Pneumothorax: Presence of air in pleural cavity

Cause
• Traumatic: Blunt, Penetrating
• Spontaneous: Rupture emphysematous bulla, TB cavity
• Iatrogenic: Positive pressure ventilation, Central line insertion

Simple (Closed): Limited amount of air entry to pleura

Symptoms: Dyspnea, Chest pain, History of trauma
Signs:
• Inspection: Diminished movement on the affected side
• Palpation: Decrease TVF, Tracheal shift to the opposite side
• Percussion: Hyper-resonance
• Auscultation: Diminished air entry
Investigations: Chest Xray (Jet black shadow, Underlying collapsed lung, Shift of mediastinum to opposite side)
Treatment:
• Small amount, No dyspnea: Conservative (Daily CXR and ABG) till spontaneous Absorption occurs
• Large amount, Dyspnea: Intercostal tube under water seal in 5th intercostal space Mid-Axillary line
Tube is removed after full Absorption of air (In end of deep inspiration after clamping, suturing of the
opening)

Open pneumothroax: Air in pleura with communication with outside (Air enters and exits throuch an opening or
bronchopleural fistula)
Pathology
• Respiratory failure
◦ Paradoxical breathing: Affected side shows slight expansion with expiration and collapse with
inspiration
◦ Pendulous breathing: Oscillation of air between 2 lungs → The normal side is filled with air rich in CO2
and low Oxygen
• Circulatory failure
◦ Mediastinal flutter: Movement of mediastinum from side to side during respiration → Kink of vessels
◦ Positive intrathoracic pressure → Decrease venous return and COP
Symptoms: History of trauma, Dyspnea, Cough, Chest pain, Cyanosis
Signs:
• General: Shock, Cyanosis, Engorged neck veins, Respiratory distress (Working ala nasi)
• Inspection: Diminished movement, Paradoxical respiration, Bruises, Ecchymosis
• Palpation: Decrease TVF, Tracheal shift to opposite side, Tenderness
• Percussion: Hyper-resonance
• Auscultation: Diminished air entry, Whistling sound is heard as air is going in and out through the opening
Investigations: CXR (Jet black shadow, Collapsed lung, Depressed copula of diaphragm, Shift of mediastinum, Wide
intercostal spaces), ABG, US (Associated visceral injury)
Treatment: Closure of the wound by adhesive strap and Management of shock then → Intercostal tube under water
seal 5th space MAL and Care of wound and Tube

Tension pneumothorax: Air inside the pleura through a valvular lesion that allows entry but not exit of air
Pathology
• Increase intra-thoracic pressure → Collapse of underlying lung and Shift of mediastinum (Other lung)
• Positive intra-thoracic pressure → Decrease venous return → Decrease cardiac output
Symptoms: As open but more severe
Signs: As open but (Tympanitic)
Investigations: No time for investigations, CXR in doubtful cases only
Treatment: ABCD (ATLS), Resuscitation, Insertion of wide bore canula in 2nd space MCL to convert into Open
pneumothorax than managed as it.

Hemothorax: Presence of blood in pleural space

Causes
• Traumatic: Lung laceration, Intercostal artery, Internal mammary artery
• Pathological: Tumors, Leaking aortic aneurysm
• Postoperative: Lung, Heart, Esophagus
• General: Bleeding tendency, Blood diseases
It usually stops spontaneously (Lowe pulmonary pressure), But never absorbed spontaneously
Pathology: Blood in pleural pass 3 stages
• Defibrination: Due to continuous movement of lung
• Clotting: Irritation of pleura → Pleural effusion → Fibrin deposition and clotting
• Organization: Formation of fibrous adhesions around lung limiting lung expansion
Symptoms: History of cause + Dypnea, Chest pain
Signs:
• General: Hypovolemic shock, Cyanosis
• Inspection: Diminished movement on the same side
• Palpation: Decrease TVF, Shift of trachea to the opposite side
• Percussion: Stony dullness
• Auscultation: Diminished air entry
Investigations:
• CXR → Obliteration of costo-phrenic angle and Shadow rising to axilla
• CT, Intercostal aspiration (Blood)
Treatment: ATLS, Management of shock
• Small amount → Aspiration
• Intercostal tube under water seal 5th space MAL
• Open drainage and ligation of the bleeder
◦ Incications: Large amount, Clotted, Loculated, Persistent for days and no lung expansion within 10 days
◦ Large amount = > 200 ml/hr for 4 hours, 100 ml/hr for 8 hours, 1200ml initial bleeding
• Decortication if fibrosis occurred

