3 pneumothorax

11

PNEUMOTHORAXPNEUMOTHORAX

Xie Can MaoXie Can Mao

1st Affiliated Hospital of Sun Yat-sen Universty1st Affiliated Hospital of Sun Yat-sen Universty

22

IntroductionIntroduction

The term pneumothorax was first coined by Itard, The term pneumothorax was first coined by Itard, a student of Laennec, in 1803a student of Laennec, in 1803

Laennec described the clinical picture of Laennec described the clinical picture of pneumothorax in 1819pneumothorax in 1819

He described most pneumothoraces as occurring He described most pneumothoraces as occurring in patients with pulmonary tuberculosis, although in patients with pulmonary tuberculosis, although he recognised that pneumothoraces also he recognised that pneumothoraces also occurred in otherwise healthy lungs, a condition occurred in otherwise healthy lungs, a condition he described as “pneumothorax simple” he described as “pneumothorax simple”

33

IntroductionIntroduction

The modern description of primary The modern description of primary spontaneous pneumothorax occurring in spontaneous pneumothorax occurring in otherwise healthy people was provided by otherwise healthy people was provided by Kjaergard in 1932Kjaergard in 1932

Primary pneumothorax remains a Primary pneumothorax remains a significant global problemsignificant global problem

The incidence is 18-28/100 000 per year for The incidence is 18-28/100 000 per year for men and 1.2-6/100 000 per year for womenmen and 1.2-6/100 000 per year for women

44

IntroductionIntroduction Secondary pneumothorax is associated with Secondary pneumothorax is associated with

underlying lung disease, whereas primary underlying lung disease, whereas primary pneumothorax is notpneumothorax is not

By definition, there is no apparent precipitating By definition, there is no apparent precipitating event in eitherevent in either

Hospital admission rates for combined primary Hospital admission rates for combined primary and secondary pneumothorax are reported in and secondary pneumothorax are reported in the UK at between 5.8/10 000 per year for the UK at between 5.8/10 000 per year for women and 16.7/10 000 per year for menwomen and 16.7/10 000 per year for men

Mortality rates in the UK were 0.62/million for Mortality rates in the UK were 0.62/million for men between 1991 and 1995men between 1991 and 1995

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ContentsContents

What is pneumothoraxWhat is pneumothoraxPathogenesis and mechanismsPathogenesis and mechanismsPathophysiology Pathophysiology Clinical typing Clinical typing Clinical manifestation Clinical manifestation Diagnosis and differentiate diagnosisDiagnosis and differentiate diagnosisTreatmentTreatment

66

What is pneumothoraxWhat is pneumothorax

Pleural cavity is a latent closed space, in Pleural cavity is a latent closed space, in which there is no airwhich there is no air

The total gas pressure of capillaries is 706 The total gas pressure of capillaries is 706 mmHg, 54 mmHg less than atmospheremmHg, 54 mmHg less than atmosphere

Pneumothorax is defined as air in the Pneumothorax is defined as air in the pleural spacepleural space

That is, air between the lung and chest That is, air between the lung and chest wall, or in other term, air between the wall, or in other term, air between the visceral pleura and the parietal pleuravisceral pleura and the parietal pleura

77

Pneumothorax Pneumothorax

88

Classification of pneumothoraxClassification of pneumothorax

Divided into three typesDivided into three types SpontaneousSpontaneous

having an unknown cause or occurring as a having an unknown cause or occurring as a consequence of the nature course of a disease consequence of the nature course of a disease process, such as COPD, tuberculosisprocess, such as COPD, tuberculosis

TraumaticTraumaticfollowing any penetrating or non-penetrating chest following any penetrating or non-penetrating chest trauma, with or without bronchial rupturetrauma, with or without bronchial rupture

Iatrogenic Iatrogenic occurring as the results of diagnostic or therapeutic occurring as the results of diagnostic or therapeutic medical procedure. Intentional or a complicationmedical procedure. Intentional or a complication

99

Spontaneous pneumothoraces are Spontaneous pneumothoraces are subclassified as:subclassified as:Primary spontaneous pneumothorax (PSP)Primary spontaneous pneumothorax (PSP)Healthy people, most young peopleHealthy people, most young peopleSecondary spontaneous pneumothorax (SSP)Secondary spontaneous pneumothorax (SSP)Underlying diseasesUnderlying diseasesChronic obstructive pulmonary disease Chronic obstructive pulmonary disease

