pneumothorax by Dr. Sajid Mumtaz Sdhar

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Pneumothorax:

Pneumothorax Dr. Sajid Mumtaz Sodhar S O D H A R COURTESY Update 2010

Pneumothorax:

Pneumothorax - Pneumothorax is the presence of air within the pleural space -Due to disruption of parietal, visceral or mediastinal pleura -May also occur from spontaneous rupture of subpleural bleb -A tension pneumothorax occurs when pleura forms a one-way flap valve -Tension pneumothorax is a medical emergency.

PowerPoint Presentation:

Pneumothorax - air leaks into the space between the chest wall and the outer tissues of the lungs. Pneumomediastinum - air leaks into the mediastinum (the space in the thoracic cavity behind the sternum and between the two pleural sacs containing the lungs). Pneumopericardium - air leaks into the sac surrounding the heart. Pulmonary interstitial emphysema (PIE) - air leaks and becomes trapped between the alveoli, the tiny air sacs of the lungs.

Classification:

Classification Spontaneous pneumothorax Primary - no identifiable pathology Secondary - underlying pulmonary disorder Catamenial Traumatic Blunt or penetrating thoracic trauma Iatrogenic Postoperative Mechanical ventilation Thoracocentesis Central venous cannulation

Diseases Associated with Ptx:

Diseases Associated with Ptx The following diseases can be associated with pneumothorax : Chronic obstructive lung disease Asthma HIV infection PCP Necrotizing pneumonia Bronchogenic carcinoma Sarcomas metastatic to the lungs Tuberculosis Cystic fibrosis Interstitial lung diseases associated with connective tissue diseases Idiopathic pulmonary fibrosis Sarcoidosis Lymphangioleiomyomatosis Langerhans cell histiocytosis High-risk occupation (eg, diving, flying)

Primary spontaneous pneumothorax:

Primary spontaneous pneumothorax Usually occurs in young healthy adult men 85% patients are less than 40 years old Male : female ratio is 6:1 Bilateral in 10% of cases Occurs as result of rupture of an acquired subpleural bleb Blebs have no epithelial lining and arise from rupture of the alveolar wall Apical blebs found in 85% of patients undergoing thoracotomy Frequency of spontaneous pneumothorax increases after each episode Most recurrences occur within 2 years of the initial episode..

Secondary spontaneous pneumothorax:

Secondary spontaneous pneumothorax Accounts for 10-20% of spontaneous pneumothoraces can be due to: Chronic obstructive pulmonary disease with bulla formation Interstitial lung disease Primary and metastatic neoplasms

Risks factors for primary spontaneous pneumothorax (PSP):

Risks factors for primary spontaneous pneumothorax (PSP) Smoking Of patients with PSP, 91% reportedly are smokers or were smokers . The risk of PSP is related to the intensity of smoking, with 102-times higher incidence rates in males who smoke heavily (ie, >22 cigarettes/d), compared to a 7-fold increase in males who smoke lightly (1-12 cigarettes/d Tall, thin stature in a healthy person Marfan syndrome /EDS Pregnancy A 10-year retrospective series of 250 SP cases found 5 pregnant women, suggesting that pregnancy is an unrecognized risk factor . The cases were all managed successfully with simple aspiration or vacuum-assisted thoracostomy (VATS), and no harm occurred to mother or fetus. Familial pneumothorax Familial spontaneous pneumothorax has been described as an autosomal dominant inheritance with incomplete penetrance. One family study reported 9 cases of SP among 54 members ascertained . A review of the literature summarized 61 reports of familial spontaneous pneumothorax among 22 families. Up to 10% patients with SP report a positive family history .

Traumatic pneumothorax:

Traumatic pneumothorax Can result from either blunt or penetrating trauma Tracheobronchial and esophageal injuries can cause both mediastinal emphysema and pneumothorax Iatrogenic pneumothorax is common Occurs after : Pneumonectomy Thoracocentesis High-pressure mechanical ventilation Subclavian venous cannulation

Catamenial pneumothorax :

Catamenial pneumothorax Catamenial pneumothorax refers to the development of pneumothorax at the time of menstruation. represents 3-6% of spontaneous pneumothorax in women. Typically, it occurs in women aged 30-40 years with a history of pelvic endometriosis (20-40%). It usually affects the right lung (90-95%) and occurs within 72 hours after the onset of menses. The recurrence rate in women receiving hormonal treatment is 50% at 1 year.

