,...

1. Haemothorax

Complications:

1.retention of clotted blood (evacuation if > 30% of

hemiTHX)

2.empyema (3 – 5%)

– shock, contamination, prolongued drainage, abdominal injuries

3.exudative pleural effusion (15 – 30%)

4.fibrothorax (< 1%)

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

CAUSES – any type of PTHX:

1. with mechanical ventilation / NIPPV

2. during cardiopulmonary resuscitation

3. in divers

4. in air travel

5. in spontaneously breathing person at constant pressures (airway,

environment)

6. improper chest tube handling

Pneumoscrotum secondary to bilateral tension pneumothorax 

Di Capua-Sacoto C, Bahilo-Mateu P, Ramírez-Backhaus M, Gimeno-Argente V, Pontones-Moreno JL, Jiménez-Cruz JF Servicio de Urología. Hospital Universitario La Fe. Valencia. Spain Actas Urol Esp. 2008;32(7):756-758 ABSTRACTPNEUMOSCROTUM SECONDARY TO BILATERAL TENSION PNEUMOTHORAXWe report a case of pneumoscrotum secondary to a large bilateral tension pneumothorax. Although pneumoscrotum is an infrequent clinical condition that is generally resolved by means of conservative management, it may be a symptom of a serious and potentially life-threatening process. The management of pneumoscrotum should be directed to resolve the underlying cause.Key words: Pneumoscrotum. Pneumothorax. Complications.

2. Tension PTHX

Patophysiology:

• 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

hyperinflation

collapsed lung

mediastinal shift

low hemidiaphragm

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

2. Tension PTHX

3. Massive pleural effusion

CAUSES:

• malignant pleural effusion

PATOPHYSIOLOGY:

• impaired venous return and decreased cardiac output

• V/Q mismatch - profound hypoxia

Clinical manifestations:

• gradual deterioration

• dyspnoe, cyanosis, tachicardia

• hypotension, low O2 saturation, distended neck veins

• unilateral distension of THX, absent respiratory mobility

3. Massive pleural effusion

3. Massive pleural effusion

mediastinal shift

distension

TH:

• thoracentesis for symptomatic relief (500 – 1000 ml)

• consider chest tube and pleurodesis

• avoid rapid evacuation of all pleural fluid (reexpansion

lung edema, PTHX)

3. Massive pleural effusion

• Haemothorax and tension pneumothorax can be

iatrogenic.

• Careful monitoring of patients and early recognition of

complications should be a standard after each invasive

procedure.

3. Conclusions

Thank you.University Clinic Golnik,

Slovenia