(COPD), pulmonary tuberculosis(COPD), pulmonary tuberculosis

Clinical typing of pneumothoraxClinical typing of pneumothorax

1010

Pathogenesis and mechanismsPathogenesis and mechanisms In normal people, the In normal people, the

pressure in pleural space pressure in pleural space is negative during the is negative during the entire respiratory cycleentire respiratory cycle

Two opposite forces Two opposite forces result in negative result in negative pressure in pleural space:pressure in pleural space:

inherent outward pull of inherent outward pull of the chest wall and the chest wall and inherent elastic recoil of inherent elastic recoil of the lung the lung • The negative pressure will

be disappeared if any communication develops

1111

When a communication When a communication develops between an develops between an alveolusalveolus or other or other intrapulmonary air space intrapulmonary air space and pleural spaceand pleural space

air will flow into the air will flow into the pleural space until there pleural space until there is no longer a pressure is no longer a pressure difference or until the difference or until the communication is sealedcommunication is sealed

Pathogenesis and mechanismsPathogenesis and mechanisms

1212

Pathogenesis and mechanismsPathogenesis and mechanisms

When a communication When a communication develops through the develops through the chest wall chest wall between the between the atmosphere and the atmosphere and the pleural space pleural space

air will enter the pleural air will enter the pleural space until the pressure space until the pressure gradient is eliminated or gradient is eliminated or the communication is the communication is closedclosed

1313

Pneumothorax:Pneumothorax: Negative pressure eliminatedNegative pressure eliminated

The lung recoil-small lung-volume decreaseThe lung recoil-small lung-volume decrease V/Q decrease-shunt increaseV/Q decrease-shunt increase

Positive pressurePositive pressure Compress blood vessels and heartCompress blood vessels and heart decreased cardiac outputdecreased cardiac output Impaired venous returnImpaired venous return Hypotension Hypotension Shock Shock

Result inResult in A decrease in vital capacity A decrease in vital capacity A decrease in PaOA decrease in PaO22

PathophysiologyPathophysiology

1414

Thoracoscopic studiesThoracoscopic studiesBlebs Blebs

Air filled spaces between the lung parenchyma and Air filled spaces between the lung parenchyma and the visceral pleurathe visceral pleura


Shows a similar cystic space,completely surrounded by pl

pleura

1515

BullaeBullaeAir filled spaces within the lung parenchyma Air filled spaces within the lung parenchyma

itselfitself


Lung parenchyma

Surrounded by fibrous tissue

BlebsBlebs

Male ， aged 22Admission for“explode dyspnea, left chest pain for 2 weeks” . Historic left pneumotorax.

镜下见：左上叶表面见数个直径 0.5～ 3cm肺大疱，部分随呼吸活动膨大缩小。

BullaeBullae

1717

1818

Blebs and bullae are also known as Blebs and bullae are also known as emphysema-like changes (ELCs)emphysema-like changes (ELCs)

The probable cause of pneumothorax is The probable cause of pneumothorax is rupture of an apical bleb or bullarupture of an apical bleb or bulla

Because the compliance of blebs or bullae Because the compliance of blebs or bullae in the apices is lower compared with that in the apices is lower compared with that of similar lesions situated in the lower of similar lesions situated in the lower parts of the lungsparts of the lungs


1919

It is often hard to assess whether bullae It is often hard to assess whether bullae are the site of leakage, and where the site are the site of leakage, and where the site of rupture of the visceral pleura isof rupture of the visceral pleura is

Smoking causes a 9-fold increase in the Smoking causes a 9-fold increase in the relative risk of a pneumothorax in femalesrelative risk of a pneumothorax in females

A 22-fold increase in male smokersA 22-fold increase in male smokersWith a dose-response relationship With a dose-response relationship

between the number of cigarettes smoked between the number of cigarettes smoked per day and occurrence of PSP per day and occurrence of PSP


