Pneumothroax Flashcards
what is pneumothorax ?
collection of air within the pleural space between the lung (visceral pleura) and the chest wall (parietal pleura) that can lead to partial or complete pulmonary collapse
classification of pneumothorax?
Spontaneous pneumothorax
Primary spontaneous pneumothorax: occurs in patients without clinically apparent underlying lung disease
Secondary spontaneous pneumothorax: occurs as a complication of underlying lung disease
Recurrent pneumothorax: a second episode of spontaneous pneumothorax, either ipsilateral or contralateral
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Traumatic pneumothorax
caused by a trauma (e.g., penetrating injury, iatrogenic trauma)
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Tension pneumothorax
life-threatening variant of pneumothorax characterized by progressively increasing pressure
aetiology of pneumothorax ?
Spontaneous pneumothorax
= Primary (idiopathic or simple pneumothorax) :
Caused by ruptured subpleural apical blebs (bulla)
= Secondary (pneumothorax as a complication of underlying lung disease)
COPD (smoking) → rupture of bullae in emphysema
Infections:
Pulmonary tuberculosis
Pneumocystis pneumonia → alveolitis, rupture of a cavity
Cystic fibrosis → bronchiectasis with obstructive emphysema and bleb or cyst rupture
Marfan syndrome
Carcinoma
Connective tissue disorders: Marfan’s syndrome, Ehlers–Danlos syndrome.
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Traumatic pneumothorax
Blunt trauma (e.g., motor vehicle accident
Penetrating injury (e.g., gunshot, stab wound)
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Iatrogenic pneumothorax: mechanical ventilation with high PEEP
CVP line insertion
what type of pneumothorax will lead to tension pneumothorax?
Any type
what is tension pneumothorax?
Disrupted visceral pleura, parietal pleura, or tracheobronchial tree
One-way valve mechanism, in which air enters the pleural space on inspiration but cannot exit during expiration
Progressive accumulation of air in the pleural space and increasing positive pressure within the chest
Collapse of ipsilateral lung; compression of contralateral lung, trachea, heart, and superior vena cava; angulation of inferior vena cava
Impaired respiratory function, reduced venous return to the heart
Reduced cardiac output
Hypoxia and hemodynamic instability
clinical features of pneumothorax ?
: Can be asymptomatic (especially in fit young people with small pneu- mothoraces)
!! Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain !!
!! dyspnea !!
Reduced or absent breath sounds,
!!!! hyperresonant percussion !!!
decreased fremitus on the ipsilateral side
Reduced expansion
Subcutaneous emphysema :
condition that results from entrapment of air or gas into the subcutaneous tissues and typically presents with sudden, painless soft tissue swelling, often around the upper chest, neck, and face.
Patients with asthma or COPD may present with a sudden deterioration
Mechanically ventilated patients can suddenly develop hypoxia or an increase in ventilation pressures
what’re the additional clinical features when there is TENSION pneumothorax ?
Severe acute respiratory distress: cyanosis, restlessness, diaphoresis
Distended neck veins and hemodynamic instability
= tachycardia, hypotension, pulsus paradoxus
Reduced chest expansion on the ipsilateral side
trachea will be deviated away from the affected side and the patient will be very unwell
what are the clinical features of tension pneumothorax in ventilated patients ?
Tachycardia, hypotension (obstructive shock)
Distention of jugular vein
Rapid decrease in SpO2
Reduced air flow
Increased ventilation pressure
Skin emphysema
what is the diagnosis for pneumothorax?
usually confirmed by chest x-ray.
Ultrasound is becoming an increasingly accepted modality for identifying pneumothorax and is part of the eFAST.
CT can provide information about the underlying cause (e.g., bullae in spontaneous pneumothorax).
Tension pneumothorax is primarily a clinical diagnosis and prolonged diagnostic studies should be avoided in favor of initiating immediate treatment.
if a tension pneumothorax request an expiratory film, and look for an area devoid of lung markings peripheral to the edge of the collapsed lung
what are the supportive findings in chest x ray for pneumothorax ?
!!!! Pneumothorax is very difficult to identify on supine CXR; consider ultrasound or CT chest in patients unable to sit upright .!!!!
Deep sulcus sign - deep cast-phrenic angle
Decreased radiodensity and deep costophrenic angle on the ipsilateral side
The sign is a result of interpleural air that collects basally and anteriorly in the supine position.
Hemidiaphragm elevation on the ipsilateral side
what are the supportive findings for tension pneumothorax in chest x ray
Ipsilateral diaphragmatic flattening/inversion and widened intercostal spaces
Mediastinal shift toward the contralateral side
Tracheal deviation toward the contralateral side
what is the stability criteria in spontaneous pneumothorax ?
