Pneumothorax Presentation by DJ as Resident Doctor

1. Short Note:
Pneumothorax
Presented by:
Dr. Dharmendra Joshi
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2. Introduction:
 Laennec described the clinical picture of
Pneumothorax in 1819.
 The modern description of primary
spontaneous pneumothorax occurring in
otherwise healthy people was provided
by Kjaergard in 1932.
 Primary pneumothorax remains a
significant global problem.
 Incidence is 18-28/100,000 per year for
men and 1.2-6/100,000 per year for
women.
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3. Definition:
 Pneumothorax is defined as
presence of air or gas in the
pleural space
(OR)
 Presence of air outside the lung,
within the pleural space.
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4. Mechanism:
 In normal people, the pressure in
pleural space is negative during the
entire respiratory cycle.
 Two opposite forces result in negative
pressure in pleural space.
(outward pull of the chest wall and
elastic recoil of the lung)
 The negative pressure will
be disappeared if any communication
develops .
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5.  When a
communication
develops between an
alveolus or other
intrapulmonary air
space and pleural
space, air will flow
into the pleural space
until there is no
longer a pressure
difference or the
communication is
sealed
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6. Pathophysiology
Negative pressure eliminated
The lung recoil-& lung-volume decrease
V/Q low –anatomic shunt
hypoxia
Positive pressure
◦ Compress blood vessels and heart
◦ Decreased cardiac output
◦ Impaired venous return
◦ Hypotension
Result in
◦ A decrease in vital capacity
◦ A decrease in PaO2
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7. CLASSIFICATION OF PNEUMOTHORAX
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Pneumothorax
Spontaneous
Primary Secondary
Traumatic
Iatrogenic
Interventional
procedures.
Positive pressure
ventilation
Non iatrogenic
Penetrating
trauma
Blunt trauma.

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Clinical type of Pneumothorax
Pneumothorax
Closed
pneumothorax
Open
pneumothorax
Tension
pneumothorax

9. Clinical manifestation:
Dyspnea
Chest pain ( pleuritic)
Uncommon manifestation:
Cough
Hemoptysis
Orthopnea
Cyanosis
Mod tachycardia
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10. Clinical manifestation
 Tension pneumothorax
◦ Distressed with rapid labored respiration
◦ Cyanosis
◦ Marked tachycardia
 Patient who suddenly deteriorate
clinically,
be suspected in the patient with
◦ Mechanical ventilation
◦ Cardiopulmonary resuscitation
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11. Physical examination:
◦ Depend on size of pneumothorax
◦ The vital signs usually normal
◦ Unilateral Chest movements
◦ The trachea may be shifted toward the
contralateral side if the pneumothorax is
large
◦ Tactile fremitus is absent
◦ The percussion note is hyper-resonant
◦ The breath sounds are reduced or absent
on the affected side
◦ The lower edge of the liver may be shifted
inferiorly with a right-side pneumothorax
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12. Lab investigations
and Diagnosis
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13. Radiological manifestation
CXR in erect position CXR in supine position
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14. Small Pneumothorax
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15. 15
Small Pneumothorax

16. 16
Pneumothorax with mediastinal shift

17. CT scanning
It is recommended in difficult cases
such as patients in whom the lungs
are obscured by overlying surgical
emphysema
To differentiate a pneumothorax from
suspected bulla in complex cystic lung
disease
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18. 18
CT can diagnose easily
Pneumothroax

19. MANAGMENT
 Goals
◦ To promote lung expansion
◦ To eliminate the pathogenesis
◦ To decrease pneumothorax recurrence
 Treatment options according to
◦ Classification of pneumothorax
◦ Pathogenesis
◦ The extension of lung collapse
◦ Severity of disease
◦ Complication and concomitant underlying
diseases
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21. 21
 Inhalation of high concentration of oxygen
may reduce the total pressure of gases in
pleural capillaries by reducing the partial
pressure of nitrogen
 This should increase the pressure gradient
between the pleural capillaries and the
pleural cavity
 Thereby increasing absorption of air from
the pleural cavity
O2 TREATMENT: PSP or SSP