2020

Clinical typing of pneumothoraxClinical typing of pneumothorax

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

2121

Clinical manifestation Clinical manifestation

SymptomSymptom Depend on whether underlying pulmonary disease or Depend on whether underlying pulmonary disease or

notnot Depend on the speed of pneumothorax occurred Depend on the speed of pneumothorax occurred Depend on size of pneumothorax Depend on size of pneumothorax Depend on the level of intrapleual pressureDepend on the level of intrapleual pressure

The patient with underlying pulmonary disease The patient with underlying pulmonary disease will undergo severe dyspnea will undergo severe dyspnea

The healthy person will have minimal symptoms The healthy person will have minimal symptoms although having large volume of pneomothoraxalthough having large volume of pneomothorax

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Happened most patients at rest and some Happened most patients at rest and some during heavy exerciseduring heavy exercise

Chest pain-prickling-like, cutting-likeChest pain-prickling-like, cutting-likeHaving an acute onsetHaving an acute onsetAir stimulates pleuraAir stimulates pleura

Dyspnea Dyspnea Collapsed lung and vital capacity decreaseCollapsed lung and vital capacity decrease

Dry coughDry cough Air stimulates pleuraAir stimulates pleura


2424

Tension pneumothoraxTension pneumothorax risk factorsrisk factors

Receiving positive-pressure mechanical Receiving positive-pressure mechanical ventilationventilation

During cardiopulmonary resuscitation During cardiopulmonary resuscitation Undergoing hyperbaric oxygen therapyUndergoing hyperbaric oxygen therapyEvolving during the course of spontaneous Evolving during the course of spontaneous

pneumothoraxpneumothorax


2525

Tension pneumothoraxTension pneumothorax

2626

Tension pneumothoraxTension pneumothoraxDistressed with rapid labored respirationDistressed with rapid labored respirationCyanosisCyanosisMarked tachycardia Marked tachycardia Profuse diaphoresis Profuse diaphoresis

Patient who suddenly deteriorate clinically,Patient who suddenly deteriorate clinically, be suspected if the patient withbe suspected if the patient with

Mechanical ventilationMechanical ventilationCardiopulmonary resuscitationCardiopulmonary resuscitation


2727

Physical examinationPhysical examinationDepend on size of pneumothoraxDepend on size of pneumothoraxDepend on whether pleural effusions or notDepend on whether pleural effusions or notThe vital signs usually normalThe vital signs usually normalThe side with pneumothorax is larger than the The side with pneumothorax is larger than the

contralateral sidecontralateral sideChest moves less during the respiratory cycleChest moves less during the respiratory cycle


2828

Physical examinationPhysical examinationTactile fremitus is absentTactile fremitus is absentThe percussion note is hypersonantThe percussion note is hypersonantThe breath sounds are reduced or absent on The breath sounds are reduced or absent on

the affected sidethe affected sideThe lower edge of the liver may be shifted The lower edge of the liver may be shifted

inferiorly with a right-side pneumothoraxinferiorly with a right-side pneumothoraxThe trachea may be shifted toward the The trachea may be shifted toward the

contralateral side if the pneumothorax is largecontralateral side if the pneumothorax is large


2929

Clinical stabilityClinical stability

Stable patientsStable patients RR: <24/minRR: <24/min HR: 60-120/minHR: 60-120/min BP: normalBP: normal SOSO22: >90% (room air): >90% (room air) Patient can speak in Patient can speak in

whole sentences whole sentences between breathsbetween breaths

All above presentAll above present

Unstable patientsUnstable patients

Not fulfilling the Not fulfilling the definition of stabledefinition of stable

Evaluate the severity and make decision for treatment

3030

Imaging- Plane chest X-ray film Imaging- Plane chest X-ray film

Establishing the diagnosisEstablishing the diagnosis The characteristics of The characteristics of

pneumothoraxpneumothorax Pleural linePleural line No lung markings in No lung markings in

pneumothoraxpneumothorax

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

3131

Plane chest X-ray filmPlane chest X-ray film

In erect patients, pleural In erect patients, pleural gas collects over the gas collects over the apex, and the space apex, and the space between the lung and between the lung and chest wall is most notable chest wall is most notable therethere

In the supine position, In the supine position, gas migrates along the gas migrates along the broad ventral surface of broad ventral surface of lung, making detection on lung, making detection on a frontal radiograph a frontal radiograph difficultdifficult

