PNEUMOTHORAX

Souheil M. Abdel Nour, MDModerator: Thomas Roy, MDPulmonary and Critical CareEast Tennessee State UniversityDiagnosis and Treatment of Pneumothorax1

Disclosure Statement of Financial InterestI DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

DefinitionsPrimary Spontaneous Pneumothorax (PSP)No underlying lung disease

Secondary Spontaneous Pneumothorax (SSP)Complication of underlying lung disease

Traumatic PneumothoraxCaused by penetrating and or blunt trauma

Iatrogenic PneumothoraxComplication of diagnostic or therapeutic intervention

Pneumomediastinum is the presence of gas in the mediastinal tissues occurring spontaneously or following procedures or trauma.A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary functio3

4PrognosisPrognosis varies among the pneumothorax classificationsRecurrence rate is about 28% for PSP and 43% for SSP over a period of 5 years.Mortality rate of 1-17% in patients with COPD 5% of patients with COPD died before a chest tube was placedPatients with AIDS: inpatient mortality rate of 25% and a median survival of 3 months after the pneumothorax.Difficult Decisions in Thoracic Surgery: An Evidence-based Approach,By Mark K. Ferguson. 2nd ed. 2011Although some authors view PSP as more of a nuisance than a major health threat, deaths have been reported. SSPs are more often life threatening,5PrognosisThe overall mortality was 1.26 per million per year for males and 0.62 per million per year for females.

Epidemiology of pneumothorax in England.Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Thorax. 2000 Aug; 55(8):666-71.Death from pneumothorax is rare.

6Primary Spontaneous Pneumothorax (PSP)No precipitating event No known lung diseaseActually most PSP have unrecognized lung disease (subpleural bleb)

The incidence: men 7.4 (USA) - 37 (UK) per 100,000 population per yearWomen 1 mm thick

Cyst: Thin-walled, air- or fluid-filled, with a wall that contains respiratory epithelium, cartilage, smooth muscle and glands

Bleb: Intrapleural cystic space

Bulla 2bullae(pronounced bully): Thin-walled( LVRS at the same time46Nonsurgical chemical pleurodesisFor patients who refuse VATS or are not operative candidates=> chemical pleurodesis (better than no further intervention)Not as effective as the VATSReduces the SSP recurrence to ~ 15 %Choice of a sclerosant is controversialwe prefer doxycyclineover talc, because we believe it is the safer option [51-53]. The usual intrapleural dose of doxycycline is 500 mg. Technical aspects of chemical pleurodesis are discussed in detail elsewhere47

Am J Respir Crit Care Med. 2000;162(6):2023.Other potential questions!!Lung transplant candidatesAir travelAvoid chemical pleurodesisIt does not preclude future lung transplantation VATS-apical pleurodesis.

Air travel is postponed for at least two weeks in PSP. In SSP ? not known. Simple drainage vs. pleurodesis influences the risk of recurrencePotential in-flight hypoxemia.

Chemical pleurodesis increases the risk of excessive bleeding during transplantation, 49Tube Thoracostomy ManagementSome physiology!!The mechanics of ventilation relate to the negative intrathoracic pressure that draws air into the lungs during spontaneous respiration. This negative pressure is best maintained in the pleural space.Collections of air, fluid, or blood in the pleural space not only compress the lung tissue but also cause the pleural pressures to become positive, causing inappropriate ventilation!51How Chest Tubes Work?!Chest drainage systems work by combining the following 3 efforts:Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough, Valsalva maneuver).Gravity helps fluid drainage as long as the chest drainage system is placed below the level of the patients chest.Suction can improve the speed at which air and fluid are pulled from the chest

52Few points!!ContraindicationsNo absolute contraindications exist for chest drain insertion.RadiographySerial chest radiographs are needed to monitor and confirm the expansion of the lung.AntibioticsAntibiotics are not needed during the presence of a chest drain for a simple pneumothorax or hydrothorax.The antibiotic cephalexin can be used to prevent the development of an empyema when a chest drain has been used in thoracic trauma.

Positioning: Emergent and elective chest drains are usually placed in the triangle of safetyThe safe triangle is the area bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and apex below the axilla

This corresponds to an insertion area between the midaxillary and anterior axillary lines at the level of the nipple.54Drainage System: underwater Seal BottleThe underwater seal bottle is the most important element in pleural drainage. Low -resistance, one-way valve.The underwater seal is an anti-reflux valve. Water can be drawn up the tube only to the height equal to the negative intrathoracic pressure (usually up to -20 cm of water).

The underwater seal is also an anti-reflux valve. Re-entry of air into the pleural space when intrapleural pressures become negative (eg, inspiration), is blocked by the underwater seal. Water can be drawn up the tube only to the height equal to the negative intrathoracic pressure (usually up to -20 cm of water). Therefore, the apparatus must be kept far enough below the patient to prevent water from being sucked up into the chest (100 cm is sufficient).[5]The water in this tube is referred to as the "column" of water; it reflects the changes in intrathoracic pressure with each inspiration and expiration.The end of the tube in the underwater seal bottle must remain covered with water at all times. When a broad-based bottle (eg, Tudor-Edwards) and a narrow tube are used, elevation of the water column in the tube lowers the level in the reservoir by only a very small amount, keeping the seal intact.The end of the tube must not be kept too far below the surface of water because the resistance to expulsion of air from the chest is equal to the length of tubing that is underwater. Keeping the tip of the tube 2-3 cm below the surface of water should be enough to act as a constant valve.[6, 2]The whole system is placed erect, 100 cm below the level of the patients chest. This placement aids gravity drainage of chest contents into the bottle and prevents reentry of fluid into the chest during the upward swing of the fluid in the tube during inspiration

55Drainage System :Trap BottleWhen excessive fluid drains from the chest, the level of fluid in the underwater seal is raised. This increases resistance to further outflow of fluid from the chest.

