Tension Pneumothorax by Ankur

8/3/2019 Tension Pneumothorax by Ankur

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Dr. Ankur Agrawal

Dept. of Respiratory

Medicine

PGIMS Rohtak


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Pneumothorax

Defined as accumulation of air in the pleural spacewith secondary collapse of surrounding lung

Due to disruption of parietal or visceral pleura


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Classification

Spontaneous pneumothorax

Primary - no identifiable pathology

Secondary - underlying pulmonary disorder

Catamenial Traumatic

Blunt or penetrating thoracic trauma

Iatrogenic

Postoperative Mechanical ventilation

Thoracocentesis

Central venous cannulation


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Primary Spontaneous Pneumothorax

Usually occurs in young healthy adult men 85% patients are less than 40 years old Male : female ratio is 6:1 Bilateral in 10% of cases Occurs as result of rupture of an acquired subpleural bleb Blebs have no epithelial lining and arise from rupture of

the alveolar wall Apical blebs found in 85% of patients undergoing

thoracotomy Frequency of spontaneous pneumothorax increases after

each episode Most recurrences occur within 2 years of the initial episode


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Secondary Spontaneous Pneumothorax---

--- underlying lung/pleural disease

Emphysema

Chronic bronchitis

Asthma TB

Necrotizing lung infections

ARDS

Pneumocystis jiroveci pneumonia ILD


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Catamenial pneumothorax Catamenial pneumothorax refers to the development

of pneumothorax at the time of menstruation. represents 3-6% of spontaneous pneumothorax in

women. Typically, it occurs in women aged 30-40 years with a

history of pelvic endometriosis (20-40%). It usually affects the right lung (90-95%) and occurs

within 72 hours after the onset of menses. The recurrence rate in women receiving hormonal

treatment is 50% at 1 year. T/t- ocp, danazol, lupron [GnRH agonist]

,hystrectomy and b/l oophorectomy


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Traumatic Pneumothorax

Open Chest wall is penetrated : outside air enters pleural space

Closed Chest wall is intact Eg. Fractured rib

Iatrogenic


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Common causes of IatrogenicPneumothorax

Positive-pressure ventilation

Central venous catheter placement

Thoracentesis

Tracheostomy Nasogastric tube placement (inadvertent insertion of the

NG tube into tracheobronchial tree)

Bronchoscopy(esp if transbronchial biopsy performed)

Pericardiocentesis

Transthoracic needle aspiration

Cardiopulmonary resuscitation.


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Tension PneumothoraxA condition in which air continuously leaks out of the

lung into the pleural space

This results in lung collapse of the affected side, andthen pressure on the mediastinum, the other lung andthe great vessels

E T


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Et o ogy o Tens on

Pneumothorax

Trauma(blunt or penetrating): disruption of the parietal or visceralpleura.

Fractures: most prevalent as a result of rib fractures, however alsoseen in displaced thoracic spine fractures.

Barotrauma: ventilator dependent patients on large volume PEEPmay rupture peripheral alveoli sacs secondarily disrupting thevisceral pleura. Index of suspicion is raised when larger peak airwaypressures are needed to achieve a specific tidal volume.

Iatrogenic: secondary to trauma induced by

Bronchoscopy Chest compressions during CPR

Central venous catheter placement

Conversion of Simple Pneumothorax -> Tension Pneumothorax


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Pathophysiology of Tension

Pneumothorax

Disruption of the lung parenchyma or parietalpleura acts like a one way valve. During inspiration air

is drawn into the pleural space. During expiration thetissue f lap/valve prevents air from escaping.Subsequent inspirations additively draw more air intothe pleural space causing increasing intrapleural

pressures greater than atmospheric pressurethroughout expiration and even during inspirationresult in collapse of ipsilateral lung and deviation ofmediastinal structures contralaterally.


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Tension PneumothoraxEach time we inhale,

the lung collapses further. Thereis no place for the air to

escape..


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Tension Pneumothorax Each time we inhale,the lung collapses further. There

is no place for the air toescape..


