4. 1 PNEUMOTHORAX
A pneumothorax is the presence of air or gas within the
pleural cavity i.e. the potential spaces between the
visceral pleural & parietal pleural of the lungs.
This is usually from the defect on the lung surface e.g.
rapture bullae(Large blister ) or through the damage of
the chest wall e.g. following trauma.
Air within the pleural cavity causes the physiological
pleural seal to be lost ,meaning the normal negative
pressure in this space , that aid the lung expanding within
the chest wall movement is lost.
This impedes(prevent) lung expansion & leads to partial
or total lung collapse.
Annual incidence of pneumothorax is around 9% per
Primary pneumothoraces occur most commonly in tall thin
men aged between 20-40
They are less common in women- consider the possibility of
underlying lung disease e.g. LAM, Catamental
Cigarette or cannabis smoking is a major risk factor for
pneumothorax increasing the risk by factor of 22 in men &
9 in women
The mechanism is unclear ; a smoking induced influx of
inflammatory cells may both break down elastic lung fibers
(causing bulla formation ) & cause small airway obstruction
(increasing alveolar pressure & the likelihood of interstitial
More common in patient with Marfans syndrome &
May rarely be farmilial
As air enters the pleural space which normally have a
negative pressure , the elastic recoil in the lung tissue
causing either a partial or full lung collapse.
Pleural space has a negative pressure
Chest wall expand ►surface tension between parietal &
visceral pleural expands the lungs.
Lung tissue has an elastic recoil► innate tendency to
10. Traumatic pneumothorax
Closed pneumothorax : blunt trauma →lung damage →air
flow from the lung into the pleural spaces.
Open pneumothorax : penetrating trauma to the chest
wall→ pathway for air directly into pleural spaces.
Close & open pneumothorax : In closed pneumothorax air
travel in & out of the pleural spaces from the lungs .
However in an open pneumothorax a defect in the chest
wall allows air to move in & out of the pleural spaces.
12. Iatrogenic pneumothorax
Induced in a patient by the treatment or comment of a
Central venous catheter insertion
Thoracentesis -removal of fluid around the lung
13. Spontaneous pneumothorax
Ruptured bleb→ air flow from the lungs into the pleural
spaces→ positive pleural pressure→ compressed lung.
Lung collapse until an equilibrium is achieved or the rupture
Vital capacity & ↓ partial pressure of oxygen
Rapture apical subpleural bleb or bullae
Chronic obstruction-COPD account for 50%
15. Tension pneumothorax
Life threatening & can develop from any type of a
Air enters the pleural space through a one way mechanism
→air cannot escape.
Air accumulate in the pleural space with each inspiratory
phase→ ↑ pleural space pressure → shifting of
mediastinum→ compression of the contralateral lung →
Eventually compress of the vena cava & atria →↓ venous
return to the heart & ↓ cardiac function .
Leads to rapid cardiopulmonary collapse.
Spontaneous & traumatic pneumothorax can develop into a
tension pneumothorax if the defect that allow air into the
pleural space becomes one way valve (air enters during
inspiration but cannot escape during exhalation which
causes rising pressure in the pleural cavity , shifting the
mediastinum to the contralateral side
Mediastinum remains central
Clinical condition stable
Can wait for CXR to confirm diagnosis
Progressive build up of air in the pleural space, causing
a shift of the heart and mediastinal structures away
from side of pneumothorax
Clinical condition unstable
Do not wait for CXR to confirm diagnosis
21. RISK FACTORS/CAUSES
Sex-men are at high risk
History of pneumothorax
22. CLINICAL PRESENTATION
Shortness of breath of varying degree depending on the
size of the pneumothorax & patients factors e.g. lung
Sudden onset chest pain, often pleuritic in nature , small
spontaneous pneumothorax can be asymptomatic
particularly in younger patients.
