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Thoracic Surgery On-Line

Thoracic Surgery On-Line. Part 4 Pneumothorax. Pneumothorax. Tension Pneumothorax – the air builds up and pushes the heart across,the ribs are expanded because of the large volume of air that can’t escape,and the diaphragm gets pushed down.

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Thoracic Surgery On-Line

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  1. Thoracic Surgery On-Line Part 4 Pneumothorax

  2. Pneumothorax • Tension Pneumothorax – the air builds up and pushes the heart across,the ribs are expanded because of the large volume of air that can’t escape,and the diaphragm gets pushed down. • An urgent diagnosis and chest drain are required to release these effects.

  3. Pneumothorax • All patients who have had a tension pneumothorax should be considered for a pleurodesis. • Patients fall into 3 groups: • Young patients with otherwise normal lungs • Elderley COPD patients with many risk factors. • Patients with complicated lung diseases.

  4. Pneumothorax • Clinical patterns vary with COPD patients almost asphyxiating from a small pneumothorax because of poor lung function • Young patients can have a total pneumothorax with minimal pain or shortness of breath.

  5. Pneumothorax • After confirming the diagnosis there are options for draining the air – • Needle aspiration • Pigtail catheter to underwater seal drain • Chest drain to underwater seal drain. • Decision is based on ease of the procedure and the likelihood that it will be satisfactory for the pnumothorax being treated.

  6. Pneumothorax • The unknown is the degree of air leak. • Sometimes a pigtail is inserted but the lung doesn’t expand because its bore is too small for effective evacuation of the air building up • Also even though suction is applied,the bore may be too small for effective clearance of the air and a pneumothorax persists despite the procedure.

  7. Pneumothorax • A Heimlich valve or similar,can be attached to the drain for mobility as long as a Chest X ray shows the lung completely expanded with the system connected. • Drains are removed 24 hrs after any air leak stops as long as the lung is expanded.

  8. Pneumothorax • Suction is applied to the drain by connecting directly to the wall suction control and dialling up a negative pressure which remains negative for the whole respiratory cycle, despite the air leak

  9. Pneumothorax • Pleurodesis • Patients may need a pleurodesis and this can be achieved by various methods: • Talc slurry up drain – usually for COPD patients • Transaxillary thoracotomy and apical pleurectomy with stapling of apical blebs/cysts. • Video Assisted Thoracotomy,pleural abrasion,stapling of apical blebs/cysts.

  10. Pneumothorax • COPD • Mix 1-2 bottles of sterile talc with 60cc sterile saline,draw into Toomey Syringe • Premedicate patient • Facemask of oxygen • May preferably be done in theatre to have anaesthetic control of sedation/analgesia • Clamp tube,break junction of drain and tubing.Insert syringe into drain,release clamp and inject talc up drain.Reclamp,withdraw syringe and reattach tubing to drain and release clamp.

  11. Pneumothorax • Position patient on side if possible,and hold tubing up,to stop talc coming back,but leaving tubing unclamped to allow air to bubble out. • Lie patient from right side to left side for ¼ hr each side,for 1 hour ie r side,L side,R side,L side, - then lower tubing and sit patient up. • This hopefully coats the chest wall with talc for a pleurodesis. • If Lung remains expanded for 5 days,usually any continuing air leak won’t matter.Clamp the tube and monitor clinical and Chest Xray progress. • Remove tube if lung stays up,or 24 hrs after air leak stops.

  12. Pneumothorax • Surgery • In DBRCT’s there was no difference between VATS and open transaxillary pleurodesis. • Recurrence rates are in the order of 3-4% • Transaxillary approach – Patient positioned on side with arm on a bar.

  13. Pneumothorax • Transaxillary thoracotomy – procedure starts with a stripping of the apical pleura-from internal mammary artery anteriorly to sympathetic chain posteriorly and over the apex of the chest,then down to the oblique fissure. • After this the lung is examined and any apical scar/bleb/cyst is stapled off using Titanium staples – sample sent to Path to exclude rare lung disease. • (Titanium staples allows patients to have MRI scans any time if necessary)

  14. Pneumothorax • 28F or 32F drain is inserted and chest is closed. • No sutures are put around the ribs – to minimise pain in the breast or nipple. • Drains are removed when no air leak for 24hrs,and drainage is <100cc/24hrs. • Pt goes home when pain controlled with oral medication,no fever or complication and is mobile for bathroom and shower.

  15. Pneumothorax • Surgery is usually never recommended for the first pneumothorax,but may be considered if the patient has a complicating factor eg Cystic fibrosis,lives in a remote area,or has infected pleural effusion or haemothorax as well • Surgery is usually recommended for recurrent pnumothoraces. • Post op- pts are advised they can’t scuba.

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