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APPROACH TO SPONTANEOUS

PNEUMOTHORAX
NURFARAHANI
CLASSIFICATION
Spontaneous pneumothorax has no
antecedent traumatic or iatrogenic cause
Can be divided into 2 types:
Where there is no underlying lung

primary abnormality or underlying disease


that predisposes to pneumothorax

Where there is underlying lung

secondary disesase
Eg: COPD and pneumonia
Primary pneumothorax
A primary spontaneous pneumothorax is one which
occurs in a patient with no known underlying lung
disease. Tall and thin people are more likely to
develop a primary spontaneous pneumothorax.
There may be a familial component, and there are
well associations:
Marfan syndrome
Ehlers-Danlos syndrome
alpha-1 antitrypsin deficiency
homocystinuria
Secondary pneumothorax
When the underlying lung is abnormal, a pneumothorax is referred to as secondary
spontaneous. There are many pulmonary diseases which predispose to pneumothorax
including:
cystic lung disease
emphysema, asthma
pneumocystis jiroveci pneumonia (PJP)
honeycombing: end stage interstitial lung disease
lymphangiomyomatosis (LAM)
Langerhans cell histiocytosis (LCH)
due to apical lung changes from ankylosing spondylitis
cystic fibrosis
parenchymal necrosis
lung abscess, necrotic pneumonia, septic emboli, fungal disease, tuberculosis
cavitating neoplasm, metastatic osteogenic sarcoma
radiation necrosis
other
catamenial pneumothorax: recurrent spontaneous pneumothorax during menstruation, associated
with endometriosis of pleura
rarely pleuroparenchymal fibroelastosis
Catamenial pneumothorax
Occur in conjunction of menstruation
Caused primarily by endometriosis of pleura
Occur in woman aged 30-40 yrs old
Begins 1-3 day after menses onset
Pathophysiology:
Endometrial tissue attaches within the thoracic cavity, forming
chocolate-like cysts
The mechanism through which endometrial tissue reaches the
thorax remains unclear.
The cysts can release blood; the endometrial cyst "menstruates" in
the lung. Air can move in by an unknown mechanism. The blood and
air cause the lung to collapse (i.e. catamenial hemopneumothorax)
CLINICAL FEATURE
Chest pain (sharp and pleuretic)
Dyspnea
Tachycardia
Tachpnoea

Symptoms in PSP may be minimal or absent. In contrast,


symptoms are greater in SSP, even if the pneumothorax is
relatively small in size.
The presence of breathlessness influences the management
strategy.
Severe symptoms and signs of respiratory distress suggest the
presence of tension pneumothorax.
PHYSICAL EXAMINATION
Decrease breath sound
Hyperressonance on the affected site
May include subcutaneous emphysema of
neck and chest wall
In tension pneumothorax:
Tracheal deviation, cyanosis, and jugular venous
distension
INITIAL MANAGEMENT
Measure vital sign,and monitor pt ECG and
pulse oximetry.
Administer 100% oxygen
Rate of reabsorption of of pneumothorax ,
assuming no persistent air leak, is between 1.25%
- 2.2% of the vol of hemithorax per day
Addition of high flow oxygen therapy (10L/min)
increases this reabsorption rate four fold (6%/day)
during that period of supplementation
INVESTIGATION
CT is considered the gold-standard in the
diagnosis of pneumothorax. Thoracic
ultrasound has more sensitivity than a supine
chest radiograph.
CXR

The diagnosis of
pneumothorax is
established by
demonstrating the outer
margin of the visceral
pleura (and lung), known as
the pleural line, separated
from the parietal pleura
(and chest wall) by a lucent
gas space devoid of
pulmonary vessels.
The presence of a deep
costophrenic angle on a
supine film may be the only
sign of pneumothorax; this
has been termed the deep
sulcus sign. The supine
radiograph is of particular
importance in trauma or
critically ill patients.
The most common
radiographic
manifestations of
tension
pneumothorax are
mediastinal shift,
diaphragmatic
depression, and rib
cage expansion.
Bullae vs pneumothorax
Bullae is the air-filled space in the lung parenchyma
due to destruction of alveolar tissue, distal to terminal
bronchiole
Bullae may be mistaken from loculated pneumothorax
The pleural line caused by pneumothorax is usually
bowed at its centers towards lateral chest wall but
inner margins of bullae is generally concave rather
than convex
DD by comparison with previous xray, or CT scanning
USG
A portable ultrasound machine with a high-
frequency (5-10 MHz) linear probe is typically
used.
Examination should begin with the patient in a
supine position and at the most superior
portion of the chest, which should correspond
to the least gravitationally dependent area of
the thorax. This is usually in the third or fourth
intercostal space in the mid-clavicular line.
The ribs are identified; these will appear
hyperechoic, and their acoustic shadows will
appear as hypoechoic rays extending from the
ribs. The interspace between the 2 ribs is used
as a fixed anatomic landmark during the
examination. Next, the pleural line is
identified; this is a hyperechoic line found at
the inferior border of the space between the 2
ribs.
The presence of a pneumothorax is
characterized by the following findings:
Absence of pleural sliding
Absence of comet tail
Absence of pleural sliding

In normal patients, the pleural line back-and-forth sliding is


easily visualized during the respiratory cycle.
In the presence of a pneumothorax, air accumulates between
the 2 layers and blocks transmission of sound waves, so that
the sliding is not visualized.
More easily visualized by viewing a still image in M-mode
The appearance of normal lung has been described as the seashore
sign. This term refers to the change in appearance between soft tissue
and lung, divided by the pleural line, a change resembling that
between sand and sea waves.
In the presence of a pneumothorax, this demarcation is lost, and the
appearance on M-mode imaging is described as the stratosphere sign
M-mode ultrasonography showing
seashore sign, indicating normal
lungs. No pneumothorax exists

M-mode ultrasonography showing


stratosphere sign, indicating
pneumothorax
Absence of comet tails

Comet tails are artifacts that are thought to be


created when ultrasound waves bounce off the
interface between the apposing visceral and
parietal layers of the pleura. They appear as
hypoechoic vertical raylike projections off the
pleural line and are parallel to the rib shadows
The presence of air in the pleural space inhibits
the propagation of sound waves, preventing
the appearance of comet tails.
The size of pneumothorax can be determined
by:
The distance from the lung apex to the ipsilateral
cupola (apex of the lung)at the parietal surface
Small pneumothorax <3cm and large >3cm
The interpleural distances
Small pneumothorax <2cm and large >2cm
MANAGEMENT
Management depend on:
Stability of patient
Size of pneumothorax
Type of pneumothorax
Heimlich valve
Mechanical one way valve. Proximal end attach
to chest tube and distal end connect to suction
device or left open to atmosphere
Allow air to escape from chest and prevent air
from entering
Advantage:
Not required water to operate
Not position sensitive
Early ambulation of patient