pneumothorax ..jack

PNEUMOTHORAX

Dr.JAKEER HUSSAINM.D,DNB

PNEUMOTHORAX--intro

Presence of air in da pleural cavity with secondary collapse of surrounding lung.

occurs due2 loss of integrity of either visceral r parietal pleura, r both.

this term was used 1st in doctoral thesis,french physician ITARD, in 1803.

In 5centuryBC, greek physician practisedHIPPOCRATIC SUCCUSSION of da chest.

PNEUMOTHORAX

Overdisten of norm lungs results in rupt of subpleu alveoli.Air dissect- bronchoalveolar sheath medially –

pneumomediastinum, subcutaneous emphysema,PTX. peripheral dissection of air = aircontaining space within r

below da visceral pleura. BULLA lined partly by thickened fibrotic pleura n partly by

fibrous tissue within lung. BLEB situated within da pleura. Periph bullae r blebs –distended n rupture in2 pleu space=

PNEUMOTHORAX.

PNEUMOTHORAX

MAIN PHYSIOLOGICAL EFFECTS↓vital capacity of lung, ↓PaO2,

↓ TLC, FRC,diffusing capacity of lungs.↓in PaO2,impaired exercise tolerance↓ in cardiac outputall these more in tension PTX.

PNEUMOTHORAX– X-rays

PNEUMOTHORAX—CT-Scan

PNEUMOTHORAX

CLASSIFICATION

PNEUMOTHORAX

SPONTANEOUS

TRAUMATIC

PNEUMOTHORAX

SPONTANEOUS

PRIMARY SPONTANEOUS

SECONDARY SPONTANEOUS

TRAUMATIC

PNEUMOTHORAX

SPONTANEOUS

PRIMARY SPONTANEOUS

SECONDARY SPONTANEOUS

TRAUMATIC

IATROGENIC

NON IATROGENIC

PNEUMOTHORAX

SPONTANEOUS

PRIMARY SPONTANEOUS

SECONDARY SPONTANEOUS

TRAUMATIC

IATROGENIC

ACCIDENTAL

ARTIFICIAL

NON-IATROGENIC

PRIMARY SPONTANEOUS PNEUMOTHORAX

PRIMARY SPONTANEOUS PNEUMOTHORAX:PTX without preceding trauma & without underlyingclinical or radiologic evidence of lung disease. age 18 – 40 years . Incidence 7.4/m,, 1.2/f tall n thin pts,, apical blebs rupture. 80-90% ass č smoking, x9 folds risk. changes in atm press, proximity to loud noise, sharp innerborder of 1st n 2nd rib.

PRIMARY SPONTANEOUS PNEUMOTHORAX

familial association. 10%,mutations in gene encoding folliculin (FLCN)

BIRT HOGG DUBE Syndrome: beningn skin growth,pulmonary cysts, & renal cancers.

specific HLA-A2,B40, antitrypsin phenotypes M1,M2

incresed levels of HYDROXYPROLINE.

SECONDARY SPONTANEOUS PNEUMOTHORAX

SECONDARY SPONTANEOUS PNEUMOTHORAX: occurs in pts č underlying pulmonary structural

pathology. air enters da pleural space via distended,damaged

or compromised alveoli. presents c serious clinical symptoms.

SECONDARY SPONTANEOUS PNEUMOTHORAX

SECONDARY SPONTANEOUS PNEUMOTHORAX: COPD or emphysema, ASTHMA. CYSTIC FIBROSIS. ILD BRONCHOGENIC or METASTATIC CARCINOMA COLLAGEN VASCULAR Ds incl MARFAN SYNDROME. PNEUMONIA (fungal,HIV,caseating) CATAMENIAL PNEUMOTHORAX.

IATROGENIC PNEUMOTHORAX

IATROGENIC PNEUMOTHORAX:medical procedures resulting in traumatic PTX.

IATROGENIC PNEUMOTHORAX

IATROGENIC PNEUMOTHORAX causes: Trans-thoracic needle aspiration procedures. Thoraco centesis CV Catheter insertion (sub,supraclavicular, IJV) Mechanical ventillation (peak airway pressure) Pleural & transbronchial lung biopsy. Tracheostomy. CPR (if ventillation becomes progressively more diff)

ARTIFICIAL IATROGENIC PTX

ARTIFICIAL IATROGENIC PNEUMOTHORAX: Deliberate intro of air inda pleural cavity,by needle. devised by FORLANI in 19th cent. MAXWELL BOX used 2 treat pulm TB, before da ATT.

TRAUMATIC PNEUMOTHORAX

TRAUMATIC PNEUMOTHORAX: stab r gunshot wounds blunt chest inj in RTAs explosions

TENSION PNEUMOTHORAX

TENSION PNEUMOTHORAX is present when intrapleural pressure is greater than atmosp pressthroughout expiration & often during inspiration.

