PNEUMOTHORA

X

PNEUMOTHORAX is the presence of air in the

pleural space.

can be

a) Spontaneous

b) Result of iatrogenic injury

c) Trauma to the lung or chest wall

Classification

1. Spontaneous

# Primary- No evidence of overt lung disease

- occurs in males aged 15-30

- air escapes from the lung into the pleural

space through rupture of a small emphysematous

bulla or pleural bleb

- smoking, tall stature & the presence of apical subpleural

blebs are additional risk factors

#Secondary- underlying lung disease

- occurs mainly in males above 55 yrs

- most commonly COPD & TB

- also seen in asthma, lung abscess, pul infarcts,

bronchogenic carcinoma, all forms of fibrotic &

cystic lung disease

2. Traumatic

- iatrogenic ( foll thoracic surgeryor biopsy)

- chest wall injury

TYPES

1. Closed spontaneous pneumothorax

2. Open spontaneous pneumothorax

3. Tension pneumothorax

Closed type

Communication b/n airway and the pleural space

seals off as the lung deflates

Mean pleural pressure remains negative

Spontaneous reabsorption of air & re-expansion of

lung occur over a few days or weeks

Infection uncommon

Open type

Communication b/n pleura & bronchus doesn’t

seals off (Bronchopleural fistula)

Intra pleural pressure = atm. Pressure

Collapsed lung, no re expansion

Transmission of infection from the airways into

the pleural space through fistula common

(empyema)

Tension type

Communication b/n the airway & the pleural

space acts as a one-way valve

Allowing air to enter the pleural space during

inspiration but not to escape on expiration

Large amt of air accumulates progressively in the

pleural space

Intrapleural pressure increases above atm

pressure

Pressure causes mediastinal shift towards the

opposite side

with compression of the opposite lung

& impairment of systemic venous return

Causing cardiovascular compromise

Occasionally tension pneumothorax may

occur without mediastinal shift, if malignant

ds or scarring has splinted the mediastinum

Clinical features

Sudden onset of unliateral pleuritic chest pain

Breathlessness

[In pts with a small pneumothorax, physical

examination may be normal ]

General examination

Cyanosis

Rapid thready pulse

Signs of peripheral circulatory failure in

severe cases

Inspection & palpation

Dyspnoea

Accessory muscles of respiration

Shift of trachea

Shift of mediastinum to opposite side

Fullness of chest on the affected side

Diminished chest movements

Marked diminished vocal fremitus on

affected side

Reduction in total chest expansion

Increase in size of affected hemithorax

Diminished expansion of the affected

hemithorax

Percussion

Hyper-resonant on affected

pneumothorax.

Right sided pneumothorax-liver dullness is

obliterated and cardiac dullness is shifted

to the opposite side

Auscultation

Diminished to absent breath sounds

Absence of adventitious sounds

Diminished vocal resonance

Bronchopleural fistula-amphoric broncial

breathing.

Investigations

Chest x ray

Shows : increased radiolucency, with absence of

bronchovascular markings

extend of mediastinal shift.

pleural fluid ,if present .

underlying pulmonary disease .

(costophrenic angles are clear)

[care must be taken to differentiate b/n a large pre-existing bulla &

a pneumothorax to avoid misdirected attempts at aspiration]

CT

Helps to differentiate between large pre

existing emphysematous bullae and

pneumothorax .

TREATMENT

Primary pneumothorax

If the lung edge is < 2cm from the chest wall and patient is not breathless

↓

Resolves normally with out intervention

If the patient is having severe symptoms

↓

Percutaneous needle aspiration

↓

If it fails , intercostal tube drainage is done

PERCUTANEOUS NEEDLE ASPIRATION OF AIR

Intercostal

drainage

Secondary pneumothorax

Even a small secondary pneumothorax may

cause respiratory failure, so all such patients require

↓

Intercostal tube drainage

[Intercostal drains are inserted in the 4th ,5th or 6th

intercostal space in the midaxillary line ,connected

to an under waterseal]

Clamping of the drain is potentially dangerous

Should be removed 24hrs after the lung has fully

reinflated and bubbling stopped .

Continued bubbling after 5 -7 days is an indication

for surgery .

All patients should receive supplemental oxygen

If intercostal tube drainage fails

↓

Thoracoscopy (VATS ) or thoracotomy with

stapling of blebs and pleural abrasion is indicated

If surgery is contraindicated, pleurodesis

should be done .

↓

Intrapleural injection of sclerosing agent

Tension pneumothorax

It is a medical emergency.

A large bore needle is inserted into pleural

space through 2nd intercostal space.

Needle should be left in place until a

thoracostomy tube can be inserted.

Traumatic pneumothorax

Supplemental oxygen or aspiration done.

Tube thoracostomy , if not improves.

If hemo pneumothorax is present, 1 chest

tube should be placed in the superior part to

evacuate air, other should be placed in the

inferior part to remove blood.

Recurrent spontaneous

pneumothorax

Surgical pleurodesis is recommended in all

patients following a 2nd pneumothorax(even

if ipsilateral)

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