PneumothoraxSisir BottaM3: Gyn-Onc

Pneumothorax DefinedDefinition What?Pneumo- gas Thorax chest cavityAnalagous to Pleural EffusionPathophysiology How?Pleural space Baseline (-) pressure space Parietal PleuraVisceral PleuraNormal inspirationDiaphragmTransmit (-) PressurePathologic inspirationXS gas disrupts transmission of (-) pressure

Types of PneumothoraxSpontaneous PneumothoraxPrimary -rupture of subpleural blebJimmy is a tall, wiry, 21-year old male, who plays trombone in the marching band.Secondary - underlying lung/pleural disease#1 emphysemaChronic bronchitis, asthma, TB, Traumatic PneumothoraxOpenChest wall is penetrated : outside air enters pleural spaceClosedChest wall is intactEx. Fractured rib

Types of Pneumothorax 2Tension PneumothoraxBall-valve mechanismInjury to pleura creates a tissue flap that opens on inspiration and closes on expirationOne of our own patientsVariationsHemo-thorax Chylo-thorax Injury to thoracic ductEmpyemaParapneumonic effusions in community-acquired pneumonia

SymptomsDyspneaPleuritic chest painNerve endings at pleural capsuleSense of impending doomSudden onsetTension pneumothoraxSpontaneous pneumothorax

Physical Exam - SignsUnstable patients vs. Stable patientsVital SignsAsymmetric chest expansionDeviated tracheaDiminished breath sounds unilaterallyHyper-resonance unilaterallyDecreased tactile fremitus

DiagnosisUnstable patientThoracentesisRapid release of airVital signs stabilize rapidly

Stable patientCXRMonitor size by measuring distance from lateral lung margin to chest wallBe sure that pneumothorax is not expanding

ImagingPlain RadiographsUpright PA on inspirationDetect other pathologies: pneumonia, cardiac, etc.Partially collapsed lungTension PneumothoraxTrachea and mediastinum deviate contralaterallyIpsilateral depressed hemi-diaphragmChest CTNot routineOnly to assess the need for surgery (thoracotomy)

TreatmentSmall pneumothoraxResolve over days to weeksSupplemental oxygen and observationTension pneumothoraxImmediate decompression via chest tube or needle thoracostomySpontaneous pneumothoraxAsymptomatic outpatient, f/u with serial CXRSymptomatic inpatient, chest tubeRecurrent pneumothorax CT to evaluate need for thoracotomy

Tube Thoracostomya.k.a. Chest tube

ReferencesRoberts: Clinical Procedures in Emergency Medicine, 4th ed. P. 187-203. 2004, Saunders.UpToDate. Stark: Imaging of Pneumothorax, April 7th, 2005.

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