One way value machanism develops.. TPTX can occur after anytype of PTX. m.c after traumatic PTX. C mech ventillation.

during CPR.

TENSION PNEUMOTHORAX

When the pleural pressure is positive throughout respiratory cycle

“Ball-valve mechanism”

Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration

TENSION PNEUMOTHORAX

SIGNS N SYMPTOMS severe dyspnea, tachycardia, profuse diaphoresis cyanosis, hypotension, exhibit distended neck viens tracheal deviation,subcutaneous emphysema, unilateral chest hyperinflation. Widend IC spaces. ABG – severe hypoximia, resp acidosis. chest X-ray – mediastinal shift to opp.

Rx - TENSION PNEUMOTHORAX

• High flow O2.• clinical confirmation of PTX- needle aspir 2nd IC• Immeadiate tube thoracostomy.

SIGNS & SYMPTOMS

Clinicalfeatures-SymptomsSharp,stabbing unilateral chest pain

exacerbates by deep inspiration,postural change

shortness of breathmild in PS-PTX, severity on sizein SS-PTX , dyspnea not on size.

cough dry –irritation of da diaphragm.generalised malaise.

SIGNSPERCUSSIONhyper resonance on affected side.

AUSCULTATIONdiminished breath soundsdecreased vocal resonance COIN soundscratch sign.

PTX in mech ventillated pt

sudden onset of tachy, hypotension increase in peak airway pressure sudden decline in o2 sat. distressed pt appers to fight c da

ventillator. if pt on pressure control mode n

paralysed, ABG shows resp acidosis. As pt cant increase his resp rate.

TitleECG pt of tension PTX,STseg elevation in II, III, Avf, V4-6,c neg cardiac enzymes. Reversible after chest tube.

Radiological signs – X ray A linear shadow of visceral pleura

with lack of lung markings peripheral to the shadow

Sharply defined lung edge convex outwards.

supine chest X-ray deep sulcus sign.very dark n deep costophrenic angle.

PNEUMOTHORAX – Xray

PNEUMOTHORAX X-ray supine.

Radiological signs –CT scanin PSPTX pts CT detects multiple blebs n bullae.

More sensitive for hemithorax, pulm contusionDistinguish btw a large bulla and a PTX &

underlying emphysema or emphysemalike changes.

Calculate exact size of PTX, esp smallPTXcan detect occult pneumothorax.

X-ray --------- CT-scan

??? PNEUMOTHORAX ,,, ?side

PNEUMOTHORAX – Lt.side

Occult PTX: A PTX identified on a CT scan dat was not seen on a preceeding

supine chest Xray AP view

Radiological signs - usgUSG used as bedside technique to detect PTXused in unstable pts, who cant b shift outside

for xrays., ct scan.acute care setting as a readily available bedside

tool, especially in ICU and emergency departments

Differential diagnosisACSARDSASTHMA,COPD,EMPHYSEMACHF, Pulm oedemaEsophagal perforation,tear,ruptureForeign bodies, tracheaMediastenitisMyocarditis, MI,Pericarditis,

Differential diagnosisPleural effusionPneumonia aspiration, bacterial, viral, pulmonary embolism.

QuantificationLIGHTS METHOD

Pneumothorax %

Size of PTX: ratio of lung diameter cubedto hemithorax diameter cubed

Quantification

Quantification

RHEA METHOD:

it uses a nomogram, that relates da average intrapleural distance to the pneumothorax size.

On this nomogram there is 10% pneumothorax for every cm of intrapleural distance.

Quantification BTS guidelines…Distance btw pleura n chestwall…

less than 1cm – small1-2 cm - moderate

greater than 2 – large.

Quantification ACCP-measuring distance from da apex

of lung to the top margin of davisceral pleura (thoracic cupola). On xray

small PTX – less than 3cm. large PTX – greater than 3cm.

TREATMENT

MANAGEMENT

Of PNEUMOTHORAX

treatment

Aim of treatment of primary spont PTX to rid da pleural space of its air achieve closure of da leak. either prevent r reduce this risk. to decrease da likelihood of a recurrance.

treatment

Observation supplemental oxygen simple aspiration tube thoraco-stomy č/čout sclerosing agent medical thoraco-scopy č da insufflation of talc video assisted thoraco-scopy č staplin of blebsInstillation of sclerosing agent or pleural abrasionOpen thoraco-tomy

treatment

The choice of therapy depends on: clinical status of da ptCause of da pneumothoraxEvidence of concomitant lung dsPrior history of pneumothorax, r risk of recurrenceAvailability of specific therapeutic optionsexperience n prefered techniques of da physician

OBSERVATION

OBSERVATIONRate of spontaneous reabsorbtion is slow,Kircher n Swartzel- 1.25% of vol was absor every 24 hso PTX occup 15% of hemithorax take 12 days recomended only for pts č PTX less than 15%asymptomatic, unilateral.

