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L6 Pneumothorax

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35 views

L6 Pneumothorax

Uploaded by

Johnny boy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Pneumothorax

Dr mohammed Alshakoor

What is a pneumothorax?
• the presence of Air within the pleural
cavity (i.e. between visceral and parietal
pleura)
• The air enters via a defect in the visceral
pleura (e.g. ruptured bulla) or the
parietal pleura (e.g. puncture following
rib fracture)
R

•Right lung more translucent than left


•Faint line just visible (zoomed view to follow)
Right pneumothorax

•Pencil-thin white line


running parallel to chest
wall
•No lung markings lateral
to the line

Blade of right scapula

Types of Pneumothorax
• Simple
– Mediastinum remains central
– Clinical condition stable
– Can wait for CXR to confirm diagnosis
• Tension
– 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
Simple Left Pneumothorax

Simple Left Pneumothorax

Visceral
pleural line
(zoomed
view on next
slide)

Small pleural
No mediastinal shift effusion
(common
finding)
Note absence of
lung markings
lateral to this line

Pneumothorax with rib fractures


Pneumothorax with rib fractures
Right pneumothorax

Surgical emphysema

Rib fractures

Tension right pneumothorax


Tension right pneumothorax

Mediastinal shift to
left

Causes of Pneumothorax
• Primary spontaneous (normal lung)
– Rupture of an apical bleb ususally occur in a
young tall thin soking male
• Secondary spontaneous (Pre-existing lung bnormality)
– Pulmonary fibrosis
– Asthma
– Vasculitis
– Pulmonary metastases close to edge of lung
• Traumatic
– blunt or penetrating chest trauma
– Iatrogenic like aspiration of pleural fluid or transthoracic
needle biopsy, bronchoscopy etc…
• Catamenial occur within few days of mensis due to
diaphragmatic fenestration or pleural endometriosis
Other causes of absent lung markings

• Large emphysematous bullae


• Large lung cysts
• Pulmonary embolism

....but only pneumothorax has a white


line parallel to the chest wall

managment
• Clinical Manifestations
• Symptoms depend on the degree of collapse of the lung and on its
previous condition. There may be no symptoms.
• Chest pain is the most common presenting symptom, followed by
dyspnea. Less common symptoms include non-productive cough and
orthopnea.
• Subcutaneous emphysema and pneumomediastinum present in
patient with extensive lung disease and a pleural space obliterated with
adhesions because air escaping from the ruptured bleb follows the path
of least resistance retrograde through the peribronchial soft tissue.
•
• On examination
• Absent or diminished breath sounds is evident on auscultation
• Hyperresonance is evident on percussion.
CXR
• The characteristic radiographic finding is absence of lung
markings and a faintly visible line defining the edge of
the lung.
• A film taken in expiration can demonstrate a small
pneumothorax more readily because of the reduction in
lung volume during forced expiration.
• When the lung collapses almost completely, it is visible
as an irregular density attached to the hilus. Presence of a
small amount of fluid with an air-fluid level is common.
• The lung fields must be examined closely for evidence of
gross abnormalities, such as apical blebs or bullae. Only
about 15 percent are visible radiographically
•

Chest CT
• The routine use of CT in patients with PSP
is not warranted because the recognition of
apical blebs does not change treatment
recommendations.
•
• The pneumothorax can be considered as
mild when it is less than 20%, moderate
when it is 20 to 40%, and large when it is
more than 40%.
•
Treatment
• An initial, small (5% to 20%) asymptomatic
pneumothorax can be observed in the hospital and
monitored by daily chest radiography.
Reabsorption of the pneumothorax is facilitated by
the administration of supplemental oxygen, which,
by lowering the PN2 of capillary blood, increases
the partial pressure difference between the pleural
space and the pulmonary capillary. Small
pneumothorax that is shown not to increase in
size over 6 to 8 h can safely be observed

• . Simple needle aspiration (usually with the


use of three way stopcock and a syringe) of
the airspace can nearly eliminate the space
in a stable pneumothorax and greatly
reduces the amount of time required for
spontaneous resolution. An uncomplicated
pneumothorax should reabsorb at a rate of
approximately 1% per day.
Chest tube
• Is adequate for most patients with large pneumothoraces
.The tube is inserted either anteriorly (second interspace,
midclavicular line) or laterally in a lower interspace
(middle to anterior axillary line), with the tip directed
toward the apex. Tube thoracostomy should be performed
in patients with:
• Persistent symptoms
• Unilateral pneumothorax greater than 15% of a
hemithorax
• All patients who present with simultaneous bilateral
pneumothoraces or previous pneumonectomy
• Those who fail observation

Open thoracotomy
1. Massive air leak preventing re-expansion of the lung.
2. Simultaneous bilateral pneumothoraces.
3. Persistant air leak (>48 hours for primary spontaneous
pneumothorax,>96 hours for secondary spontaneous pneumothorax).
4. Reccurent pneumothorax.
5. Previous contralateral pneumothorax or pneumonectomy.
6. First episode with occupational hazard for pneumothorax (pilot, scuba
diver, parachutist).
7. Obvious or large bullae or cysts are seen in the collapsed lung.
8. Complete (100%) pneumothorax.
9. Pneumothorax associated with tension.
10. Poor cardiopulmonary reserves
11. Complications such as empyema or hemothorax.
12. Persons living in remote areas
For patient who is unfit or unwilling
to do surgery
• Chemical pleurodesis : talc ,
doxycycline and bleomycin
• Hemlich valve

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