Pneumothorax in AIDS :

Pneumothorax in AIDS Spontaneous pneumothorax develops in 2-6% of HIV-infected patients and is associated with P carinii pneumonia in 80% of those patients. Pneumothorax is associated with a high mortality rate in patients with HIV infection with P carinii pneumonia. Pathogenesis of the pneumothorax in this setting is the rupture of large subpleural cysts, which are associated with subpleural necrosis. Recurrent ipsilateral or contralateral pneumothorax also is common

Clinical features:

Clinical features Predominant symptom is acute pleuritic chest pain Dyspnoea results form pulmonary compression Symptoms are proportional to the size of the pneumothorax Also depend on the degree of pulmonary reserve Physical signs include Tachypnoea Increased resonance Absent breath sounds

Clinical features :

Clinical features In a tension pneumothorax The patient is hypotensive with acute respiratory distress The trachea may be shifted away from the affected side Neck veins may be engorged Diagnosis can be confirmed with a chest x-ray

Size Matters:

Size Matters Size estimation A common but often poorly performed exercise is to estimate the size of the pneumothorax on radiographic grounds. In order to perform this estimation correctly, the lung is viewed as a sphere within a sphere. Using this model it is possible to estimate the size of the pneumothorax using the following equations: DL = average diameter of lung DH = average diameter of hemithorax % PTX = (1 - DL 3/DH3) X 100 In performing this calculation, the pneumothorax is much larger than is estimated from the 2-D image alone.

PowerPoint Presentation:

Tension Pneumothorax

Tension Pneumothorax :

Tension Pneumothorax

PowerPoint Presentation:

This CXR shows a long thorax with hyperexpanded lungs. The aortic shadow is not obviously widened. The cardiac silhouette is not enlarged. There is no obvious pneumothorax, pneumomediastinum, or subcutaneous emphysema. Aortic dissection is suspected because of his Marfanoid appearance. A CT scan of the chest and aorta is ordered.

PowerPoint Presentation:

The CT scan demonstrates a small left-sided pneumothorax. The arrows point to the visceral pleura of the lung. An air space is evident within the pleural space. The aorta is normal.

close-up of left apex and expiratory view. :

close-up of left apex and expiratory view.

Management:

Management Patient's presentation Likelihood of resolution Likelihood of recurrence 2)Selection of site of care 3)Interval of observation 4)Options to restore an air-free pleural space 1)Risk stratification The decision to observe or to treat with an immediate intervention should be guided by a risk stratification that considers the patient's presentation and the likelihood of spontaneous resolution and recurrence .

Patient's presentation :

Asymptomatic (incidental finding): Treatment decisions are guided by estimate of long-term recurrence risk. Symptomatic but clinically stable: Treatment is guided by local resources and conventions for the site of care. The British Thoracic Society (BTS) advocates for simple aspiration and deferring hospitalization in primary spontaneous pneumothorax (PSP) as initial management if stable.A small bore catheter or chest tube placement is recommended by the American College of Chest Physicians (ACCP). Clinically fragile: Treatment is guided by local practice patterns for air evacuation and observation. Comorbid conditions may preclude observation because of decreased cardiopulmonary reserve. Life threatening: Pneumothorax that causes hemodynamic instability is life-threatening and must be treated immediately with tube thoracostomy. Patient's presentation

Likelihood of resolution :

Likelihood of resolution Very likely to resolve - Small pneumothorax in a hemodynamically stable patient without significant parenchymal lung disease; small iatrogenic pneumothorax May resolve - Large pneumothorax in a normal lung (eg, PSP or iatrogenic pneumothorax) Unlikely to resolve - Secondary pneumothorax, enlarging pneumothorax (suggests a continuing air leak) Won't resolve, could be fatal - Tension pneumothorax; unrecognized air leak

Likelihood of recurrence:

Likelihood of recurrence Unlikely to recur (iatrogenic pneumothorax in normal lung) May recur, but will likely be clinically stable May recur and be clinically unstable but emergency care readily accessible Very likely to recur (diffuse and progressive pulmonary pathology; eg, lymphangioleiomyomatosis [LAM]) Recurrence could be life-threatening (poor cardiopulmonary reserve, limited access to emergency medical care)

Selection of site of care:

Selection of site of care Outpatient care: This can occur in asymptomatic patients or those with a small pneumothorax and reliable follow-up . Emergency department (ED) care: ED care is changing. Prolonged periods of observation are less practical because of large patient volumes; efficacy studies of manual aspiration and placement of one-way valves are based in EDs in an attempt to address these practical issues . Inpatient observation: This site of care is generally selected when high-flow oxygen is needed, the pneumothorax is larger but the patient is stable, or comorbidities increase concern about risk or follow-up. The average hospital stay is 2.8 days . ICU: ICU treatment and observation is appropriate for patients who are unstable or intubated .

Interval of observation:

Interval of observation Monitoring pneumothorax size during this time is important . 0-6 hours : The ACCP Delphi consensus statement recommends observation in an ED for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement of the lesion, in reliable patients Emergency room observation with a repeat radiograph 6 hours later used to be common but may be used less often now . 24-96 hours : Additional follow up in 2 days is recommended, with preference given to a 24-48 hour follow-up radiograph in the outpatient setting. Outpatient follow-up during the 96-h (4-d) window is essential to distinguish between a resolved pneumothorax and one that needs evacuation. A CT scan at this time distinguishes between PSP and secondary spontaneous pneumothorax (SSP) . 1 month: Full re-expansion can occur, on average, 3 weeks after the initial event .