O2 Supplementation

SUPPLEMENTAL O2admin of o2 accelerates da rate of pleural air

absorption .Northfield- rate of absorp on ↑ 4 mes č 02

O2 high conc recomended for hosp pts..

O2 Supplementation

Rate of gas reabsorption depends on: press gradient for da gases

btw pleu space to venous blood diffusion properties of da gases area of contact btw pleural gas n pleura permeability of da pleural surface…

(thickend,fibro c pleura will absorb ↓normal pleura)

SIMPLE ASPIRATION

ASPIRATIONinitial Rx of pts if PTX > 15%16 G needle – ( 2nd IC ,M.C.line), (4-5th IC, M.A.line)use a 3 way,This procedure is done in emergency in tension ptx ,

to relive pressure. As emergency decompression.

SIMPLE ASPIRATION

When no more air can be aspirated or the patient suddenly coughs, the lung most likely has reexpanded

Remove the catheter, and massage the insertion site with sterile gauze to seal the channel into the pleural space .

Devanand et all- metaanalysis –simple aspiration is adv than ICD – shorter hospitalization.

Noppen – recurr rate c aspiration is 19%

SIMPLE ASPIRATION

TUBE THORACOSTOMY

TUBE THORACOSTOMY Air in pleural space canbe rapidly evacuated.positioned in da uppermost part of pleural space.mc site is 2nd IC space in Mid-Clavicular line.now- 4,5th IC space btw ant n post axillary lines.

TUBE THORACOSTOMY

Indications for ICD in SPTX tension pneumothorax presence of dyspnea Intermittent positive pressure ventillation Prev contralateral pneumothorax b/l pneumothoraces, or large pneumothorax Presence of pleural fluid failed manual aspiration

TUBE THORACOSTOMY

Placement of ICD irritate pleura – partial pleurodesisthus ↓ recurrence of PTX.

treat c small tubes 14F as insertion less traumatic.if lung not expanded in 48hrs –large tubes be placed

TUBE THORACOSTOMY

TT C Instillation of SCLEROSING AGENTS:Injec n sclerosin agents ↓recurrence rates of PTXIt create intense inflam reaction – obliterate pl space.Agents – quinacrine, talc slurry, olive oil, bleomycin

silver nitrate, tetracycline.best are – TALC SLURRY, TETRACYCLINE derivatives.

injected as soon as lung has reexpanded.

TUBE THORACOSTOMY

TALC SLURRY: 5 – 10 gms in 250ml of saline intrapleurallyvery effective as a slurry via chest tubetalc poudrage during thoracoscopy.meta analysis shows success rate of 91%.can be performed easily at bedside.inhomogeniety in distru – loculation n incomple symphysis.

↑incidence of ARDS, size of talc particles (↓15mm), dose(↑5g) ass c higher incidence of ARDS.

TUBE THORACOSTOMY

TETRACYCLINES.Minocycline – 600mg in 50-100ml of saline.Doxycycline – 500 mg in 50 -100ml of saline.very effective, c less recurrence rate.injected as lung re expanded, n position da pt so dat tetracycline comes incontact c apical pleura

very painful intrapleural injection.

MEDICAL THORACO SCOPY

MEDICAL THORACO SCOPY:performed ↓local anesthesia, r c conscious sedation.cost effective than drianage alone. Tschopp et all –recurrance rate is 7.5%

MT c talc recurrance rate is 5%.in MT blebs were not treated.

VATS

VATS performed ↓ GA. c double lumen ET tube.c single lung ventillation – collapse of operated lung.

AIM to treat bullous ds responsible for PTXto create pleurodesis.

bullae r treated c an endoscopic stapling device. very less recurrence rate than electrocoagulation, r ligation c Roeder loop

VATS

OPEN THORACO TOMY

THORACOTOMY – ultimate n most eff therapy fot PTXallows examination of lung for da site of an air leak

lysis of prev adhesions – (loculated PTX)enables release of fibrotic peel pleura is scarified, ---↓↓recurance rate.

recurrance rate is < 2%.thoracotomy recom only after failed thoracoscopy.

OPEN THORACO TOMY

potential risk ass c GA,increased costs, significant pt discomfort.more severe c lateral r post lateral thoracotomy

c muscle division n rib spreading.nowadays smaller incisions –muscle sparing thoracotomies

mini axillary thoracotomy performed.open thoracotomy still remains valuable option for

complicated cases

recommendations

If PTX small, pt asymptomatic – OBSERVATIONIf pt near hospital – high flow O2 supplementation.If PTX >15% - aspiration – if successful- discharge pt.if unsuccessful – plan thoraco scopy if both medical n VATS avail – VATS prefered (blebs)if rec PTX- thoracoscopy – in pilots, divers - fatal PTXif no thoracoscopy - tube thoracostomy c doxy.

