Pneumothorax
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Transcript of Pneumothorax
PneumothoraxPneumothoraxSisir BottaSisir Botta
M3: Gyn-OncM3: Gyn-Onc
Pneumothorax DefinedPneumothorax Defined Definition – Definition – “What?”“What?”
““Pneumo”- Pneumo”- gasgas “Thorax” – “Thorax” – chest cavitychest cavity
Analagous to Pleural Analagous to Pleural EffusionEffusion
Pathophysiology – Pathophysiology – “How?“How? Pleural space Pleural space
Baseline (-) pressure space Baseline (-) pressure space Parietal PleuraParietal Pleura Visceral PleuraVisceral Pleura
Normal inspirationNormal inspiration DiaphragmDiaphragm Transmit (-) PressureTransmit (-) Pressure
Pathologic inspirationPathologic inspiration XS gas disrupts XS gas disrupts
transmission of (-) pressuretransmission of (-) pressure
Types of PneumothoraxTypes of Pneumothorax Spontaneous PneumothoraxSpontaneous Pneumothorax
Primary -Primary - rupture of subpleural blebrupture of subpleural bleb ““Jimmy is a tall, wiry, 21-year old male, who plays Jimmy is a tall, wiry, 21-year old male, who plays
trombone in the marching band….”trombone in the marching band….” Secondary - Secondary - underlying lung/pleural diseaseunderlying lung/pleural disease
#1 – emphysema#1 – emphysema Chronic bronchitis, asthma, TB, …Chronic bronchitis, asthma, TB, …
Traumatic PneumothoraxTraumatic Pneumothorax OpenOpen
Chest wall is penetrated : outside air enters pleural Chest wall is penetrated : outside air enters pleural spacespace
ClosedClosed Chest wall is intactChest wall is intact Ex. Fractured ribEx. Fractured rib
Types of Pneumothorax 2Types of Pneumothorax 2 Tension PneumothoraxTension Pneumothorax
““Ball-valve mechanism”Ball-valve mechanism” Injury to pleura creates a Injury to pleura creates a
tissue flaptissue flap that opens on that opens on inspiration and closes on inspiration and closes on expirationexpiration
One of our own patientsOne of our own patients VariationsVariations
Hemo-thorax Hemo-thorax Chylo-thorax Chylo-thorax
Injury to thoracic ductInjury to thoracic duct EmpyemaEmpyema
Parapneumonic effusions in Parapneumonic effusions in community-acquired pneumoniacommunity-acquired pneumonia
SymptomsSymptoms DyspneaDyspnea Pleuritic chest painPleuritic chest pain
Nerve endings at pleural capsuleNerve endings at pleural capsule Sense of impending doomSense of impending doom Sudden onsetSudden onset
Tension pneumothoraxTension pneumothorax Spontaneous pneumothoraxSpontaneous pneumothorax
Physical Exam - SignsPhysical Exam - Signs Unstable patients vs. Stable patientsUnstable patients vs. Stable patients
Vital SignsVital Signs Asymmetric chest expansionAsymmetric chest expansion Deviated tracheaDeviated trachea Diminished breath sounds Diminished breath sounds
unilaterallyunilaterally Hyper-resonance unilaterallyHyper-resonance unilaterally Decreased tactile fremitusDecreased tactile fremitus
DiagnosisDiagnosis Unstable patientUnstable patient
ThoracentesisThoracentesis Rapid release of airRapid release of air Vital signs stabilize Vital signs stabilize
rapidlyrapidly
Stable patientStable patient CXRCXR
Monitor size by Monitor size by measuring distance measuring distance from lateral lung from lateral lung margin to chest wallmargin to chest wall
Be sure that Be sure that pneumothorax is not pneumothorax is not expandingexpanding
ImagingImaging Plain RadiographsPlain Radiographs
Upright PA on inspirationUpright PA on inspiration Detect other pathologies: Detect other pathologies:
pneumonia, cardiac, etc.pneumonia, cardiac, etc. Partially collapsed lungPartially collapsed lung Tension PneumothoraxTension Pneumothorax
Trachea and mediastinum Trachea and mediastinum deviate contralaterallydeviate contralaterally
Ipsilateral depressed hemi-Ipsilateral depressed hemi-diaphragmdiaphragm
Chest CTChest CT Not routineNot routine Only to assess the need for Only to assess the need for
surgery (thoracotomy)surgery (thoracotomy)
TreatmentTreatment Small pneumothoraxSmall pneumothorax
Resolve over days to weeksResolve over days to weeks Supplemental oxygen and observationSupplemental oxygen and observation
Tension pneumothoraxTension pneumothorax Immediate decompression via chest tube or Immediate decompression via chest tube or
needle thoracostomyneedle thoracostomy Spontaneous pneumothoraxSpontaneous pneumothorax
Asymptomatic – outpatient, f/u with serial CXRAsymptomatic – outpatient, f/u with serial CXR Symptomatic – inpatient, chest tubeSymptomatic – inpatient, chest tube Recurrent pneumothorax – CT to evaluate Recurrent pneumothorax – CT to evaluate
need for thoracotomyneed for thoracotomy
Tube Tube ThoracostoThoracosto
mymy a.k.a. Chest tubea.k.a. Chest tube
ReferencesReferences Roberts: Clinical Procedures in Roberts: Clinical Procedures in
Emergency Medicine, 4Emergency Medicine, 4thth ed. P. 187- ed. P. 187-203. 2004, Saunders.203. 2004, Saunders.
UpToDate. Stark: Imaging of UpToDate. Stark: Imaging of Pneumothorax, April 7Pneumothorax, April 7thth, 2005., 2005.
Questions??Questions??