3232


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

Careful inspection of the Careful inspection of the film may show that the film may show that the artifact extends beyond the artifact extends beyond the thorax, or that lung thorax, or that lung markings are visible markings are visible beyond the apparent beyond the apparent pleural linepleural line

3333


In the absence of In the absence of underlying lung disease, underlying lung disease, the pleural line of a the pleural line of a pneumothorax usually pneumothorax usually parallels the shape of parallels the shape of chest wallchest wall

Artifactual densities Artifactual densities generally do not parallel generally do not parallel the course of the chest the course of the chest wall over their entire wall over their entire lengthlength

3434


Quantification of the sizeQuantification of the size The size of a pneumothorax, in terms of The size of a pneumothorax, in terms of

volume, is difficult to assess accurately volume, is difficult to assess accurately from a chest radiographfrom a chest radiograph

The simple method to estimate the sizeThe simple method to estimate the sizeSmall,Small, a visible rim of < 2 cm between the a visible rim of < 2 cm between the

lung margin and the chest walllung margin and the chest wallLarge,Large, a visible rim of ≥2 cm between the lung a visible rim of ≥2 cm between the lung

margin and chest wallmargin and chest wall

3535

Estimation of pneumothorax volumeEstimation of pneumothorax volume

Light equationLight equationpneumothoraxpneumothorax％＝（％＝（ 11－－ LL33/HT/HT33）） 100100

Kircher equationKircher equationpneumothoraxpneumothorax％％Thorax areaThorax area －－ lung arealung area

Thorax areaThorax area

Collins equationCollins equation4.2+[4.74.2+[4.7(A+B+C)](A+B+C)]

100

Hemithorax (HT)

Lung (L)

3636

BTS guideline(1993)BTS guideline(1993) SmallSmall ModerateModerate largelarge

BTS guideline(2003)BTS guideline(2003) Lung margin to chest Lung margin to chest

wallwall small<2cmsmall<2cm largelarge≥≥ 2cm2cm

ACCP guidelineACCP guideline Lung apex to chest topLung apex to chest top Small <3cmSmall <3cm largelarge≥≥3cm3cm

Estimation of pneumothorax volumeEstimation of pneumothorax volume

3737

Since the volume of a pneumothorax Since the volume of a pneumothorax approximates to the ratio of the cube of the lung approximates to the ratio of the cube of the lung diameter to the hemithorax diameterdiameter to the hemithorax diameter

A pneumothorax of 1 cm on the PA chest A pneumothorax of 1 cm on the PA chest radiograph occupies about 27% of the radiograph occupies about 27% of the hemithorax volumehemithorax volume Lung is 9 cm, hemithorax is 10 cm in diameterLung is 9 cm, hemithorax is 10 cm in diameter

Equation Equation Volume of pneumothorax = (HTVolume of pneumothorax = (HT33 – L – L33) ÷ HT) ÷ HT33

= (10= (1033 – 9 – 933) ÷ 10) ÷ 1033 = (1000 – 729) ÷1000= (1000 – 729) ÷1000= 0.27 = 0.27


3838

A pneumothorax of 2 cm on the PA chest A pneumothorax of 2 cm on the PA chest radiograph occupies about 49% of the radiograph occupies about 49% of the hemithorax volumehemithorax volumeLung is 8 cm, hemithorax is 10 cm in diameterLung is 8 cm, hemithorax is 10 cm in diameter

Equation Equation Volume of pneumothorax = (HTVolume of pneumothorax = (HT33 – L – L33) ÷ HT) ÷ HT33

= (10= (1033 – 8 – 833) ÷ 10) ÷ 1033 = (1000 – 512) ÷1000= (1000 – 512) ÷1000= 0.49= 0.49


3939

CT scanningCT scanning

CT scanning is the most robust approach CT scanning is the most robust approach if accurate size estimates are requiredif accurate size estimates are required

It is only recommended to difficult cases It is only recommended to difficult cases such as patients in whom the lungs are such as patients in whom the lungs are obscured by overlying surgical obscured by overlying surgical emphysemaemphysema

To differentiate a pneumothorax from To differentiate a pneumothorax from suspected bulla in complex cystic lung suspected bulla in complex cystic lung disease disease