O/E there will be:
Hyperresonance on percussion
Reduced or absent breath sound on auscultation
Reduced chest expansion
Decrease in tactile fremitus
In cases of tension pneumothorax:
Patients will be hypoxic
Potential distended neck vein
Tracheal deviation away from the affected side
Tachypnea-abnormal rapid breathing
Cardiovascular-jugular venous distension
-Pulsus paradoxus-↓ stroke volume
Initial investigation should run alongside this(expect for
cases of tension pneumothorax when urgent needle
decompression is required in 2 or 3rd ICS
Tension pneumothorax is a clinical diagnosis &
management should not wait for imaging confirmation
1 Plain chest radiograph(CXR)
The size of pneumothorax is determined by measuring
interpleural distance at the level of hilum.
Should be performed in upright position (when possible)
White visceral pleural lining defining lung & pleural air
Bronchovascular markings are not visible beyond pleural edge
Ipsilateral hemidiaphragm elevation
Potential mediastinum shift
Ipsilateral hemidiaphragm flattening
Ribs are spread a part
2 Routine blood –FBC
-U & Es & clotting
Arterial blood gas (ABG)
3 CT imaging
determine underlying cause in context of trauma &
Findings –air in the space , can evaluate the location ,
pleural pathology & lung disease
Presence of a lung point –boundary between the lung &
Lung sliding will be absent at the location of pneumothorax
Management is determined by both size or type of the
pneumothorax & patient factor.
As a minimal ensure all patient have sufficient analgesia &
started on oxygen if required.
For patient with chest drain inserted ensure it is attached
to underwater seal.
Primary spontaneous pneumothorax those that are small
(<2) & asymptomatic patients should be admitted for
Symptomatic or large primary pneumothoraces needle
decompression should be attempted placed in 2nd or
3rd intercostal spaces at the midclavicular line if no
improvement chest drain via seldinger technique to be
5th ICS space in the anterior or midaxillary line in SAFTEY
TRIAGE is another option-followed by chest tube
Small spontaneous pneumothorax will required
admission for observation with a low threshold for
attempting needle decompression ,
Those that are large & symptomatic required chest drain
via seldinger technique to be placed.
Traumatic pneumothoraces will normally require surgical
chest drain insertion or otherwise admitting for observation
if small & asymptomatic.
Importantly there is no role in needle decompression in
traumatic non-tensioning pneumothoraces.
For traumatic tension pneumothoraces either needle
decompression (in 5th intercostal space mid-axillary line)
or finger thoracostomy is required prior to chest drain
Considered in those with persistence air leak or failure of lung
Spontaneous cases medical pleurodesis is often trailed
resulting in partial obliteration of the pleural space through
introducing irritant agent aiming to prevent recurrences
,alternatively Heimlich valve can be trailed a one way valve
attached to a chest tube & enable evacuation of air that is not
Those failing these intervention or in traumatic cases should ne
considered surgical intervention which includes video
assisted thoracoscopic surgery (VATS) for pleurectomy +/-
pleural abrasion or open thoracostomy& pleurectomy .
Hypoxemic respiratory failure-low level of oxygen
Respiratory or cardiac arrest-heart suddenly stop pumping blood
Hemopneumothorax-combination of pneumothorax &
Bronchopulmonary fistula-abnormal communication btwn
bronchial tree & pleural cavity
Pulmonary edema –following lung re-expansion
Empyema-collection of pus in the pleural cavity
Pneumomediastinum-presence of air in mediastinum
Pneumopericardium-presence of air in pericardium
Pneumoperitoneum-presence of air in peritoneal cavity
Pyopneumothorax-accumulation of gas & pus in pleural cavity
COMPLICATIONS OF SURGICAL PROCEDURE
Failure to cure the problem
Acute respiratory distress or failure
Infection of the pleural spaces
Cutaneous or systemic infection
Persistent air leak
Pain at the site of chest tube insertion
Prolonged tube drainage & hospital stay
Hemothorax is the accumulation of blood in the intrapleural
Bleeding is usually from intercostal artery in lacerated chest
wall or from underlying contused lung, heart or great vessel.
