Pneumotorace Flashcards
Epidemiology
Primary spontaneous pneumothorax
Sex: ♂ > ♀ (approx. 6:1)
Peak incidence: 20–30 years
Secondary spontaneous pneumothorax
Sex: ♂ > ♀ (approx. 3:1)
Peak incidence: 60–65 years
Classificazione
A 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
-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
- Traumatic pneumothorax: a type of pneumothorax caused by a trauma (e.g., penetrating injury, iatrogenic trauma)
- Tension pneumothorax: a life-threatening variant of pneumothorax characterized by progressively increasing pressure within the chest and cardiorespiratory compromise (agire immediadamente ancor prima di imaging)
◽Spontaneous pneumothorax
1.Primary (idiopathic or simple pneumothorax)
Caused by ruptured subpleural apical blebs
-Risk factors
-Family history
-Male gender
-Young age
-Asthenic body habitus (slim, tall stature) (e.g., in Marfan syndrome)
💥Smoking (90% of cases): up to 20-fold increase in risk (risk increases with the cumulative number of cigarettes smoked)
-Homocystinuria
- Secondary (pneumothorax as a complication of underlying lung disease)
- COPD (smoking) → rupture of bullae in emphysema
- Pulmonary tuberculosis
- Cystic fibrosis → bronchiectasis with obstructive emphysema and bleb or cyst rupture
- Pneumocystis pneumonia → alveolitis, rupture of a cavity
- Catamenial pneumothorax (thoracic endometriosis): extremely rare
Pathophysiology
C’è shunt fisiologico, abbiamo alveoli perfusi ma non ventilati!
Increased intrapleural pressure → alveolar collapse → decreased V/Q ratio and increased right-to-left shunting
(una stenosi mitralica con edema polmonare genera uno shunt destro sinistro)
Traumatic pneumothorax
-Closed pneumothorax: air enters through a hole in the lung (e.g., following blunt trauma)
-Open pneumothorax: air enters through a lesion in the chest wall (e.g., following penetrating trauma)
▫Air enters the pleural space on inspiration and leaks
to the exterior on expiration
▫Air shifts between the lungs (On inspiration, air from the collapsed lung may enter the unaffected lung. On expiration, air from the healthy lung returns to the collapsed lung, causing it to reexpand)
Tension pneumothorax
Tension pneumothorax: disrupted visceral pleura, parietal pleura, or tracheobronchial tree → air enters the pleural space on inspiration but cannot exit → progressive accumulation of air in the pleural space and increasing positive pressure within the chest → collapse of ipsilateral lung and compression of contralateral lung, trachea, heart, and superior vena cava → impaired respiratory function, reduced venous return to the heart and reduced cardiac output → hypoxia and hemodynamic instability
- Severe acute respiratory distress: cyanosis, restlessness, diaphoresis
- Reduced chest expansion on the ipsilateral side
- Distended neck veins and hemodynamic instability (tachycardia, hypotension, pulsus paradoxus)
- Secondary injuries may be present (e.g., open or closed wounds).
- Signs of tension pneumothorax in ventilated patients
Tachycardia, hypotension 🧨Rapid decrease in SpO2 Reduced air flow Increased ventilation pressure Skin emphysema
💥RX
- Ipsilateral diaphragmatic flattening/inversion and -widened intercostal spaces
- Mediastinal shift toward the contralateral side
- Tracheal deviation toward the contralateral side
Clinical features
- Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea
- Reduced or absent breath sounds, hyperresonant percussion, decreased fremitus on the ipsilateral side
- Subcutaneous emphysema
- diminuzione o abolizione sia del FVT che del murmure vescicolare
PNEUMOTORACE IPERTESO
P-THORAX: Pleuritic pain, Tracheal deviation, Hyperresonance, Onset sudden, Reduced breath sounds (and dyspnea), Absent fremitus, X-rays show collapse.
Tension pneumothorax is primarily a clinical diagnosis and prolonged diagnostic studies should be avoided in favor of initiating immediate treatment.
In cases of tension pneumothorax, immediate decompression is a priority and should not be delayed by imaging.
🧨Suspected tension pneumothorax: emergency needle thoracostomy, followed by chest tube placement
🧨Unstable patients or bilateral pneumothorax: emergency chest decompression via chest tube placement
Chest x-ray
(in posizione ortostatica gli apici polmonari sono sottoposti ad un forte stress soprattuto in giovani alti e longilinei, ciò spiega perchè soprattuto Pnx spontanei si verificano agli apici polmonari)
- Ipsilateral pleural line with reduced/absent lung markings (i.e., increased transparency) (The visceral pleura may be visible as a thin line parallel to the chest wall. Pulmonary vessels that are usually visible up to the periphery are no longer visible beyond the pleural line. This is most evident in the apex and/or along the lateral pulmonary edge.)
- Abrupt change in radiolucency (iperdiafania)
- 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 (invece nello pneumotorace iperteso c’è un abbassamento o addirittura inversione dell’emifiaframma)
- If pulmonary disease is present: airway or parenchymal lesions
Ultrasound
Indications
- Trauma (eFAST)
- Quick bedside assessment
Supportive findings
-Absence of pleural sliding
-Absence of B-lines
-Combination of prominent A-lines and absent B-lines
(linee b presenti in edema polmonare o fibrosi e interstiziopatie)
Laboratory studies
Laboratory analysis is generally not indicated.
Arterial blood gas analysis (ABG) [4]
Indications
SpO2 < 92% on room air
Evaluation for CO2 retention in patients with lung disease (e.g., COPD) receiving supplemental O2
Findings: ↓PaO2 may be present
Treatment (il trattamento dipende dalle dimensioni ma soprattutto dalla sintomaticità: in generale si agisce quando c’è presenza di dispnea)
- Tension pneumothorax, unstable patients, bilateral pneumothorax: immediate chest decompression
- Spontaneous pneumothorax: conservative management or chest tube placement (dipende da dimensioni e sintomi)
- Mechanical ventilation necessary: chest tube placement
Dimensioni pneumotorace
Nb. In caso di pneumotorace recidivante si utilizza CT scan come metodo diagnostico
Si definisce grande quando
- maggiore di 3 centimetri da apice
- maggiore di 2 centimetri da parete laterale
Pneumotorace spontaneo primario
NB qualsiasi sia l’entità, se è sintomatico riceve tubo di drenaggio
-minore di 3 cm: osservazione per 3-6 ore, con ossigeno
maggiore di 3 cm o sintomatico: tubo di drenaggio
Trattamento recidive (bullectomia, pleurodesi)
- al secondo episodio omolaterale o primo controlaterale
- al primo episodio se bilaterale contemporaneo
- al primo episodio se gravidanza o professioni a rischio
- fuga di aria oltre i 5-7 giorni
Pnx spontaneo secondario (è sempre più grave di un primario per via della già aòterata funzionalità polmonare di base)
Sempre ricovero, tubo di drenaggio e chirurgia al primo episodio per le recidive
complicanze
Complete pulmonary collapse → respiratory failure
Tension pneumothorax → cardiac failure
Mediastinal flutter in case of open pneumothorax → hemodynamic shock
Hemothorax in cases of trauma
Pneumomediastinum
Pneumoperitoneum
Recurrence
Post-surgical/-procedural complications
Persistent fistula with continuous air leak
Injury to intercostal nerves and vessels
Infection