4040


bullae

pneumothorax

4141


bullae

pneumothorax

pneumothorax

4242


pneumothorax

4343

CT scanningCT scanningSmall pneumothorax

Subcutaneous emphysema

4444

Differentiation Differentiation

Asthma and obstructive emphysemaAsthma and obstructive emphysemaRepeated wheezing episodeRepeated wheezing episodeDyspnea gradually progressDyspnea gradually progress In the course of disease, if patients In the course of disease, if patients

Onset of severe dyspnea, cold sweat, dysphoriaOnset of severe dyspnea, cold sweat, dysphoriaNo response to bronchial dilators, antibioticsNo response to bronchial dilators, antibiotics

Consider pneumothorax Consider pneumothorax Chest X-ray radiograph to conform the Chest X-ray radiograph to conform the

diagnosisdiagnosis

4545

Goals Goals To promote lung expansion To promote lung expansion To eliminate the pathogenesis To eliminate the pathogenesis To decrease pneumothorax recurrence To decrease pneumothorax recurrence

Treatment options according toTreatment options according to Classification of pneumothoraxClassification of pneumothorax PathogenesisPathogenesis Pneumothorax frequency Pneumothorax frequency The extension of lung collapse The extension of lung collapse Severity of diseaseSeverity of disease Complication and concomitant underlying diseasesComplication and concomitant underlying diseases

Treatment Treatment

4646

Observation - PSPObservation - PSP

Observation along is advised for small, closed Observation along is advised for small, closed mildly symptomatic spontaneous mildly symptomatic spontaneous pneumothoracespneumothoraces

Patients with small PSP and minimal symptoms Patients with small PSP and minimal symptoms do not require hospital admission do not require hospital admission

However, it should be stressed before discharge However, it should be stressed before discharge that they should be return directly to hospital in that they should be return directly to hospital in the event of developing breathlessnessthe event of developing breathlessness

Most patients in this group who fail this Most patients in this group who fail this treatment have secondary pneumothoracestreatment have secondary pneumothoraces

4747

Observation along is only recommend in Observation along is only recommend in patients with small SSP of less than 1 cm patients with small SSP of less than 1 cm depth or isolated apical pneumothoraces depth or isolated apical pneumothoraces in asymptomatic patientsin asymptomatic patients

Hospitalisation is recommended in these Hospitalisation is recommended in these casescases

All other cases will require active All other cases will require active intervention ( aspiration or chest drain intervention ( aspiration or chest drain insertion)insertion)

Observation - SSPObservation - SSP

4848

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

Observation along is inappropriate and Observation along is inappropriate and active intervation is requiredactive intervation is required

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

Observation - PSP or SSPObservation - PSP or SSP

4949

Inhalation of high concentration of oxygen Inhalation of high concentration of oxygen may reduce the total pressure of gases in may reduce the total pressure of gases in pleural capillaries by reducing the partial pleural capillaries by reducing the partial pressure of nitrogenpressure of nitrogen

This should increase the pressure gradient This should increase the pressure gradient between the pleural capillaries and the between the pleural capillaries and the pleural cavitypleural cavity

Thereby increasing absorption of air from Thereby increasing absorption of air from the pleural cavitythe pleural cavity


5050

The rate of resolution/reabsorption of The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25 – spontaneous pneumothoraces is 1.25 – 1.8% of volume of hemithorax every 24 1.8% of volume of hemithorax every 24 hourshours

The addition of high flow oxygen therapy The addition of high flow oxygen therapy has been shown to result in a 4-fold has been shown to result in a 4-fold increase in the rate of peumothorax increase in the rate of peumothorax reabsorption during the periods of oxygen reabsorption during the periods of oxygen supplementation supplementation


5151

Simple aspirationSimple aspiration

Simple aspiration is recommended as first line Simple aspiration is recommended as first line treatment for all PSP requiring interventiontreatment for all PSP requiring intervention

Simple aspiration is less likely to succeed in Simple aspiration is less likely to succeed in secondary pneumothoraces and in this situation, secondary pneumothoraces and in this situation, is only recommended as an initial treatment in is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally small (<2 cm) pneumothoraces in minimally breathless patients under the age of 50 yearsbreathless patients under the age of 50 years