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Tension Pneumothorax

Heart is beingcompressed

The trachea ispushed to

the good side


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Symptoms Dyspnea

Cough

Pleuritic chest pain Nerve endings at pleural capsule

Sense of impending doom

Sudden onset


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SignAsymmetric chest expansion Deviated trachea Diminished breath sounds unilaterally Hyper-resonance unilaterally Decreased tactile fremitus

Cyanosis Profuse diaphoresis Marked tachycardia Hypotension


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Etiology of symptomsHypoxia

- Decreased PaO2

- Perfusion of atelectatic lung- VQ mismatchDecrease venous return

- increase intrathorasic pressure

-decrease cardiac output


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LAB STUDIESABGs: Often seen in tension pneumothorax is a

varying degree of acidemia, hypercarbia, and hypoxia.The reduction in PaO2 is caused by alveolarhypoperfusion secondary to atelectasis, lowventilation/perfusion ratios, and anatomic shunts

Cardiac Enzymes: necessary to r/o acute MI andresulting cardiogenic shock, must have serial readingto accurately r/o acute MI


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Findings on CXR:

Large radiodense lung field

Absent lung markings on ipsilateral side

Contralateral deviation of trachea and mediastinal

structures If tension pneumothorax involves left lung the left

hemidiaphragm may be depressed/flattened. The liverprevents this radiographic finding on the right side

Imp -Laboratory and diagnostics may confirm thediagnosis of a tension pneumothorax (i.e. ABG, CXR)however the diagnosis lies predominantly on clinicalpresenting symptoms


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D/D Myocardial infarction Pulmonary infarction Pleural infection Perforated peptic ulcer Generalized emphysema Massive emphysematous bulla

Congenital lung cyst Diaphragmatic hernia COPD, asthma


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Treatment of Tension

PneumothoraxABC to be maintained

High Flow oxygen

Treat for S/S of Shock If Open Pneumothorax and occlusive dressing present

apply occlusive dressing

Monitor Cardiac Rhythm

Needle Decompression of Affected Side

Tube Thoracostomy


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NEEDLE CHEST DECOMPRESSION Locate 2d intercostal space at midclavicular line

Insert 14-gauge catheter-over-needle into chest cavityover superior edge of rib

Listen for gush of air and observe for improvement ofsymptoms

Tape catheter in place with cap or valve in place to

prevent re-entry of air May also place Asherman chest seal over catheter

Dress open chest wound if present


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NEEDLE CHEST

DECOMPRESSION


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Tube Thoracostomy Identify and prepare the area w/ Betadine at ICS 4 or 5 along the mid-axillary or anterior axillary line

Anesthetize the area (subcutaneous tissue, intercostal muscles) withLidocaine. Some physicians use opioid analgesia or a combination of an

opioid + Benzo. Make a 2 cm incision Insert a large blunt clamp over superior aspect of rib (preventing

damage to the neurovascular bundle that lies on the inferior border ofthe rib). Apply gentle pressure until the parietal pleura is pierced.

Open clamp to establish a tract for the chest tube.

Bluntly dissect w/ finger. Clamp proximal end of tube tangentially w/ Clamp. Insert tube over

superior aspect of rib into pleural space. Insert the chest tube past the last hole. Suture chest tube w/ Silk

sutures.


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Monitor patient continuously with arterial O2saturationwatch for sudden desaturations

F/U CXR may be ordered to assess re-expansion oflung and resolution of pneumothorax. Important: re-expansion pulmonary edema may occur with rapidlung re-expansion s/p tube thoracostomy. This is apotential life threatening situation which can lead tocardiovascular collapse.


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Pulmonary edema occur most commonly unilateral,on the collapsed lung side but can become bilateral

REPE is due to increased permeability of pulmonarycapillary that are damaged by mechanical stress anddecrease surfactant.

Other theories include ischemic reperfusion injury,

free radical injury and decrease lymphatic flow Chances of REPE are high when pneumothorax

present for more than 3 days or lung expanded withmore than -20cm H2O pleural pressure


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Onset of symptoms can be immediate or within 24 hr

Pt. will present with severe persistent cough, chestpain, hypoxia, tachycardia, tachypea and hypotension

Corticosteroid, diuretics, bronchodilator, and highflow oxygen is given and sometimes pt may needmechanical ventilator support

If pt survive the first 48 hr recovery is usually complete


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Keep chest tube on water seal. Chest tube may beremoved when indication for placing it has resolved.F/U CXR must be ordered immediately s/p chest tube

removal and 24 hrs post-removal to assess for presenceof a reoccurring pneumothorax.


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Tension Pneumothorax by Ankur

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