Pneumothorax

Presence of air in pleural cavity with secondary lung collapse

1. PNEUMOTHORAX Dr. Noorulhaque Shaikh MBBS; DA; DNB(Anaesthesiology) Fellow in Critical Care Medicine SMBT Institute of Medical Sciences & Research Centre Nashik

2. Presence of air in pleural cavity with secondary lung collapse

3. Well-known inherited diseases associated with pneumothorax Birt -Hogg- Dube syndrome Marfan's syndrome Homocystinuria Ehlers- Danlos syndrome Alpha1-antitrypsin deficiency

4. Diseases and conditions associated with secondary spontaneous pneumothorax Obstructive lung disease Chronic obstructive lung disease (COPD) Asthma Interstitial lung disease Idiopathic pulmonary fibrosis (usual interstitial pneumonitis [UIP]) Non-specific interstitial pneumonitis Eosinophillic granuloma Lymphangioleiomyomatosis Sarcoidosis Langerhans cell granulomatosis Radiation pneumonitis or fibrosis Histocytosis X

5. Infection P. jerovici pneumonia Tuberculosis Coccidioidomycosis Acute bacterial pneumonia (i.e.: staphylococcus) Malignancy Primary lung carcinoma Pulmonary metastasis (especially sarcomas) Complications of chemotherapy

6. Connective tissue disease Rheumatoid arthritis Ankylosing spondylitis Marfan’s syndrome Ehlers- Danlos syndrome Polymyositis / dermatomyositis Scleroderma

7. Other Catamenial pneumothorax Pulmonary infarction Pulmonary hemorrhage Pulmonary alveolar proteinosis Tuberous sclerosis Von Recklinghausen’s disease Wegener’s granulomatosis

8. Causes of iatrogenic pneumothorax Transthoracic needle aspiration biopsy ( 28%) Central venous catheter insertion(22%) , Thoracentesis (12) Transbronchial biopsy(2-5%) Intercostal nerve block, Tracheostomy Positive pressure ventilation and ARDS in the ICU

9. Causes of non iatrogenic pneumothorax Trauma - Penetrating and nonpenetrating injury Rib fracture High-risk occupation.

10. Pathogenesis and mechanisms In normal people, the pressure in pleural space is negative during the entire respiratory cycle Two opposite forces result in negative pressure in pleural space: inherent outward pull of the chest wall and inherent elastic recoil of the lung The negative pressure will be disappeared if any communication develops

11. Pathogenesis and mechanisms When a communication develops between an alveolus or other intrapulmonary air space and pleural space, air will flow into the pleural space until there is no longer a pressure difference or until the communication is sealed.

12. Pathogenesis and mechanisms When a communication develops through the chest wall between the atmosphere and the pleural space air will enter the pleural space until the pressure gradient is eliminated or the communication is closed

13. Pathophysiology Changes due to Pneumothorax: Negative pressure eliminated The lung recoil-small lung-volume decrease V/Q decrease-shunt increase Positive pressure causes- Compression of blood vessels and heart Decreased cardiac output Impaired venous return Hypotension Shock Result in A decrease in vital capacity , DLCo A decrease in PaO2

14. Clinical manifestation Symptom : Depend on whether underlying pulmonary disease or not Depend on the speed of pneumothorax occurred Depend on size of pneumothorax Depend on the level of intrapleual pressure The patient with underlying pulmonary disease will undergo severe dyspnea The healthy person will have minimal symptoms although having large volume of pneomothorax

15. Chest pain-prickling-like, cutting-like Dyspnea Dry cough

16. Tension pneumothorax risk factors: Receiving positive-pressure mechanical ventilation During cardiopulmonary resuscitation Undergoing hyperbaric oxygen therapy Evolving during the course of spontaneous pneumothorax

17. Clinical manifestation Tension pneumothorax -Distressed with rapid labored respiration -Cyanosis -Marked tachycardia -Profuse diaphoresis Patient who suddenly deteriorate clinically, be suspected if the patient with -Mechanical ventilation -Cardiopulmonary resuscitation

18. General examination Depend on size of pneumothorax Tachypnoea Tachycardia Raised JVP Cyanosis Subcutaneous emphysema

19. Physical examination The breath sounds are reduced or absent on the affected side The trachea may be shifted toward the contralateral side if the pneumothorax is large Tactile fremitus is absent The percussion note is hyperesonant The lower edge of the liver may be shifted inferiorly with a right-side pneumothorax Hamman’s sign ( pneumomediastinum )