Patients with secondary pneumothoraces Patients with secondary pneumothoraces treated successfully with simple aspiration treated successfully with simple aspiration should be admitted to hospital and observed for should be admitted to hospital and observed for at least 24 hours before dischargeat least 24 hours before discharge

5252

Repeated aspiration is reasonable for Repeated aspiration is reasonable for primary pneumothorax when the first primary pneumothorax when the first aspiration has been unsuccessful aspiration has been unsuccessful

A volume of < 2.5 L has been aspirated on A volume of < 2.5 L has been aspirated on the first attemptthe first attempt

The aspiration can be used by needle or The aspiration can be used by needle or cathetercatheter

Repeated and catheter aspiration Repeated and catheter aspiration

5353

Catheter aspirationCatheter aspiration

Catheter aspiration Catheter aspiration of pneumothorax of pneumothorax can be used where can be used where the equipment and the equipment and experience is experience is availableavailable

5454

Intercostal tube drainageIntercostal tube drainage

Fix the catheter and cover with gauze

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

5555


5656

INDICATIONS INDICATIONS Unstable pneumothoraxUnstable pneumothoraxSevere dyspneaSevere dyspneaLarge lung collapse Large lung collapse Open or tension pneumothoracesOpen or tension pneumothoracesFrequent recurrent pneumothoracesFrequent recurrent pneumothoracesSimple aspiration or catheter aspiration Simple aspiration or catheter aspiration

drainage is unsuccessful in controlling drainage is unsuccessful in controlling symptomssymptoms


5757

Position of intercostal tubePosition of intercostal tubeThe chest tube should be positioned in the The chest tube should be positioned in the

uppermost part of the pleural space, uppermost part of the pleural space, where residual air accumulates where residual air accumulates

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


5858

The site of chest The site of chest tube insertion is in tube insertion is in the midclavicular the midclavicular line of second and line of second and third intercostalthird intercostal

or anterior axillary or anterior axillary line of fifth and line of fifth and sixth intercostalsixth intercostal


5959

Guidewire tube thoracostomy Guidewire tube thoracostomy

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

6060

Introduction of 18-Introduction of 18-gauge needle into gauge needle into the pleural spacethe pleural space


6161

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


6262

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


6363

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


6464

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


6565

Trocar tube thoracostomy Trocar tube thoracostomy

Insertion of trocar into the pleural spaceInsertion of trocar into the pleural spaceNote the position of the hands, the position Note the position of the hands, the position

of the trocar relative to the ribsof the trocar relative to the ribs

6666

Trocar tube thoracostomy Trocar tube thoracostomy

Insertion of the chest tube through the Insertion of the chest tube through the trocar trocar

6767

Operative tube thoracostomyOperative tube thoracostomy

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

Is it brutal?No!

6868

Placement of chest Placement of chest tube intrapleurally tube intrapleurally using large using large hemostat hemostat

Operative tube thoracostomyOperative tube thoracostomy

6969

Drainage system Drainage system

7070

One bottle systemOne bottle system

Consists of one bottle that serves as both a Consists of one bottle that serves as both a collection container and a collection container and a water sealwater seal

The chest tube is connected to a rigid straw The chest tube is connected to a rigid straw inserted through a stopper into a sterile bottleinserted through a stopper into a sterile bottle

Enough sterile saline solution is instilled into the Enough sterile saline solution is instilled into the bottle so that the tip of the rigid straw is about 2 bottle so that the tip of the rigid straw is about 2 cm below the surface of the saline solutioncm below the surface of the saline solution

The bottle’s stopper must have a vent to prevent The bottle’s stopper must have a vent to prevent pressure from building up when air or fluid pressure from building up when air or fluid coming from the pleural space enters the bottlecoming from the pleural space enters the bottle

7171

One bottle systemOne bottle system

7272

This system works as followThis system works as followWhen the pleural pressure is positive, the When the pleural pressure is positive, the

pressure in the rigid straw becomes positivepressure in the rigid straw becomes positive If the pressure inside the rigid straw is greater If the pressure inside the rigid straw is greater

than the depth to which the straw is inserted than the depth to which the straw is inserted into the saline solution, air will enter the bottleinto the saline solution, air will enter the bottle

