Pneumothorax Flashcards
What is Pneumothorax and how is it classified?
• Pneumothorax is the presence of air in the pleural space.
It is classified as;
• Spontaneous pneumothorax: Develops
without preceding trauma or other obvious
cause.
• Traumatic pneumothorax: Develops as a
result of trauma to the chest, including
diagnostic or therapeutic maneuvers (i.e.
iatrogenic)
What is the classification of pneumothorax?
• Spontaneous pneumothoraxes are
subclassified as primary or secondary.
• A primary spontaneous pneumothorax
presents in an otherwise healthy person
without underlying lung disease.
• A secondary spontaneous pneumothorax
complicates an underlying lung disease, most commonly chronic obstructive pulmonary disease (COPD).
What is Primary spontaneous pneumothorax?
• Usually due to rupture of apical pleural blebs (small cystic spaces that lie within or
immediately under the visceral pleura).
• It occurs almost exclusively in smokers.
• It is common in young, tall and thin males
• Recurrence of (PSP) is common (~50%)
What is Secondary pneumothorax?
• Most are usually due to chronic obstructive pulmonary disease
• Pneumothoraxes have however been reported with virtually every lung disease.
• Pneumothorax in patients with lung disease is more life-threatening than it is in normal individuals because of the lack of pulmonary reserve in these patients
Types of Spontaneous Pneumothorax
• Closed
• Open
• Valvular (tension)
What is Closed spontaneous pneumothorax?
• The communication between the lung and pleural space seals off as the lung deflates and does not reopen.
• The mean pleural pressure remains negative.
• Air in the pleural space gets reabsorbed
spontaneously, the underlying lung re-
expands over a few days or weeks.
• Infection is rare
What is Open pneumothorax?
• The communication between the lung and pleural space fails to seal
• Air continues to move freely between the lung and pleural space.
• Usually develops following rupture of a
tuberculosis cavity, an emphysematous bulla or lung abscess into the pleural space.
• The mean pleural pressure remains equal to atmospheric pressure; lung cannot expand.
• Bronchopleural fistula, spread of infection
from the airways into the pleural space
resulting in empyema are common.
What is Tension pneumothorax?
• The communication between the airway and the pleura acts as a one-way valve allowing air to enter the pleural space during inspiration but not to escape on expiration.
• This results in large amounts of air being
trapped in the pleural space
• The intrapleural pressure may become more than the atmospheric pressure.
• This may cause mediastinal shift towards the opposite side, compression of the opposite normal lung, impairment of systemic venous return and may result in cardiovascular compromise.
• It usually occurs during mechanical ventilation or resuscitative efforts.
What is Traumatic pneumothorax?
• It can result from both penetrating and
nonpenetrating chest trauma.
• Iatrogenic pneumothorax is a type of
traumatic pneumothorax that is becoming
more common.
• The leading causes of iatrogenic
pneumothorax are transthoracic needle
aspiration, thoracentesis, and the insertion of central intravenous catheters
CLINICAL FEATURES
• The most common symptoms are sudden-onset unilateral pleuritic chest pain or breathlessness.
• Breathlessness may be mild and resolve
spontaneously or it may be severe (especially in patients with underlying chest disease) and fail to resolve spontaneously.
• In patients with a small pneumothorax,
physical examination may be normal.
• Decreased or absent breath sounds may be seen in patients with a large pneumothorax (>15% of the hemithorax)
• The combination of absent breath sounds and hyperresonant percussion note is diagnostic of pneumothorax.
• Tension pneumothorax manifests with rapidly progressive breathlessness associated with the following;
– marked tachycardia,
– hypotension,
– cyanosis and;
– tracheal displacement away from the side of the silent hemithorax.
• Occasionally, mediastinal shift may be absent in tension pneumothorax, if malignant disease or scarring has splinted the mediastinum.
INVESTIGATIONS
• Chest X-ray shows the sharply defined edge of the deflated lung with no lung markings between this and the chest wall
• X-rays may also show the extent of any
mediastinal displacement and reveal any
pleural fluid or underlying pulmonary disease
• Chest CT scan may be necessary in difficult cases.
What is the treatment for Primary spontaneous pneumothorax (PSP)?
When is thoracoscopy indicated?
• If the lung edge is <2 cm from the chest wall and the patient is not breathless, resolution occurs spontaneouly without intervention
• Moderate or large PSP requires simple
aspiration.
• Thoracoscopy with stapling of blebs and
pleural abrasion is indicated if;
– the lung does not expand with aspiration or;
– if the patient has a recurrent pneumothorax.
What is the treatment for Secondary Pneumothorax?
• Almost all patients with this condition should be treated with tube thoracostomy.
• Most should also be treated with
thoracoscopy or thoracotomy with the
stapling of blebs and pleural abrasion.
• If surgery is not feasible, pleurodesis should be attempted by the intrapleural injection of a sclerosing agent such as doxycycline.
What is the treatment for Traumatic Pneumothorax?
• Treatment is with tube thoracostomy unless they are very small.
• If a haemopneumothorax is present, one chest tube should be placed in the superior part of the hemithorax to evacuate the air and another should be placed in the inferior part of the hemithorax to remove the blood.
• Iatrogenic pneumothorax is treated with
supplemental oxygen or aspiration, (or tube thoracostomy if these fails).
What is the treatment for Tension pneumothorax?
• It must be treated as a medical emergency.
• Death can arise from inadequate cardiac
output or marked hypoxemia if the tension in the pleural space is not relieved urgently.
• A large-bore needle should be inserted into the pleural space through the second anterior intercostal space.
• If large amounts of air escape from the needle after insertion, the diagnosis is confirmed.
• The needle should be left in place until a
thoracostomy tube can be inserted.
What is advise would you give to a patient with a closed pneumothorax?
• In general, Patients with a closed
pneumothorax should be advised not to fly, as the trapped gas expands at altitude
• Diving is potentially dangerous after
pneumothorax, unless a surgical pleurodesis has sealed the lung to the chest wall.
What is the Simple aspiration of pneumothorax?
• Explain the nature of the procedure and
obtain consent.
• Infiltrate the skin down to the pleura with 2% lidocaine in the second intercostal space in the mid-clavicular line.
• Push a 3–4 cm 16 French gauge cannula
through the pleura.
• Connect the cannula to a three-way tap and 50 mL syringe.
• Aspirate up to 2.5 L of air.
• Stop if resistance to suction is felt or the
patient coughs excessively.
• Repeat chest X-ray (in expiration) in the X-ray department.
