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The Chest:

Pneumothorax, Hemothorax, Effusions, & Empyema

Bradley J. Phillips, M.D.

Burn-Trauma-ICU Adults & Pediatrics

definition, classification, & management



collection of air within the pleural space

transforms the potential space into a real one may lead to various degrees of respiratory compromise with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario
impairs respiratory function decreases venous return to the right-side of the heart

General Management
First: Second: Third: evacuate the air


address the underlying source promote pleural symphysis

Classification System
Spontaneous Pneumothorax
Primary Secondary


Traumatic Pneumothorax
Pulmonary source Tracheobronchial source Esophageal source

Primary Spontaneous Ptx
males > females tall, slim body habitus cigarette smoking implicated usual cause: parenchymal blebs apex of the upper lobe superior segment of the lower lobe


a disease of younger individuals (15 - 35 yrs of age)

Primary Spontaneous Ptx:


in most instances, the treatment of a first-occurrence consists of hospitalization, tube-thoracostomy to closed drainage, lung-re-expansion against the chest wall, and control of any persistent air-leak
[Graeber 98]



when do you operate on a primary spontaneous pneumothorax ?

COPD / Asthma / Cystic Fibrosis Immunocompromised Infections
Tb & Cocci PCP (becoming more common)


Secondary Ptx: due to underlying pulmonary disease

Treatment: Closed Thoracostomy

Water-seal Heimlich-Flutter Valve V.A.T.S.

Traumatic Ptx


Parenchymal Injury vs. Tracheobronchial vs. Esophageal

Blunt or Penetrating Iatrogenic central lines / thoracentesis / biopsy endotracheal tube placement (esp. dual-lumen tubes !) endoscopy / dilational techniques Barotrauma Ventilation / blast injury / Boerhaves syndrome Operative

The Tension Ptx


path of least resistance life-threatening emergencyhow do you treat a tension ptx ??

The Open Ptx: sucking-chest wound

intrinsic lung compliance creates complete collapse 3-sided dressing thoracostomy away from the traumatic wound

Treatment Options
Observation: Inpatient vs. Outpatient Thoracostomy Drainage
3rd Interspace / 5th Interspace Negative Suction / Water-seal


V.A.T.S. (becoming the standard) Muscle-sparing Thoracotomy Posterolateral & Anterolateral Thoracotomy

Pneumothorax Questions ?




Questionswell, I have some -

1. What is the best diagnostic study ? 2. What is the role of 100 % Oxygen & Conservative-mgmt ? 3. How would YOU treat a small Ptx (1 cm) in acute trauma ? 4. What is the predicted recurrence rate for a spontaneous Ptx ? 5. What is a deep sulcus sign ?

Pleural Effusions
what are they ? where do they come from ? & how do you treat them ?

the accumulation of excess fluid within the pleural space in response to injury, inflammation, or both

may represent a local response to disease or may just be a manifestation of a systemic illness

Pathogenesis of Effusions
Rate of Fluid Accumulation
1. Altered Pleural Membrane Permeability 2. Decreased Intravascular Oncotic Pressure 3. Increased Capillary Hydrostatic Pressure 4. Lymphatic Obstruction 5. Abnormal Sites of Entry

Rate of Fluid Removal

Clinical Manifestations
Pain Cough Dyspnea Dullness to Percussion Diminished or Absent Vocal Resonance Diminished or Absent Tactile Vocal Fremitus Friction Rub

Clinical: A Few Points

Large Effusions that prevent contact between the Visceral & Parietal Pleura during respiration are seldom associated with pleuritic chest pain.
Tumors involving the parietal pleura generally produce constant dull pain (Remember Ben Daly, M.D.)

Large effusions interfere with expansion of the lung and produce dyspnea, shortness of breath, and atelectasis

Radiologic Assessment
Chest X-Ray: PA & Lateral-Decub


blunting of either costophrenic angle is indicative of the accumulation of between 250 - 500 ml of fluid Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening & fibrosis Sub-Pulmonic Effusion: accumulation of fluid between the lung & the diaphragm which gives the false impression of an elevated hemidiaphragm

Radiologic Assessment


Ultrasound: Helpful in Confirming the Presence of a

Small Pleural Effusion & Identifying Loculations

C.T. : Extremely Sensitive !!

also helps to view the underlying lung (which may be obscured by pleural disease) can distinguish between Lung Abscess & Empyema

Pleural Fluid Analysis

Thoracentesis = Pneumothorax

Pleural Fluid Analysis

Thoracentesis: Transudate vs. Exudate
1. Gross Appearance 2. Cell Count & Differential 3. Gm Stain, C & S 4. Cytology 5. LDH 6. Protein 7. Glucose, Amylase

straw-colored, clear, odorless fluid with a WBC less than 1000 / ul
Pleural Membranes are Intact Secondary to Altered Starling Forces Low in Protein & other Large Molecules
CHF, Cirrhosis, Nephrotic Syndrome

