Pneumothorax class

Dr. Boney Cheriyan ThavalathilEmergency Physician & Intensivist,

Normal pleural space = closed sac in which negative pressure is essential for normal lung expansion during breathing

What’s the normal pleural pressure?

Beginning of inspiration - 5 cm H2O

End of inspiration - 7.5 cm H2O

“Pneumo” – Gas “Thorax” – Chest cavity Occurs when air leaks into the space between the

lungs and chest wall, creating pressure against the lung

SourcesVisceral pleuraRuptured esophagusChest wall defectGas-forming organisms

TraumaticBluntPenetrating

IatrogenicDiagnosticTherapeutic

Spontaneous PrimarySecondary

COPDInfectionNeoplasm

Penetrating Trauma Air entering pleural space directly through chest wall

Blunt Trauma

High Risk Occupations

Transthoracic Needle Aspiration biopsy

Transbronchial Biopsy

Thoracocentesis

Central Venous Catheter Placement

Intercostal Nerve Block

Tracheostomy

Positive Pressure Ventillation

NG tube placement

Penetrating & Non- Penetrating traumaThoracic Spine Fracture Dislocations

Cohesive forces between visceral & parietal pleura disruptedCollapse of the lung

Signs Tachypnea

Tachycardia

Hypotension

Hypoxia

Symptoms

Breathlessness Pleuritic Chest pain

Sudden onset

Tension pneumothorax

Spontaneous pneumothorax

Respiratory

Decreased Breath Sounds

Hyperresonance to percussion

Decreased Tactile Fremitus

Altered Mental Status

Cardiovascular

JVDShift in mediastinum

OtherSubcutaneous

EmphysemaShifted Trachea

Tension pneumothoraxFailure to reexpandPersistent air leakRecurrence

Removal of intrapleural airInfection Reexpansion pulmonary edema

Mediastinal shift

Kinking of SVC & IVC

Decrease in Venous Return to heart

Decrease In C.O

SHOCK & HYPOPERFUSION

ABG

PO2 : decreased

PCO2:Decreased from Hyperventilation

Elevated with respiratory compromise

CXR Inspiratory & expiratory

imagesUnderlying Pul. disease

Harder to detect

CTPSP – Blebs & Bullae Small pneumothoraxAssess the need for

thoracotomy

Absence of “lung sliding” as assessed on the time-motion view

Demonstration of a "lung point" on the time-motion view

Absence of vertical comet-tail artifacts

USGUSG 95% sensitivity95% sensitivity 100% specificity100% specificity

“Seashore sign” “Stratosphere sign”

Normal Abnormal

Normal Abnormal

ABC

History

Examination

Needle aspiration and small chest tube drainage

Goals

Elimination of intrapleural air

Optimization of pleural healing

Prevention of recurrences

Immediate decompression via chest tube or needle thoracostomy

If a tension pneumothorax is present, a “hiss of air” may be heard escaping from the chest cavity

Remove the needle, leave the catheter in place

Rx

Immediate managementWound dressing

Flutter-Type Valve Effect

Rx

Clear and manage the airway

Provide oxygen

Seal an open wound with an occlusive dressing

Rx

Tape down three sides and create a flutter valve

Rx

Chest tubeRemote from the wound

Definite managementSurgical closure of the wound

Rx

OxygenPneumothorax is smaller than 15% Patient is asymptomatic

Needle aspirationPneumothorax is smaller than 15%Symptomatic & hemodynamically stable

Pigtail catheterPneumothorax is greater than 15%

Rx

Tube Thoracostomy

Recurrent PneumothoraxCT to evaluate need for thoracotomy

Thoracoscopy with stapling of blebs

Pleural abrasion & Sclerosing agent (Doxycycline or Talc)

Rx

Aspiration

Tube thoracostomy

Rx