Rx of SS-PTX

PTX in pts c lung ds is life threatening.aim is to get rid of air in pleural space, ↓recurrence.ASPIRATION is NOT recommended.every pt – hospitalised, plan TUBE THOROCO STOMY.in SS PTX, tube thoracostomy less effecttive, than PS PTXdelayed lung expansion n persistant air leaks.in COPD meantime 5days for lung expansion.in 20% SS PTX pts air leak lasts for 7 days,

Rx of SS-PTX

After lung expansion – prevent recurrence of PTX.VATS (stapling of blebs,pleu abrasion) as recurence rate < 5%.medical thoracoscopy c talc insufflation.mini thoracotomy good alternative to thoracoscopy.BTS guidelines: Open thoracotomy & repair.

thoracoscopy reserved for pts c poor lung funct, not fit.intrapleural inj of doxy through chest tube ↓50 to 30%.

(only if above procedures not available.)

CATAMENIAL PNEUMOTHORAX

Recurrent PTX in women in 30 -40 s during periodswith incidence 3 – 6%, occurs within 48- 72hrs.c/o chestpain, dyspnea.ass c mental n physical stress.90% on rt side, but b/l, lt side PTX also occurs.diaphragm defects,Ectopic endometriosis in subpleural area.

CATAMENIAL PNEUMOTHORAX

Medical rxSupress da ectopic endometrium using ocps

supress ovulation,, danazol.GnRH agonists used 2 supress CP,,,Lupron

Surgical rxThoracoscopy-closure of diaph def, stapling blebs, pleural

abrasions, -- diaphragm mesh (bagan)Hysterectomy c b/l oopherectomy induce surg menopause

PTX 2 CYSTIC FIBROSIS

SSPTX is frequently seen in pts c CYSTIC FIBROSIS.Incidence is 6%, c mean age of 1st episode 21.9 yrFreq seen in pts c severe resp impairement, ↑age.FEV1 < 40% seen in 75% of pts c PTX.

↑press, vol in alveoli due2 mucous pluggin n inflam of prox airways leadin to rupture inda pleural space.

Rx to prevent recurrence..

initially stabalised c tube thoracostomy .

PTX 2 CYSTIC FIBROSIS

thoracoscopy if persistant air leak, lung not expands for 3 days after tube thoracostomy.

As many pts require lung transplantation, procedure of choice is VATS c staplin of blebs, &

pleural abrasion.

PTX 2 Lymphangio leiomyomatosis

LAM rare condition, char by peribronchial, perivascular,& perilymphatic proliferation of abnormal smooth muscle cells.

affects women of child bearing age. Incidence 66%.presents c progressive dyspnea, chylothorax,

recurrent SPTX, hemoptysis….Rx VATS,c stapling of blebs, n pleural abrasion.

COMPLICATIONS

TENSION PNEUMOTHORAXBRONCHO – PLEURAL FISTULARe expansion PULM OEDEMAHEMO THORAXPYO THORAX.

Title

BRONCHO PLEURAL FISTULA

BRONCHOPLEURAL FISTULA. Rare but serious.a communication btw pleural space n bronchial tree.usually airleak seals within 24-48 hrs.only 3- 5% have persistant air leak.

pts c COPD, cystic fibrosis- ↑risk of persistant BPF.

BRONCHO PLEURAL FISTULA

ACCP guidelines recommend – if leak for 4 days, pt should be evaluated for Sx, to close airleak n perform pleurodesis to prevent recurrence.

THORACO SCOPY preff - to prevent recurrence.Pts not fit for Sx - BPF localised by bronchoscopic

baloon cath occlusion, n injected to seal airleak.fibrin glue, liquid bioadhesive, sterile gelatin sponge, lead shot, & autologous blood patch.

Title

Re expansion pulmonary oedema

REEXPANSION PULM EDEMA: rare , potentially fatalcondition that occur after rapid reexpansion of collapsed

lung. Usually in long standing PTX.usually unilateral.due to ↑permeability of pulm capillaries that r damagedby mechanical stress during re expansion of lung.reperfusion inj due 2 free radicals, decreased surfactant.

ischemic reperfusion inj, airway obstruc on, ↓lymp flow.

Re expansion pulmonary oedema

REPE depends on duration(3days), severity of PTX,method (suction) &rate of expansion.

symptoms- severe cough, chest pain.within an hr.hypoximia,tachypnea,tachycardia, hypotension.last for 24 – 48 hrs only.

Rx supportive, c high flow O2.try to prevent. (c no negative pressure.)

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