Air will be vented to the atmosphere Air will be vented to the atmosphere If the pleural pressure is negative, saline will If the pleural pressure is negative, saline will

be drawn from the bottle into the rigid straw be drawn from the bottle into the rigid straw and no extra air will enter the system and no extra air will enter the system

One bottle system One bottle system

7373

Three bottle systemThree bottle systemThree bottle system consists of Three bottle system consists of

Collection bottle – for collecting pleural fluidCollection bottle – for collecting pleural fluid Water seal bottle – for regulating pressureWater seal bottle – for regulating pressure Suction control bottle – connect to the negative Suction control bottle – connect to the negative

pressure pump, for suction of the air of pleural space, pressure pump, for suction of the air of pleural space, pres level: -10 - -20 cm Hpres level: -10 - -20 cm H22OO

7474

When suction is applied to the suction-control When suction is applied to the suction-control bottle, air enter this bottle through its rigid straw bottle, air enter this bottle through its rigid straw if the pressure in the bottle is more negative if the pressure in the bottle is more negative than the depth to which the straw is submergedthan the depth to which the straw is submerged

Three bottle systemThree bottle system

7575

Observation of drainageObservation of drainage

No bubble released No bubble released The lung reexpansion The lung reexpansion The chest tube is obstructed by secretion or blood clotThe chest tube is obstructed by secretion or blood clot The chest tube shift to chest wall, the hole of the The chest tube shift to chest wall, the hole of the

chest tube is located in the chest wall chest tube is located in the chest wall

If the lung reexpansion, removing the chest tube If the lung reexpansion, removing the chest tube 24 hours after reexpansion24 hours after reexpansion

Otherwise, the chest tube will be inserted again Otherwise, the chest tube will be inserted again or regulated the position or regulated the position

7676

Complications of intercostal tube Complications of intercostal tube drainagedrainage

Penetration of major organsPenetration of major organsLung, stomach, spleen, liver, heart and great Lung, stomach, spleen, liver, heart and great

vesselsvessels It occurs more commonly when a sharp metal It occurs more commonly when a sharp metal

trocar is inappropriately appliedtrocar is inappropriately appliedPleural infectionPleural infection

Empyema, the rate of 1%Empyema, the rate of 1%Surgical emphysema Surgical emphysema

Subcutaneous emphysemaSubcutaneous emphysema

7777

Chemical pleurodesisChemical pleurodesis

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

adhesionsadhesions IndicationsIndications

Persist air leak and repeated pneumothoraxPersist air leak and repeated pneumothoraxBilateral pneumothoracesBilateral pneumothoracesComplicated with bullaeComplicated with bullaeLung dysfunction, not tolerate to operationLung dysfunction, not tolerate to operation

7878


Sclerosing agentsSclerosing agents TetracyclineTetracycline MinocyclineMinocycline Doxycline Doxycline Talc Talc Erythromycin Erythromycin

The instillation of sclerosing agents into the The instillation of sclerosing agents into the pleural space should lead to an aseptic pleural space should lead to an aseptic inflammation with dense adhesions, leading inflammation with dense adhesions, leading ultimately to pleural symphysisultimately to pleural symphysis

7979

Methods Methods Via chest tube or by surgical mean Via chest tube or by surgical mean Administration of intrapleural local anaesthesia, 200 – Administration of intrapleural local anaesthesia, 200 –

400 mg lidocaine intrapleurally injection400 mg lidocaine intrapleurally injection Agents diluted by 60 – 100 ml salineAgents diluted by 60 – 100 ml saline Injected to pleural space Injected to pleural space Clamp the tube 1 – 2 hoursClamp the tube 1 – 2 hours Drainage againDrainage again Observed by chest X-ray film, if air of pleural space is Observed by chest X-ray film, if air of pleural space is

absorption, remove the chest tubeabsorption, remove the chest tube If pneumothorax still exist, repeated pleurodesisIf pneumothorax still exist, repeated pleurodesis


8080

Side effctSide effctChest painChest painFeverFeverDyspneaDyspneaAcute respiratory distress syndromeAcute respiratory distress syndromeAcute respiratory failureAcute respiratory failure


