PneumothoraxPneumothoraxSisir BottaSisir Botta

M3: Gyn-OncM3: Gyn-Onc

Pneumothorax DefinedPneumothorax Defined Definition – Definition – “What?”“What?”

““Pneumo”- Pneumo”- gasgas “Thorax” – “Thorax” – chest cavitychest cavity

Analagous to Pleural Analagous to Pleural EffusionEffusion

Pathophysiology – Pathophysiology – “How?“How? Pleural space Pleural space

Baseline (-) pressure space Baseline (-) pressure space Parietal PleuraParietal Pleura Visceral PleuraVisceral Pleura

Normal inspirationNormal inspiration DiaphragmDiaphragm Transmit (-) PressureTransmit (-) Pressure

Pathologic inspirationPathologic inspiration XS gas disrupts XS gas disrupts

transmission of (-) pressuretransmission of (-) pressure

Types of PneumothoraxTypes of Pneumothorax Spontaneous PneumothoraxSpontaneous Pneumothorax

Primary -Primary - rupture of subpleural blebrupture of subpleural bleb ““Jimmy is a tall, wiry, 21-year old male, who plays Jimmy is a tall, wiry, 21-year old male, who plays

trombone in the marching band….”trombone in the marching band….” Secondary - Secondary - underlying lung/pleural diseaseunderlying lung/pleural disease

#1 – emphysema#1 – emphysema Chronic bronchitis, asthma, TB, …Chronic bronchitis, asthma, TB, …

Traumatic PneumothoraxTraumatic Pneumothorax OpenOpen

Chest wall is penetrated : outside air enters pleural Chest wall is penetrated : outside air enters pleural spacespace

ClosedClosed Chest wall is intactChest wall is intact Ex. Fractured ribEx. Fractured rib

Types of Pneumothorax 2Types of Pneumothorax 2 Tension PneumothoraxTension Pneumothorax

““Ball-valve mechanism”Ball-valve mechanism” Injury to pleura creates a Injury to pleura creates a

tissue flaptissue flap that opens on that opens on inspiration and closes on inspiration and closes on expirationexpiration

One of our own patientsOne of our own patients VariationsVariations

Hemo-thorax Hemo-thorax Chylo-thorax Chylo-thorax

Injury to thoracic ductInjury to thoracic duct EmpyemaEmpyema

Parapneumonic effusions in Parapneumonic effusions in community-acquired pneumoniacommunity-acquired pneumonia

SymptomsSymptoms DyspneaDyspnea Pleuritic chest painPleuritic chest pain

Nerve endings at pleural capsuleNerve endings at pleural capsule Sense of impending doomSense of impending doom Sudden onsetSudden onset

Tension pneumothoraxTension pneumothorax Spontaneous pneumothoraxSpontaneous pneumothorax

Physical Exam - SignsPhysical Exam - Signs Unstable patients vs. Stable patientsUnstable patients vs. Stable patients

Vital SignsVital Signs Asymmetric chest expansionAsymmetric chest expansion Deviated tracheaDeviated trachea Diminished breath sounds Diminished breath sounds

unilaterallyunilaterally Hyper-resonance unilaterallyHyper-resonance unilaterally Decreased tactile fremitusDecreased tactile fremitus

DiagnosisDiagnosis Unstable patientUnstable patient

ThoracentesisThoracentesis Rapid release of airRapid release of air Vital signs stabilize Vital signs stabilize

rapidlyrapidly

Stable patientStable patient CXRCXR

Monitor size by Monitor size by measuring distance measuring distance from lateral lung from lateral lung margin to chest wallmargin to chest wall

Be sure that Be sure that pneumothorax is not pneumothorax is not expandingexpanding

ImagingImaging Plain RadiographsPlain Radiographs

Upright PA on inspirationUpright PA on inspiration Detect other pathologies: Detect other pathologies:

pneumonia, cardiac, etc.pneumonia, cardiac, etc. Partially collapsed lungPartially collapsed lung Tension PneumothoraxTension Pneumothorax

Trachea and mediastinum Trachea and mediastinum deviate contralaterallydeviate contralaterally

Ipsilateral depressed hemi-Ipsilateral depressed hemi-diaphragmdiaphragm

Chest CTChest CT Not routineNot routine Only to assess the need for Only to assess the need for

surgery (thoracotomy)surgery (thoracotomy)

TreatmentTreatment Small pneumothoraxSmall pneumothorax

Resolve over days to weeksResolve over days to weeks Supplemental oxygen and observationSupplemental oxygen and observation

Tension pneumothoraxTension pneumothorax Immediate decompression via chest tube or Immediate decompression via chest tube or

needle thoracostomyneedle thoracostomy Spontaneous pneumothoraxSpontaneous pneumothorax

Asymptomatic – outpatient, f/u with serial CXRAsymptomatic – outpatient, f/u with serial CXR Symptomatic – inpatient, chest tubeSymptomatic – inpatient, chest tube Recurrent pneumothorax – CT to evaluate Recurrent pneumothorax – CT to evaluate

need for thoracotomyneed for thoracotomy

Tube Tube ThoracostoThoracosto

mymy a.k.a. Chest tubea.k.a. Chest tube

ReferencesReferences Roberts: Clinical Procedures in Roberts: Clinical Procedures in

Emergency Medicine, 4Emergency Medicine, 4thth ed. P. 187- ed. P. 187-203. 2004, Saunders.203. 2004, Saunders.

UpToDate. Stark: Imaging of UpToDate. Stark: Imaging of Pneumothorax, April 7Pneumothorax, April 7thth, 2005., 2005.

Questions??Questions??