Hypoalbuminemia, Constrictive Pericarditis, SVC Obstruction, PE

Characterized by Increased Protein & LDH
[Pleural Fluid vs. Serum Levels]

Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic Drainage

Parapneumonic, Infections, Malignancy, Vasculitic Disease, GI Disease, TB, PE

Criteria for Exudative Effusion

1. Pleural Protein : Serum Protein 2. Pleural LDH : Serum LDH 3. Pleural LDH

> 0.5 > 0.6 > 200

only need 1 critical value to establish the diagnosis of exudate

a bloody pleural effusion occurring in a patient without a history of trauma or pulmonary infarction is Indicative of Neoplasm in 90 % of cases!
Because a RBC count as low as 5000 - 10,000 /ul, can cause a pleural effusion to turn red, the finding of blood-tinged fluid per se has little diagnostic value (usually from needle trauma) A True Hemothorax is when the Pleural Fluid Hct exceeds 50 % of the Peripheral Blood Hct !

Transudative Effusion: focus on the systemic cause
Exudative Effusion: dependent on the exact sub-type Consider Chest Thoracostomy
Gross Pus / Empyema pH < 7.2 Hemothorax Complicated Parapneumonic Processes Malignant Effusionsbut remember the role of pleurodesis!

although pleural disease itself is rarely fatal, it may be a significant cause of patient morbidity

appropriate treatment may produce dramatic symptomatic relief !

Pleural Effusions
Questions ?

the collection of blood between the visceral and parietal pleura



Causes of a Spontaneous Hemothorax

bullous emphysema, PE, infarction, Tb, AVMs

Pleural: torn adhesions, endometriosis Neoplastic: primary, metastatic (melanoma) Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation Thoracic Pathology: ruptured aorta, dissection Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum



The Pathophysiologic Process

the accumulation of pleural blood forms a stable clot overall ventilation & oxygenation becomes impaired
mechanical compression of the lung parenchyma mediastinal shift flattening of the hemidiaphragm



The Pathophysiologic Process

over time, the clot is partially-absorbed, leaving behind loculated fluid and fibrinous septations macro-fibrin deposition begins to provide a structural framework this peel slowly contracts to entrap the underlying lung



Goal of Treatment
to remove the pleural blood and allow for complete lung re-expansion

General Management Options


thoracentesis: bedside / ultrasound-guided / C.T.-guided thoracostomy drainage: the mainstay thorascopic surgery: less than 2 wks. & use a 30-degree scope thoracotomy: massive hemothorax / instability / chronic hemothorax local fibrinolytic therapy: urokinase (1000 IU/ml) in 150cc solution

Dual Chest Tube Management


Often, there is an accompanying pneumothorax

Superior-Apical: Ptx Diaphragmatic-posterior: Htx Consider targeted-drainage into a loculated collection

All tubes to negative suction with protective water-seal Prophylactic antibiotics may be indicated while the tubes are in (controversial!!) Chest tubes removed: 100 -150 ccs / day



Undrained hemothorax increases the risk of empyema & fibrothorax

Large collections should be drained slowly to minimize the development of re-expansion-pulmonary-edema [R.E.E.P.] (stop after 2 literswait 6-8 hrs, then drain out another 1-2 liters, etc) Computed tomography is the diagnostic of choice

Questions ?

Questionswell, I have some

1. 2. 3.

When do YOU operate on a Traumatic Hemothorax ? What options exist in trying to drain a hemothorax (chest tube placement) ? What are the reported complications of chest tube placement ?

What is an Empyema ?

Empyema Thoracis
An Accumulation of Pus in the Pleural Cavity
1-2 % incidence in the pediatric population

Up to 18 % in immunocompromised adults
General Management
Appropriate Antibiotic Coverage Thoracostomy Drainage Streptokinase / Urokinase Surgical Intervention - Decortication

The Stages of Empyema

Stage I - Exudative
sterile pleural fluid develops secondary to inflammation without fusion of the pleura

Stage II - Fibrinopurulent
a fibrinous peel develops on both pleural surfaces limiting lung expansion

Stage III - Organizing

in-growth of capillaries & fibroblasts into the fibrinous peel

Empyema: A Pediatric Review

# of Cases # of Positive Cultures

Strep pneumo Staph aureus # of Positive Cultures # of Cases

Staph aureus Strep pneumo

Questions ?

dont let it happen !!!

The Chest:
Pneumothorax, Hemothorax, Effusions, & Empyema

Any Questions?