Massive hemothorax is bleeding of more than 1500ml into
Hemothorax can be associated with a single rib fracture.
Approximately 150,000 deaths occurs from trauma each
Approximately 3times this number of individuals are
permanently disabled because of trauma.
Chest injuries occurs in approximately 60% of multiple
Accumulation of blood in the pleural space caused by
bleeding from; penetration or blunt lung injury, chest wall
vessels or intercostal vessels.
Hemothorax is manifested by;
>hemodynamic response-hypovolemic shock rapid
>respiratory response-slow bleeding.
Blood that enters the pleural cavity is exposed to the
motion of the diaphragm, the lungs, and other intrathoracic
Occurs due to penetration injury of the lungs, heart, great
vessels, or chest wall
non Traumatic hemothorax
Malignancy pleural diseases(sarcoma, angiosarcoma)
Bleeding disorders(hemophilia, thrombocytopenia, rupture of
Pulmonary embolism with infarction
Central venous catheterization
Injury during trans lumber aortography
Trans brachial biopsy
ABC of resuscitation
Large bow cannular &begin IV fluids-crystolliods
Vital check up including SPO2
Intercostal drainage tube thoracostomy
Large bore tube in 5th spacing between mid and posterior axillary
Can be done before x-ray
Draining of blood from chest cavity
Thoracostomy(indicated when total chest tube output exceeds 1500ml
Video assisted thoracoscopic surgery(VATS)
Shock care due to blood loss
Accumulation of pus in pleural cavity.
Emphyema come from Greek word Empyein which means
Also called Pyothorax
Its also a secondary disease to other underlyind diseases
60. STAGE 1 EXUDATIVE PHASE
This is purely on inflammatory process in which there is
increase in permeability of small blood vessesls leading to
exudation of fluid in the pleural cavity.
The fluid is very thin with low cellular content.
Approximately in 7 days
STAGE 2 FIBRINO PURULENT STAGE
This is whereby there is fibrin clot and fibrin membranes in the
pleural cavity leading to fluid loculation
From day 7 to 21 days
STAGE 3 ORGANIZING STAGE
Proliferation of fibroblasts on the pleural surface,which forms
covering preventing adequate lung expansion.
There is also scarring of pleural membranes with possible
inability of the lung to expand
Takes about 4 to 6 weeks
62. TREATMENT &
Treatment of the underlying cause of precipitating factor
Mild cases –observation is appropriate
Patient with discomfort –give high oxygen concertation
Use of empiric broad spectrum antibiotic
Extensive phase -2cm intravascular incision bilaterally can
reduce further subcutaneous expansion
In severe cases ICT on one side or both sides placement
68. CLINICAL FEATURES /SIGNS
Hypotension/shock(rapid weak pulse)
Grossly distended neck vein (raised JVP)
Elevated central venous pressure
faint heart sound
Penetrating injury in the proximity to the heart
The classic findings /a hallmark signs of beck triad
2 Distended neck vein
3 Faint heart sound
69. BECKS TRAID
Collection of three clinical signs associated with pericardial
tamponade which is due to excessive accumulation of fluid
within the pericardial sac
1 Sharp pain in the chest –pain may radiate to the nearby parts
of the body like abdomen ,arm ,neck & shoulder
2 trouble breathing /breathing rapidly
3 fainting ,dizziness/light headache
4 changes in skin color
5 heart palpitation
6 fast pulse
7 Altered mental status /confusion
8 decreased urine output
Removal of the fluid around the heart
Its done through pericardiocentesis –the procedure use a
needle that is inserted into the chest until in enters the
pericardial sac & the fluid is aspirated
PERICARDIOCENTESIS & SURGERY COMPLICATION
Injury to the heart chambers
Injury to nearby organs