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ALOK SINHA Department of Medicine Manipal College of Medical Sciences Pokhara, Nepal Slide 2 Defined as the presence of air in the pleural cavity Negative intrapleural pressure: ~ 5mm Slide 3 PNEUMOTHORAXSpontaneous: 1. Primary spontaneous P. 2. Secondary spontaneous P. Secondary:Iatrogenictraumatic Slide 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 - Marfans syndrome Defect of connective tissue Slide 5 High arched palate Slide 6 Secondary spontaneous pneumothoraces (SSP) occur in the presence of lung disease COPD COPDTuberculosissarcoidosis cystic fibrosis malignancy idiopathic pulmonary fibrosis Pneumocystis carinii pneumonia [PCP]) in patients with AIDS Sub pleural focus rupturing in pleural cavity Slide 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 Slide 8 Slide 9 Intra pleural pressure (-) Slide 10 Intra pleural pressure (0) Broncho pleural fistula Slide 11 Intra pleural pressure (+) Slide 12 Slide 13 Symptoms: Sudden onset (usually after a bout of coughing) of Sudden onset (usually after a bout of coughing) of Chest pain dyspnoea Asymptomatic when small Asymptomatic when smallSigns: In sever cases low volume pulse with tachycardia In sever cases low volume pulse with tachycardia Collapse & signs of peripheral circulatory failure Collapse & signs of peripheral circulatory failure Cyanosis Cyanosis (See when there is tension pneumothorax) Vitals are normal in closed & open pneumothorax Vitals are normal in closed & open pneumothorax Slide 14 Inspection: Dyspnoea with accessory muscles active Dyspnoea with accessory muscles active Tracheal shift may be visible trails sign Tracheal shift may be visible trails sign Fullness of chest on affected side Fullness of chest on affected side Diminished chest movement Diminished chest movement Slide 15 Palpation: Trachea & medistinum shifted to opposite side Trachea & medistinum shifted to opposite side Vocal fremitus markedly diminished Vocal fremitus markedly diminished Diminished expansion of affected hemithorax Diminished expansion of affected hemithoraxPercussion: Hyper resonant note on the affected side Hyper resonant note on the affected side Liver dullness obliterated: right sided pneumothorax Liver dullness obliterated: right sided pneumothorax Cardiac dullness shifted to opposite side Cardiac dullness shifted to opposite side Slide 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 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 Slide 17 CXR -diagnostic in most cases visible lung edge and absent lung markings peripherally visible lung edge and absent lung markings peripherally increased lucency & hemidiaphragm depression on the affected side increased lucency & hemidiaphragm depression on the affected side CXR appearance may also show features of underlying lung disease Slide 18 CT chest may be required To differentiate pneumothorax from bullous disease To differentiate pneumothorax from bullous disease Useful in diagnosing unsuspected pneumothorax following trauma Useful in diagnosing unsuspected pneumothorax following trauma In looking for evidence of underlying lung disease In looking for evidence of underlying lung disease Slide 19 Slide 20 Slide 21 Partial pneumothorax Slide 22 Slide 23 Determined by 1. Degree of breathlessness & lung collapse 2. Hypoxia 3. Evidence of haemodynamic compromise 4. Presence and severity of any underlying lung disease 5. Pneumothorax size Slide 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 Slide 25 Aspiration Slide 26 Chest Aspiration Slide 27 Suction apparatus Slide 28 Inserting a inter coastal drainage tube 1 Slide 29 2 Slide 30 3 Slide 31 4 Slide 32 5 Slide 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 Slide 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 Slide 35 Slide 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 Slide 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 Slide 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 Slide 39 Patients should not fly for at least 6 weeks. avoid flying for a longer period, e.g. 1 year Advise about flying Slide 40 Advise NEVER TO DIVE in the future, unless patient has undergone a definitive surgical procedure Slide 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 Slide 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) Slide 43 Tension pneumothorax Slide 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 Slide 45 Patients present with Acute respiratory distress & agitation Acute respiratory distress & agitation Hypotension Hypotension Raised jugular venous pressure Raised jugular venous pressure Tracheal deviation away from the pneumothorax side Tracheal deviation away from the pneumothorax side Reduced air entry on affected side Reduced air entry on affected side May present with cardiac arrest (pulseless electrical activity) May present with cardiac arrest (pulseless electrical activity) Acute deterioration in ventilated patients Acute deterioration in ventilated patients Slide 46 Management Give high-flow oxygen Give high-flow oxygen Insert a needle into second intercostal space in midclavicular line on side of pneumothorax 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 Hissing air confirms diagnosis. Aspirate air until the patient is less distressed Insert chest drain in mid axillary line afterwards Insert chest drain in mid axillary line afterwards