20. Radiological manifestations

21. Imaging- Plane chest X-ray film Establishing the diagnosis The characteristics of pneumothorax Pleural line No lung markings in pneumothorax The outer margin of visceral pleura separated from the parietal pleura by a lucent gas space devoid of pulmonary vessels

22. If suspected clinically Xray in full expiration In lateral decubitus position Very small pneumothorax also can be detected

23. Pneumothorax signs Deep Costophrenic Sulcus Sign

24. Double diaphragm sign subpulmonic pneumothorax

25. Estimation of pneumothorax volume 1. Light equation Pneumothorax％＝ （1－L3/HT3）x 100 Lung (L) Hemithorax (HT)

26. 2.Rhea method= on Xray there is 10% pneumothorax for every 1 cm of intrapleural distance. 3.Collin’s index % pneumothorax = 4.2 + [4.7 X (A + B + C))

27. BTS guideline Lung margin to chest wall small<2cm large≥2cm ACCP guideline Lung apex to chest top Small <3cm large≥3cm

28. Treatment Goals To promote lung expansion To eliminate the pathogenesis To decrease pneumothorax recurrence Treatment options according to Classification of pneumothorax Pathogenesis Pneumothorax frequency The extension of lung collapse Severity of disease Complication and concomitant underlying diseases

29. TREATMENT MODALITIES Observation Supplemental oxygen Simple aspiration Tube thoracostomy with or without instillation of sclerosing agent Medical thoracoscopy with the insufflation of talc Video assisted thoracoscopy with stappling of blebs.

30. Observation Observation alone is advised for small, closed mildly symptomatic spontaneous pneumothoraces Patients with small PSP and minimal symptoms do not require hospital admission. However, it should be stressed before discharge that they should return directly to hospital in the event of developing breathlessness No heavy physical exertion. Most patients in this group who fail this treatment have secondary pneumothoraces

31. Observation - SSP Observation only is recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothoraces in asymptomatic patients

32. Marked breathlessness in a patient with a small (<2 cm) PSP may be forerunner of tension pneumothorax Observation alone is inappropriate and active intervention is required If a patient is hospitalized for observation, supplemental high flow (10 l/min) oxygen should be given where feasible

33. Inhalation of high concentration of oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen This should increase the pressure gradient between the pleural capillaries and the pleural cavity Thereby increasing absorption of air from the pleural cavity

34. The rate of resolution/reabsorption of spontaneous pneumothoraces is 1.25 – 1.8% of volume of hemithorax every 24 hours The addition of high flow oxygen therapy has been shown to result in a 4-fold increase in the rate of peumothorax reabsorption during the periods of oxygen supplementation

35. Simple aspiration Simple aspiration is recommended as first line treatment for all PSP requiring intervention Simple aspiration is less likely to succeed in secondary pneumothoraces and in this situation, is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients under the age of 50 years Patients with secondary pneumothoraces treated successfully with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge

36. Repeated catheter aspiration Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful A volume of < 3 L can be aspirated on the first attempt,provided pts condition is stable The aspiration can be done by needle or catheter

37. Intercostal tube drainage INDICATIONS Tension pneumothorax Severe dyspnea Intermittent positive pressure ventilation Previous contralateral pneumothorax B/L pneumothorax Presence of pleural fluid Large or complete pneumothoraces Frequent recurrent pneumothoraces Simple aspiration or catheter aspiration drainage is unsuccessful in controlling symptoms

38. Drainage system

39. One bottle system Consists of one bottle that serves as both a collection container and a water seal The chest tube is connected to a rigid straw inserted through a stopper into a sterile bottle Enough sterile saline solution is instilled into the bottle so that the tip of the rigid straw is about 2 cm below the surface of the saline solution The bottle’s stopper must have a vent to prevent pressure from building up when air or fluid coming from the pleural space enters the bottle

40. Three bottle system consists of Collection bottle – for collecting pleural fluid Water seal bottle – for regulating pressure Suction control bottle – connect to the negative pressure pump, for suction of the air of pleural space, pres level: -10 - -20 cm H 2 O

41. Heimlich valve A flutter valve (also known as the Heimlich valve) is a  one-way   valve   It is most commonly used to help remove air from a  pneumothorax . Advantages : no need for under water seal ambulation

42. Chemical pleurodesis Goals To prevent pneumothorax recurrence To produce inflammation of pleura and adhesions Indications Persist air leak and repeated pneumothorax Bilateral pneumothoraces Complicated with bullae Lung dysfunction, not tolerate to operation

43. Chemical pleurodesis Sclerosing agents Tetracycline Talc The instillation of sclerosing agents into the pleural space should lead to an aseptic inflammation with dense adhesions, leading ultimately to pleural adhesion