ALL OF THE FOLLOWING MUST BE PRESENT FOR THE PATIENT TO BE CONSIDERED STABLE
Respiratory rate < 24 breaths/minute
SpO2 (room air): > 90%
Patient able to speak in complete sentences
HR 60–120/minute
Normal BP
All other patients are considered unstable.
management of unstable pneumothorax ?
= Suspected tension pneumothorax
Emergency needle thoracostomy ( potentially life-saving intervention) , followed immediately by chest tube placement
Consider a finger thoracostomy if needle thoracostomy is unsuccessful.
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Bilateral pneumothorax OR any patient who require mechanical ventilation or do not meet pneumothorax stability criteria: Emergency chest tube placement
what is the management for spontaneous pneumothorax?
RESPIRATORY SUPPORT
Upright positioning
Provide supplemental high-flow oxygen as needed (target SpO2 ≥ 96–100%)
( Positive pressure ventilation can turn a simple pneumothorax into a life-threatening tension pneumothorax.
Decompression of a pneumothorax can sometimes rapidly improve dyspnea, making mechanical ventilation unnecessary. )
what is the management of stable (high risk ) pneumothorax ?
usually caused by Secondary spontaneous pneumothorax
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Apex-to-cupola distance < 3 cm: Consider observation or chest tube placement.
Apex-to-cupola distance ≥ 3 cm
Chest tube placement
ICU transfer and thoracic surgery consultation
what is apex-to-cupola distance ?
interpleural distance between the visceral pleura at the tip of the lung (apex) and the parietal side at the thoracic wall (cupola). Can be measured in a chest x-ray to evaluate the size of a pneumothorax
what is the management of stable (low risk) pneumothorax ?
usually caused by primary spontaneous pneumothorax
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Apex-to-cupola distance < 3 cm
Usually resolves spontaneously within a few days (∼ 10 days)
Perform a repeat chest x-ray at 3–6 hours
if enlarging appearance: Place a chest tube.
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Apex-to-cupola distance ≥ 3 cm
= Chest tube placement typically recommended
Using a small-bore catheter
= Consider conservative management in healthy patients experiencing :
An initial episode
No respiratory distress or progression on repeat 4-hour CXR
= Needle aspiration may also be considered
management of traumatic pneumothorax ?
treatment of unstable or high-risk traumatic pneumothorax (e.g., tension pneumothorax) is identical to the treatment of unstable spontaneous pneumothorax: emergency chest decompression.
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A chest tube is required for all patients with any of the following:
Suspected or proven hemopneumothorax
Ongoing or anticipated mechanical ventilation
Moderate to large pneumothorax
Small pneumothorax with hemodynamic instability
Suspected hemopneumothorax: Use a large-bore chest tube.
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Open pneumothorax
Immediately apply simple, partially occlusive dressings taped at 3 out of 4 sides of the lesion.
Follow dressing with tube thoracostomy.
Observe for development of tension pneumothorax.
( !!!! Never pack the chest wound in an open pneumothorax as the packing may be sucked into the chest cavity during inspiration !!!!!! )
procedure of needle thoracotomy ?
insertion of a large-bore needle with a syringe, partially filled with 0.9% saline
adults : 2nd intercostal space at the midclavicular line or the 4th–5th intercostal space between the anterior and midaxillary line
indications of finger thoracostomy ?
Tension pneumothorax with unsuccessful needle decompression
Traumatic cardiac arrest
what is the procedure of finger thoracotomy ?
identical to chest tube placement
=most appropriate site for chest tube placement is the 4th or 5th intercostal space in the mid- or anterior- axillary line
Difference compared to chest tube placement
A gloved finger is inserted into the pleural space to create an open pneumothorax.
No chest tube is inserted or secured.
what is the indication of chest tube placement ?
Spontaneous pneumothorax management.
what is the procedure of chest tube placement ?
Use a small tube (10–14F)
unless blood/pus is also present.
Most commonly in the 4th–5th intercostal space (nipple line), between the anterior and midaxillary line (safe triangle )
Primarily used for emergency chest decompression
lways check CXR after the procedure is complete
Tubes may be removed 24h after the lung has re- expanded and air leak has stopped (ie the tube stops bubbling). This is done during expiration or a Valsalva manoeuvre.
complications of pneumothorax ?
Complete pulmonary collapse → respiratory failure
Tension pneumothorax → cardiac failure
Mediastinal flutter in open pneumothorax → hemodynamic shock
when should surgical advice be sought for ?
bilateral pneumothoraces; lung fails to expand within 48h of intercostal drain insertion; persistent air leak; two or more previous pneumo- thoraces on the same side; or history of pneumothorax on the opposite side