Fracture ribs
Simple fracture: Fracture of one or more ribs at one site only
Commonly affect ribs from 3-10 (1st and 2nd are protected by clavicle, 11th and 12th are floating)
Cause
• Direct trauma: Fracture at site of trauma, More visceral injury
• Indirect trauma: Fracture occurs at weakest point (Angle) → Fractured ends are driven outward → Less
visceral injury
Clinical picture → Describe as fractures (No deformity, Pain increase with breathing and cough)
Complications: Pneumothorax, Hemothorax, Visceral injury, Hemorrhage, Brachial plexus and Subclavian vessels
Investigations: CXR → Fracture rib, Associated pneumonia and hemothorax, Abdominal US → Visceral injury
Treatment: Conservative (Analgesics, Antibiotics, Rest in bed)
• If pain is severe → Intercostal nerve block → Epidural anaesthesia

Flail chest: Fracture of one or more ribs at multiple sites (Part of chest is flail)
Symptoms: As simple + Dyspnea
Signs
• General: Shock, Cyanosis, Engorged neck veins, Restlessness
• Inspection: Decrease movement, Flail segment shows paradoxical respiration
• Palpation: Tenderness
• Auscultation: Diminished air entry
Complications: Paradoxical respiration, Pendulous breathing, Mediastinal flutter (As before)
Treatment: ATLS, Shock, Stabilize flail segment by adhesive strapping, If unstable (ORIF)

Stove-in chest: As flail chest but affected segment is sucked in

Empyema thoracis: Presence of pus in pleural space
Acute empyema
Source
• Lobar pneumonia
 • Direct spread: Lung abscess, Subphrenic abscess, Pyogenic liver abscess, Mediastinitis, Carcinoma
• Hematogenous spread: Pyaemia, Septicemia
• Post-operative: Cardiac, Lung, Esophageal injury
Causative organism: Usually Pneumococci, Others (Staph, Sterpt, G -ve)
Pneumococcal empyema Streptococcal empyema
Thick greenish pus, Heavy fibrin deposition Thin yellowish pus, Little fibrin deposition
After resolution of pneumonia During pneumonia
Early localization, Rapid adhesions Late localization, Late adhesions
Clinical picture: Dypnea, Chest pain, Cough, Cyanosis + FAHMRT
Examination:
• General → FAHMRT
• Inspection: Diminished movement
• Palpation: Decrease TVF, Tracheal shift to opposite side
• Percussion: Stony dullness
• Auscultation: Diminished air entry
Complications:
• Dissimination: Septicemia, Pyaemia, Toxemia, Septic shock, Bronchopleural fistula, Pericarditis, Mediastinitis
• Localization: SC space → Empyema necissitanes
Investigations: CXR (As hemothorax), Aspiration (Pus → C&S), ESR, CRP, TLC
Treatment:
• Repeated aspiration and Antibiotic injection according to C&S
• Intercostal tube under water seal if thick pus 5th space MAL
• Open drainage → Via thoracotomy and Rib resection
• If no localization → Decortication

Chronic empyema
Causes
• Bad management of Acute empyema: Faulty drainage (Too high, Too low, Too late), Early removal of
intercostal tube, Omission of breathing exercises
• Underlying disease: Osteomyelitis of ribs, FB, Bronchopleural fisula
Clinical picture: Chronic sinus discharging pus in chest wall + Chronic toxemia (Clubbing, Anemia)
Examination → Signs of fibrosis → Crowded ribs, Elevation of diaphragm, Shift of mediastinum to the same side,
Diminished air entry, Dullness
Complications: Empyema necissitans (May perforate in intercostal space → Subcutaneous abscess giving expansile
impulse on cough)

Investigations:
• CXR (Crowded ribs, Tenting of diaphragm, Shift of mediastinum to the same side, Underlying cause)
• Lipidol pleurogram through the sinus opening
• CT scan, Bronchosopy to detect cause

Treatment:
• Intercostal tube drainage (Rib resection in dependent position + Physiotherapy to allow lung expansion)
• Decortication (Excision of thick visceral pleura and Expansion of lung by positive pressure ventilation
• Pleuro-penumolobectomy (Bronchiectasis or Lung abscess)