44. Surgical treatment Indication No response to medical treatment Persist air leak Hemopneumothorax Bilateral pneumothoraces Recurrent pneumothorax Tension pneumothorax failed to drainage Thicken pleura makes lung unable to reexpansion Multiple blebs or bullae

45. Medical thoracoscopy VATS – bullectomy stapling pleural abration laser/electro cautrey pleurectomy Open thoracotomy

46. Bronchopleural fistula 1) FOB: glue, gel foams, endobronchial valves autulogus blood 2) VATS: pleurodesis , stapling, segmentectomy , lobectomy

47. Risk of recurrence Without treatment 1 st year-36% 2 nd year-62% 3 rd year-83%

48. With treatment Observation - 30-40% Aspiration – 25-40% Chest tube- 25-30% Pleurodesis (tetracycline)- 20-25% (talc) 7-15% Surgical 0.6-2%

49. TENSION PNEUMOTHORAX present when the intrapleural pressure exceeds atmospheric pressure throughout expiration and often during inspiration as well Most tension pneumothoraces occur in patients who are receiving positive-pressure ventilation either from mechanical ventilation or during resuscitation

50. Pathophysiology The combination of a decreased cardiac output due to impaired venous return and marked hypoxemia.

51. Clinical manifestation The patient appears distressed with rapid labored respirations, cyanosis, and usually profuse diaphoresis, hypotension, and marked tachycardia. Arterial blood gases reveal marked hypoxemia and, sometimes, respiratory acidosis. The physical findings are those of any large pneumothorax, but in addition, the involved hemithorax is larger than the contralateral hemithorax with the interspaces widened. The trachea is usually shifted toward the contralateral side.

52. management Valuable time should not be wasted on radiologic studies Clinical situation and the physical findings are usually sufficient to establish the diagnosis. given a high concentration of supplemental oxygen to combat the hypoxia. Needle thoracotomy. Immediate insertion of a large chest tube.

53. Complications of pneumothorax Recurrence of spontaneous pneumothorax Heamopneumothorax Pyopneumothorax Respiratory failure Failure of expansion of the collapsed lung Re-expansion pulmonary edema Pneumomediastinum Complications of management

54. BTS Pleural Disease Guideline 2010 A Quick Reference Guide MANAGEMENT OF SPONTANEOUS PNEUMOTHORAX Andrew MacDuff , Anthony Arnold, John Harvey

55. Management of PSP ► Patients with PSP or SSP and significant breathlessness associated with any size of pneumothorax, should undergo active intervention. ► Chest drains are usually required for patients with tension or bilateral pneumothorax, who should be admitted to hospital. ► Observation is the treatment of choice for small PSP, without significant breathlessness. ► Selected, asymptomatic patients with a large PSP may be managed by observation alone. ► Patients with small PSP, without breathlessness, should be considered for discharge with early outpatient review. These patients should also receive clear written advice to return in the event of worsening breathlessness

56. Needle aspiration or chest drain? ► Needle (14–16G) aspiration (NA) is as effective as large bore (>20Fr) chest drains, and may be associated with reduced hospitalisation and length of stay. ► NA should not be repeated, unless there were technical difficulties. ► Following failed NA, small bore (<14Fr) chest drain insertion is recommended. ► Large bore chest drains are not needed for pneumothorax. Suction ► Suction should not be routinely employed. ► High volume low pressure suction systems are recommended

57. Management of SSP ► All patients with SSP should be admitted to hospital for at least 24 hours, and receive supplemental oxygen ► Most patients will require the insertion of a small-bore chest drain. Patients with SSP but unfit for surgery ► Medical pleurodesis may be appropriate for inoperable patients. ► Patients with SSP can be considered for ambulatory management with a Heimlich valve

58. Discharge and follow-up ► Patients should be advised to return to hospital if increasing breathlessness develops. ► All patients should be followed up by respiratory physicians until full resolution. ► Air travel should be avoided until full resolution. ► Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively

59. Medical chemical pleurodesis ► Chemical pleurodesis can control difficult or recurrent pneumothoraces but, since surgical options are more effective, it should only be used if a patient is either unwilling or unable to undergo surgery

60. Surgical strategies: open thoracotomy or VATS? ► Open thoracotomy and pleurectomy remain the procedure with the lowest recurrence rate (approximately 1%) for difficult or recurrent pneumothoraces . ► Video-assisted thoracoscopic surgery (VATS) with pleurectomy and pleural abrasion is better tolerated, but has a higher recurrence rate of approximately 5%.