Understanding Pneumothorax: Types, Causes, and Management

1. PNEUMOTHORAX ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal

2. Defined as the presence of air in the pleural cavity Negative intrapleural pressure: ~ 5mm

3. PNEUMOTHORAX Spontaneous: 1. Primary spontaneous P. 2. Secondary spontaneous P. • Secondary: • Iatrogenic • traumatic

4. Primary spontaneous pneumothoraces • Do not have overt parenchymal disease • increased shear forces in the apex • commonly are smokers & tall young males • risk much more pronounced in female smokers • Genetic factors - Marfan’s syndrome • Defect of connective tissue

5. High arched palate

6. Secondary spontaneous pneumothoraces (SSP) occur in the presence of lung disease • COPD • Tuberculosis • sarcoidosis • cystic fibrosis • malignancy • idiopathic pulmonary fibrosis • Pneumocystis carinii pneumonia [PCP]) in patients with AIDS Sub pleural focus rupturing in pleural cavity

7. Iatrogenic pneumothorax a complication of medical or surgical procedures. results from • Therapeutic thoracentesis • Positive pressure mechanical ventilation • Pleural biopsy • Central venous catheter insertion • Transbronchial biopsy routine use of ultrasonography guided diagnostic thoracentesis is associated with lower rates of pneumothorax

9. Intra pleural pressure (-)

10. Broncho pleural fistula Intra pleural pressure(0)

11. Intra pleural pressure(+)

12. Clinical features

13. Symptoms: • Sudden onset (usually after a bout of coughing) of • Chest pain • dyspnoea • Asymptomatic when small Signs: • In sever cases low volume pulse with tachycardia • Collapse & signs of peripheral circulatory failure • Cyanosis (See when there is tension pneumothorax) • Vitals are normal in closed & open pneumothorax

14. Inspection: Dyspnoea with accessory muscles active Tracheal shift may be visible – trail’s sign Fullness of chest on affected side Diminished chest movement

15. Palpation: • Trachea & medistinum shifted to opposite side • Vocal fremitus – markedly diminished • Diminished expansion of affected hemithorax Percussion: • Hyper resonant note on the affected side • Liver dullness obliterated: right sided pneumothorax • Cardiac dullness shifted to opposite side

16. Auscultation • Vocal resonance reduced/absent • Breath sounds reduced/absent on affected side • Hamman's sign: refers to a click on auscultation in time with the heart sounds, due to movement of pleural surfaces with a left-sided pneumothorax In open pneumothorax • Amphoric breath sound due to broncho pleural fistula may be heard

17. CXR -diagnostic in most cases • visible lung edge and absent lung markings peripherally • increased lucency & hemidiaphragm depression on the affected side • CXR appearance may also show features of underlying lung disease

18. CT chest may be required • To differentiate pneumothorax from bullous disease • Useful in diagnosing unsuspected pneumothorax following trauma • In looking for evidence of underlying lung disease

21. Partial pneumothorax

22. Management

23. Determined by • Degree of breathlessness & lung collapse • Hypoxia • Evidence of haemodynamic compromise • Presence and severity of any underlying lung disease • Pneumothorax size

24. Severe breathlessness out of proportion to pneumothorax size may be a feature of tension pneumothorax • Secondary pneumothorax has a significant mortality (10%), and should be managed more aggressively. Treat also the underlying disease

25. Aspiration

26. Chest Aspiration

27. Chest Aspiration Suction apparatus

28. Inserting a inter coastal drainage tube 1

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33. Aspiration Indications Primary pneumothorax Consider aspiration if • patient breathless and/or • pneumothorax large (rim of air > 2 cm on CXR) Secondary pneumothorax Consider aspiration • patient aged > 50 years (all cases) • with small pneumothorax (rim of air < 2 cm on CXR) • minimal breathlessness

34. Chest drainage • Associated with significant morbidity and even mortality due to subcutaneous emphysema • not required in the majority of patients with primary spontaneous pneumothorax

36. Oxygen • All hospitalized patients should receive high flow (10 l/min) inspired oxygen (unless CO2 retention is a problem) • Reduces the partial pressure of nitrogen in blood, encouraging removal of air from the pleural space and speeding up resolution of the pneumothorax

37. Persistent air leak • Defined as continued bubbling of chest drain 48 hours after insertion In indicates: • Inability of lung to expand after the drainage • Broncho pleural fistula - communication with out side air • Will develop secondary infection and pyopneumothorax until closed by surgery

38. Out-patient follow-up Repeat CXR to ensure resolution of pneumothorax and normal appearance of underlying lungs Discuss risk of recurrence and emphasize smoking cessation, if appropriate

39. Patients should not fly for at least 6 weeks. avoid flying for a longer period, e.g. 1 year Advise about flying

40. Advise NEVER TO DIVE in the future, unless patient has undergone a definitive surgical procedure

41. Indications for cardiothoracic surgical referral • Second ipsilateral pneumothorax • Bilateral spontaneous pneumothorax • Persistent air leak (>5 -7 days of drainage) • Spontaneous haemothorax • Professions at risk (e.g. pilots, divers) after first pneumothorax

42. Chemical pleurodesis • As an alternative for surgery specially in case of recurrent pneumothorax • seal the visceral to the parietal pleura to prevent pleural fluid accumulating. (already described previously)

43. Tension pneumothorax

44. Pneumothorax acts as a one-way valve • Progressive increase in pleural pressure compresses both lungs and mediastinum • Reduced venous return to the heart, leading to hypotension and cardiac arrest • not related to pneumothorax size can occur with very small pneumothoraces in the context of air trapping in the lung from obstructive lung disease

45. Patients present with • Acute respiratory distress & agitation • Hypotension • Raised jugular venous pressure • Tracheal deviation away from the pneumothorax side • Reduced air entry on affected side • May present with cardiac arrest (pulseless electrical activity) • Acute deterioration in ventilated patients

46. Management • Give high-flow oxygen • Insert a needle into second intercostal space in midclavicular line on side of pneumothorax • Do not wait for a CXR if cardiac arrest has occurred or the diagnosis is clinically certain • Hissing air confirms diagnosis. Aspirate air until the patient is less distressed • Insert chest drain in mid axillary line afterwards