To decrease this resistance, a trap bottle is introduced between the chest tube and the underwater seal.

Drainage System: suction Regulator BottleTo obtain a suction of -20 cm of water, set the tip of the tube 20 cm below the surface of the fluid. Now, increase the vacuum gradually until air bubbles gently and constantly through the atmospheric vent in the water during both phases of respiration.

The role of suction is now being debated. Some schools of thought say suction delays the sealing of air leaks from the underlying lung

Suction hastens the expansion of the lung. Another bottle is needed to introduce suction regulation to this system.The suction regulator bottle has a 3-hole stopcock. Short tubes are passed through 2 of the holes. One short tube connects to the underwater seal bottles vent tube and the other short tube connects to the suction source. An atmospheric vent runs through the 3rdhole, passing below the level of water in this bottle.When suction is applied, air is drawn down the atmospheric vent in this bottle, equal to the pressure inside the bottle that is decreased by the vacuum. Under stronger vacuum, airflow through the atmospheric vent commences, and air bubbles through the water in the bottle, but the level of suction in the bottle remains the same.This constant level of low pressure suction is now transmitted to the underwater seal bottle and then into the pleural cavity, thus aiding evacuation of contents there, allowing a quicker reexpansion of the underlying lung. The maximum force of suction is determined by the depth of the atmospheric vent underwater in the suction regulation bottle.[2]To obtain a suction of -20 cm of water, set the tip of the tube 20 cm below the surface of the fluid. Now, increase the vacuum gradually until air bubbles gently and constantly through the atmospheric vent in the water during both phases of respiration. A constant pressure of -20 cm of water is now transmitted to the underwater seal and on to the chest drain.The role of suction is now being debated. Some schools of thought say suction delays the sealing of air leaks from the underlying lung

57Multifunction Chest Drainage SystemFollow the manufacturers instructions for adding water to the chambers. This is usually 2 cm in the water seal chamber and 20 cm in the suction control chamber.Slowly increase vacuum until gentle bubbling appears in the suction control chamber.

Follow the manufacturers instructions for adding water to the chambers. This is usually 2 cm in the water seal chamber and 20 cm in the suction control chamber.Connect the 6-ft patient tube to the thoracic catheter.Connect the drain to vacuum.Slowly increase vacuum until gentle bubbling appears in the suction control chamber.Be sure not to allow too much bubbling in the suction control chamber. Excessive bubbling is not needed clinically in 98% of patients. Vigorous bubbling is loud and disturbing to most patients. Vigorous bubbling also causes rapid evaporation in the chamber, which lowers the level of suction

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59Pearls!The collection chamber should be kept below the level of the patients chest at all times.Absence of fluid oscillations may indicate obstruction of the drainage system by clots or kinks, loss of subatmospheric pressure, or complete reexpansion of the lung.Persistent bubbling indicates a continuing bronchopleural air leak.Clamping a pleural drain in the presence of a continuing air leak results in a tension pneumothorax.Clamp tubes only for procedures related to the tube or bottle (eg, to change the tube or bottle, to empty the bottle, to reconnect an accidental disconnection of the tube at any of the joints).

Troubleshooting chest drain managementColumn is not oscillating: Tube has been blockedRestore patency by squeezing, milking, and even flushing the drainage tubingRestoration of patency= respiration-related swing in the draining tube

Tubes got disconnected: Not a great disaster!Reconnect the tubes and ask the patient to cough

Reconnect the tubes and ask the patient to cough; any air that has entered the chest is forced out

61Troubleshooting chest drain managementLeak around the tube:First r/o partial block in the draining systemA single suture may need to be placed along the side of the tube to narrow the wound and seal the leak Use of tapes and heavy dressings to occlude such leaks is not usefulUnderwater seal bottle broken: A broken bottle has to be replaced immediately Then ask the patient to cough.

62Chest Drain ComplicationsBlocked tube due to poor positioning: Trapped in the major fissure of the lungTube needs to be withdrawn and reinserted

Cardiac dysrhythmia: The tube abut the mediastinumTry withdrawing the tube 2-3 cm. If this does not resolve the problem=> reinserted at a separate location.

Chest drain complicationsPersistent pneumothorax: Clear any obstructions and seal any leaks in the drainage system. If no leak or obstruction is found, apply suction of up to -20 cm of water to the drainage system.Infections: Range from wound infection to empyemas. Reflect breaks in sterility and incorrect management of the chest drain.Re-expansion pulmonary edema: Large effusions are drained in a short period of timePrevented by gradual decompression

Collapse , usually by retained sputum Fiberoptic bronchoscopy helps clear secretions and rule out other causes of bronchial obstruction [eg, tumor]

Thickened visceral pleura over the collapsed lung tissueDelayed treatment of an empyemaDecortication

http://www.surgicalcriticalcare.net/Guidelines/chest_tube_2009

Chronic left ptx s/p cabg due to trapped lung. Ct shows left ptx with chest tube in place + adhesions+ thick visceral pleura encasing the collapsed left lung!67

Ptx ex vacuo: Cxr with rul atelectasis and ptx surrounding strictly the atelectatic lobe.After broch and removal of the mucus plu, the ptx disappeared68

Herniated gas filled stomach through left hemidiaphragm mimicking left sided tension ptx69

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