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 The rate of resolution/re-absorption of
spontaneous pneumothorax is 1.25 –
1.8% of volume of hemi thorax every 24
hours
 The addition of high flow oxygen
therapy has been shown to result in a
4-fold increase in the rate of
pneumothorax reabsorption during the
periods of oxygen supplementation

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Simple aspiration
 Simple aspiration is recommended as first line
treatment for all PSP requiring intervention
 Simple aspiration is less likely to succeed in
secondary pneumothoraces and in this situation,
is only recommended as an initial treatment in
small (<2 cm) pneumothoraces in minimally
breathless patients under the age of 50 years
 Patients with secondary pneumothoraces
treated successfully with simple aspiration
should be admitted to hospital and observed for
at least 24 hours before discharge

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 Repeated aspiration is reasonable for
primary pneumothorax when the first
aspiration has been unsuccessful
 A volume of < 2.5 L has been aspirated on
the first attempt
 The aspiration can be used by needle or
catheter
Catheter aspiration

25. Intercostal tube drainage
 INDICATIONS
◦ Unstable
pneumothorax
◦ Severe dyspnea
◦ Large lung collapse
◦ Open or tension
pneumothorax
◦ Recurrent
pneumothorax
◦ Simple aspiration or
catheter aspiration
drainage is
unsuccessful in
controlling symptoms 25

26. 26
 The safest site for
Insertion of a drain
is in the triangle
that lies:
a. Anterior to the mid
axillary line
b. Above the level of
the nipple (fifth
space)
c. Below and lateral
to the pectoralis
major muscle.
Intercostal tube drainage

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Intercostal tube drainage
Fix the catheter and cover with
gauze
Making a small incision
Using a forceps to extend the
hole
Inserting a catheter into
pleural cavity

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Observation of drainage
 No bubble released:
◦ The lung re-expansion
◦ The chest tube is obstructed by secretion or blood clot
◦ The chest tube shift to chest wall, the hole of the chest
tube is located in the chest wall
 If the lung re-expand, the chest tube may be removed
24 hours after re-expansion.
 Otherwise, the chest tube will be inserted again or
regulated the position.

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Surgical treatment
 Indications
◦ No response to medical treatment
◦ Persist air leak
◦ Haemopneumothorax
◦ Bilateral pneumothoraces
◦ Recurrent pneumothorax
◦ Tension pneumothorax failed to drainage
◦ Thicken pleura makes lung unable to re-
expansion
◦ Multiple blebs or bullae

30. Definitive Management of
Pneumothorax
PLEURECTOMY AND
PLEURODESIS
 Surgery for pneumothorax can be performed by
video-assisted thoracoscopic surgery (VATS) or as
an open procedure (thoracotomy).
 The object of the exercise is three-fold:
• to deal with any leaks from the lung;
• to search for and obliterate any blebs and bullae
(Bullectomy);
• to make the visceral pleura adherent to the parietal
pleura so that any subsequent leaks are contained
and the lung cannot completely collapse.
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31. Pleural adhesion is achieved in
one of three ways:
• Pleurectomy: systematically strip the
parietal pleura from the chest wall.
• Pleural abrasion: a scourer is used to
scrape off the slick surface of the
parietal pleura.
• Chemical pleurodesis: usually talc is
used and is insufflated into the chest
cavity.
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32. 32
Complications of Pneumothorax
 Pyopneumothorax
 Hydropneumothorax.
 Hemopneumotorax
 Mediastinal and subcutaneous
emphysema

33. Recurrence:
The best estimates of recurrence rates
are:
 • of patients who experience a first event,
only about one-third experience
recurrence;
 • of those who have a second episode,
about one-half go on to experience a
third episode;
 • those who have had three episodes will
probably go on to have repeated
recurrences.
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34. Thank You!!!
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