PNEUMOTHORAX

PNEUMOTHORAX

الدكتور خلدون العبايجي - كلية طب نينوى- المرحلة الرابعة
Objectives The student should focus attention on:
1. Spontaneous and traumatic p.
2. Differences between primary and secondary types.
3. Salient features: Sudden onset of chest pain and dyspnea.
4. Physical signs of p.
5. Most dangerous form is tension p.
6. Chest X-ray is diagnostic.
7. Management includes observation for mild cases, needle aspiration and
chest tube for more severe cases.
8. Indications of pleurodesis.

Definition

Presence of air in the pleural space.

Classification

A. spontaneous
1. primary
Rupture of small subpleural emphysematous bulla, bleb, or pulmonary pleural adhesion.
No evidence of overt lung disease.
Associated with smoking and tall stature.


2. Secondary
Evidence of underlying lung disease e.g COPD &TB (two most common), asthma, lung abscess, pulmonary infarction, bronchial cancer, fibrotic & cystic lung disease.
Carries higher mortality.

B. Traumatic

Iatrogenic: after thoracic surgery or biopsy.
Non-iatrogenic: after chest wall injury.

Types of spontaneous pneumothorax

Closed pneumothorax Communication between lung and pleural space seals off and the mean pleural pressure is negative, air will be absorbed and the lung re-expands over a few days or weeks.

Open pneumothorax Communication fails to seal and air transfers freely between lung and pleural space through bronchopleural fistula, mean pleural pressure is atmospheric, which may result in infection and empyema, seen after rupture of emphysematous bulla, TB cavity, or lung abscess.

Tension pneumothorax

Communication between pleura & lung acts as one way valve allowing air to enter pleural space during inspiration and
coughing & prevent it from escaping, intrapleural pressure may
rise above atmospheric pressure compressing the underlying lung
and shifting the mediastinum to the opposite side with consequent
compression of opposite lung & cardiovascular compromise.

 SHAPE \* MERGEFORMAT 


Clinical features
Sudden onset of unilateral chest pain or breathlessness, which can be severe in those with chest disease in whom pneumothorax does not resolve spontaneously.
Small pneumothorax: often normal physical examination.
Large pneumothorax >15% of hemithorax manifests hyper-resonant percussion note and diminished or absent breath sounds.
Signs of infection and empyema complicating open pneumothorax
In severe pneumothorax and tension type signs of progressive dyspnea, tachycardia, hypotension & cyanosis. Shifting of trachea and cardiac apex to opposite side may be elicited.


Investigations
Chest x-ray
Sharply defined edge of the deflated lung with complete translucency between the edge & chest wall without lung markings.
May show mediastinal shift, pleural fluid, underlying lung disease.
Diagnosis of tension type is clinical as sometime there is no mediastinal shift.
CT Can differentiate between large emphysematous bulla and pneumothorax.

Management

Mild pneumothorax: lung edge < 2cm from chest wall without underlying lung disease or dyspnea observe for spontaneous recovery.
Percutaneous needle aspiration indicated in :
Young patient with moderate or large spontaneous p.
>15% of hemithorax.
2. <50 year age with significant dyspnea.
3. Tension p. prior to insertion of chest tube.
Intercostal tube drainage attached to underwater seal drainage device indicated in :
1. Tension p. with cardiovascular collapse.
2. Chronic lung disease , even small p. may cause respiratory
failure.
3. Pneumothorax >15% of hemithorax or significant dyspnea,
age >50 Y.
4. Age <50 Y if pneumothorax persists after needle aspiration.


Needle: iserted in 2nd intercostal space anteriorly in MCL.
Intercostal tube: inserted in 4th, 5th, 6th intercostal space MAL.
Clamping of drain is dangerous & is rarely indicated. The drain should be removed the morning after the lung has fully re-inflated and bubbling has stopped.
Oxygen accelerates air reabsorption and improves dyspnea.
Continued bubbling after 5-7 days is an indication for surgery.
Patient with closed pneumothorax should not fly as trapped gas may expand. A wait two weeks before allowing to fly after full inflation of lung is confirmed.
Advice patient to stop smoking.
Diving is potentially dangerous after pneumothorax, unless a surgical pleurodesis has sealed the lung to the chest wall

Recurrent spontaneous pneumothorax

Inform patient about risk of future recurrence.
Recurrence in primary spontaneous p. occurs within a year of either aspiration or tube drainage in approximately 25% of patients.

Surgical pleurodesis

Through pleural abrasion or parietal pleurectomy at thoracotomy or thoracoscopy.
It is indicated in:
Second attack of pneumothorax.
First episode of secondary pneumothorax in patients with low respiratory reserve.










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