Options to restore an air-free pleural space:

Options to restore an air-free pleural space Observation without oxygen : Simple observation is appropriate for asymptomatic patients with a minimal pneumothorax (<15-20% by Light's criteria; 2-3 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement. Air is reabsorbed spontaneously by 1.25% of size pneumothorax per day.

PowerPoint Presentation:

Supplemental oxygen: Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone. Simple aspiration, recent ED study supports needle aspiration as safe and effective as chest tube for PSP, conferring the additional benefits of shorter length of stay and fewer hospital admissions. Chest tube for air removal: A tube inserted into the pleural space is connected to a device with one-way flow. Examples of such devices are Heimlich valves or water seal canisters , and tubes connected to wall suction devices. Thoracostomy with continuous (wall) suction.

Treatment:

Treatment Pneumothorax associated with mechanical ventilation should almost always be treated with chest tube placement because of the high risk of progression to tension pneumothorax. A spontaneous pneumothorax which is relatively asymptomatic and occupies up to 15 to 25 percent of the hemithorax can be followed clinically and with serial chest xrays. An uncomplicated, untreated pneumothorax will resolve slowly-- approximately 1.25 percent per day. This rate of resorbtion can be increased by using supplemental oxygen, which increases the nitrogen gradient from the lung to the pleura, ( N-washout)

Treatment:

Treatment Surgery is often indicated for recurrent pneumothorax, bilateral pneumothorax, prolonged air leak (longer than five to seven days), or inability to fully expand the lung. Treatment of secondary pneumothorax is often more difficult because of the associated underlying lung disease and because the patients are often symptomatic. Pneumothorax tends to recur more often in these patients, and thus requires more definitive therapy.

Treatment:

Treatment Sclerotherapy with doxycline or talc should be considered for poor surgical candidates, but this approach may complicate future surgical intervention or lung transplant. A thoracic surgeon should be consulted on these patients. If it is decided that the best treatment is surgical, the recent development of thoracoscopic intervention offers certain benefits. The surgeon can thoracoscopically visualize the full pleura, staple or resect blebs, apply electrocautery, laser, resect pleura or instill sclerosant (usually talc).

Indications for surgical assistance :

Indications for surgical assistance Persistent air leak for more than 7 days Recurrent ipsilateral pneumothorax Contralateral pneumothorax Bilateral pneumothorax First-time presentation in a patient with a high-risk occupation (eg, diver, pilot) Patients with AIDS often need this intervention because of extensive underlying necrosis. The risk of recurrent pneumothorax may also be unacceptable for patients with plans for extended stays at remote sites. Lymphangiomyomatosis , a condition causing a high risk of pneumothorax.

Video-assisted thoracoscopic surgery (VATS):

Video-assisted thoracoscopic surgery (VATS) VATS is appropriate for recurrent primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). VATS with resection of large bullous lesions is associated with a recurrence rate of 2-14%. VATS is done under general anesthesia using a camera and 2 trocar ports.

Thoracotomy:

Thoracotomy Insufflation of talc and thoracotomy has a recurrence rate of 0-7%. Recurrence rates are as low as 4%,33 which may be higher than open procedure case series. Talc is the preferred agent for pleurodesis. It can be administered by insufflation or as a slurry.

Cases:

Cases

PowerPoint Presentation:

This CXR shows two signs of pneumothorax: a visible pleural line with absent lung markings peripherally and a deep sulcus sign. The "deep sulcus" is due to anterior pneumothorax accentuating the costophronic angle.

PowerPoint Presentation:

A chest tube was placed with resolution of the left pneumothorax. However, the patient required mechanical ventilation for recurrent pulmonary edema exacerbated by inferior myocardial ischemia and mitral valve dysfunction. Her cardiopulmonary status slowly improved. Several days later, the intern was called with a stat radiology report of a large right pneumothorax. The patient's clinical status had not significantly changed.

This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the ED after experiencing multiple episodes of vomiting and a rigid abdomen. The patient was taken immediately to the operating room, where a large rupture of the esophagus was repaired. :

This chest radiograph shows pneumomediastinum (radiolucency noted around the left heart border) in this patient who had a respiratory and circulatory arrest in the ED after experiencing multiple episodes of vomiting and a rigid abdomen. The patient was taken immediately to the operating room, where a large rupture of the esophagus was repaired.

An older man admitted to ICU postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position :

An older man admitted to ICU postoperatively. Note the right-sided pneumothorax induced by the incorrectly positioned small bowel feeding tube in the right-sided bronchial tree. Marked depression of the right hemidiaphragm is noted, and mediastinal shift is to the left side, suggestive of tension pneumothorax. The endotracheal tube is in a good position

PowerPoint Presentation:

Thanks for your paying attention

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