8181

Surgical treatmentSurgical treatment

IndicationIndication No response to medical treatmentNo response to medical treatmentPersist air leakPersist air leakHemopneumothorax Hemopneumothorax Bilateral pneumothoracesBilateral pneumothoracesRecurrent pneumothoraxRecurrent pneumothoraxTension pneumothorax failed to dainageTension pneumothorax failed to dainageThicken pleura makes lung unable to Thicken pleura makes lung unable to

reexpansionreexpansionMultiple blebs or bullaeMultiple blebs or bullae

8282

Complications of pneumothorax Complications of pneumothorax

PyopneumothoraxPyopneumothorax Caused by aspiration or intercostal chest tube Caused by aspiration or intercostal chest tube

insertion (iatrogenic)insertion (iatrogenic)Also results from necrotic pneumonia, lung Also results from necrotic pneumonia, lung

abscess, or caseous pneumoniaabscess, or caseous pneumoniaChest X-ray shows hydropneumothoraxChest X-ray shows hydropneumothoraxThe pleural effusion is purulent The pleural effusion is purulent Antibiotics and intercostal drainageAntibiotics and intercostal drainageSurgical meanSurgical mean

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HemopneumotoraxHemopneumotorax Bleeding in pleural spaceBleeding in pleural spaceCommon cause is rupture of vessels in Common cause is rupture of vessels in

adhesionsadhesionsWhen lung reexpansion, bleeding will stopWhen lung reexpansion, bleeding will stop

When bleeding persists, surgical ligation When bleeding persists, surgical ligation will be neededwill be needed

Infusion Infusion

Complications Complications

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Mediastinal and subcutaneous emphysemaMediastinal and subcutaneous emphysemaAlveoli rupture, the air enter into pulmonary Alveoli rupture, the air enter into pulmonary

interstitial, and then goes into mediastinal and interstitial, and then goes into mediastinal and subcutaneous tissues subcutaneous tissues

After aspiration or intercostal chest tube After aspiration or intercostal chest tube insertion, the air enters the subcutaneous by insertion, the air enters the subcutaneous by the needle hole or incision – surgical the needle hole or incision – surgical emphysemaemphysema

Physical exam – crepitus is present Physical exam – crepitus is present


8787Pneumomediastinum

PneumocardiumPneumoperitoneumSurgical emphysema


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Subcutaneous emphysema

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complicationscomplications

Treatment Treatment Automatic absorption when pneumothorax is Automatic absorption when pneumothorax is

gone gone Inhalation of high concentration of oxygenInhalation of high concentration of oxygenMaking a small incision in suprasternal pit for Making a small incision in suprasternal pit for

draining the air from mediastinal and draining the air from mediastinal and subcutaneous tissuessubcutaneous tissues

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Case studyCase study

Female, 20Female, 20 Chest pain 3 hours, Chest pain 3 hours,

and suddenly and suddenly dyspneadyspnea

CyanosisCyanosis Marked tachycardia Marked tachycardia Profuse diaphoresis Profuse diaphoresis

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Questions Questions

The diagnosis isThe diagnosis is

A. PSPA. PSP

B. SSPB. SSP

C. pulmonary C. pulmonary embolism embolism

D. Asthma episode D. Asthma episode

The type of The type of pneumothorax ispneumothorax is

A. closedA. closed

B. openB. open

C. tension C. tension

D. hemothoraxD. hemothorax

Questions Questions

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Which choice is Which choice is rightright

A.A. Stable Stable

B.B. unstableunstable

Which treatment is Which treatment is the first stepthe first step

A. oxygen inhalationA. oxygen inhalation

B. bronchial dilatorsB. bronchial dilators

C. aspirationC. aspiration

D. chest tube D. chest tube drainagedrainage

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Case studyCase study

Male, 70Male, 70 Dyspnea 24 hoursDyspnea 24 hours No chest painNo chest pain COPD history 20 ysCOPD history 20 ys CyanosisCyanosis Marked tachycardiaMarked tachycardia

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Questions Questions

The diagnosis isThe diagnosis is

A. AECOPDA. AECOPD

B. asthma episodeB. asthma episode

C. PSPC. PSP

D. SSPD. SSP

Which treatment Which treatment preferprefer

A. oxygen therapyA. oxygen therapy

B. aspirationB. aspiration

C. chest tube C. chest tube

D. surgical procedure D. surgical procedure

3 pneumothorax

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