Pneumothorax

Sisir Botta M3: Gyn-Onc

Pneumothorax Defined

Definition What?

Pneumo- gas Thorax chest cavity Analagous to Pleural Effusion Pleural space

Pathophysiology How?

Baseline (-) pressure space Parietal Pleura Visceral Pleura Diaphragm Transmit (-) Pressure XS gas disrupts transmission of (-) pressure

Normal inspiration

Pathologic inspiration

Types of Pneumothorax

Spontaneous Pneumothorax

Primary

rupture of subpleural bleb

underlying lung/pleural disease

Jimmy is a tall, wiry, 21-year old male, who plays trombone in the marching band.

Secondary

#1 emphysema Chronic bronchitis, asthma, TB,

Traumatic Pneumothorax

Open

Chest wall is penetrated : outside air enters pleural space

Chest wall is intact Ex. Fractured rib

Closed

Types of Pneumothorax 2

Tension Pneumothorax

Ball-valve mechanism Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration One of our own patients
Hemo-thorax Chylo-thorax

Variations

Injury to thoracic duct Parapneumonic effusions in communityacquired pneumonia

Empyema

Symptoms

Dyspnea Pleuritic chest pain

Nerve endings at pleural capsule

Sense of impending doom Sudden onset

Tension pneumothorax Spontaneous pneumothorax

Physical Exam - Signs

Unstable patients vs. Stable patients

Vital Signs

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

Diagnosis

Unstable patient

Stable patient

Thoracentesis

CXR

Rapid release of air Vital signs stabilize rapidly

Monitor size by measuring distance from lateral lung margin to chest wall Be sure that pneumothorax is not expanding

Imaging

Plain Radiographs

Upright PA on inspiration

Detect other pathologies: pneumonia, cardiac, etc.

Partially collapsed lung Tension Pneumothorax

Trachea and mediastinum deviate contralaterally Ipsilateral depressed hemidiaphragm

Chest CT

Not routine Only to assess the need for surgery (thoracotomy)

Treatment

Small pneumothorax

Resolve over days to weeks Supplemental oxygen and observation

Immediate decompression via chest tube or needle thoracostomy Asymptomatic outpatient, f/u with serial CXR Symptomatic inpatient, chest tube Recurrent pneumothorax CT to evaluate need for thoracotomy

Tension pneumothorax

Spontaneous pneumothorax

Tube Thoracostomy

a.k.a. Chest tube

References

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

Questions??