Pneumothorax PPT -----topic presentation

cause, pathology, diagnosis, management discussed

1. Pneumothorax Dr. Irfat Mahjabeen Clinical fellow (Respiratory Medicine) Worcestershire Acute Hospitals NHS Trust

2. Definition Pneumothorax is the presence of air in Pleural space Normally pleural space is closed latent sac with no air Negative pressure exists in pleural space throughout the respiratory cycle. If any communication develop between pleural space and lung, pressure difference is altered.

3. Classification 1. Spontaneous/ simple 2. Traumatic P rimary : no evidence of lung disease smoking, tall stature are additional risk factors. usually seen in young age <30 years usually rupture of apical or sub pleural blebs Secondary : Occurs due to Underlying diseases : COPD and Pulmonary TB mostly Others : asthma, (ILD), necrotizing pneumonia, cystic fibrosis (CF), Marfan’s syndrome, lung cancer, pulmonary infarction Usually seen in males above 55 years Mortality is 10% Iatrogenic or traumatic chest injury : percutaneous biopsy endoscopic perforation of the esophagus nasogastric tube placement esophageal rupture post CPR Can be associated with haemothorax or haemopneumothoraz

4. Tension Pneumothorax : Life threatening condition One way valve , air enters the pleural space on inspiration, but unable to escape on expiration The progressive increase in pleural pressure > atmospheric pressure Shifting of mediastinum compresses opposite lung and vessels result in impairment of venous return & CVS compromise

5. Clinical features: Symptoms : Pleuritic chest pain and/or Breathlessness , more severe in 2° pneumothorax In tension pneumothorax, features of shock or cardiac arrest or acute deterioration, increasing inflation pressures in mechanical ventilation Signs: tachycardia, tachypnoea, hyoxia, cyanosis, accessory muscles of respiration, raised JVP, Lung : tracheal deviation, reduced expansion, hyper-resonant percussion note, reduced air entry, diminished breath sounds .

6. Investigation: 1. CXR : visceral pleural edge is seen as a very thin, sharp white line. Absent lung markings peripheral to the line Mediastinal shift +/-, lung collapse +/- Peripheral space is radiolucent compared to the adjacent lung

7. 2. Computed tomography (CT): More accurate in detrmining size of pneumothorax Differentiate pneumothorax from bullous disease/ associated underlying lung disease 3.Ultrasound (US) chest : 4. Arterial blood gases (ABGs) - hypoxia and or hypercapnia in 2° pneumothorax

8. Management: 1. degree of breathlessness and hypoxia, haemodynamic compromise. 2. background lung disease/respiratory reserve : 3. size of the pneumothorax : Width of the rim of air, measured from chest wall to lung edge at the level of the hilum , <2 cm: small & ≥2 cm: large (BTS guideline 2010) A 2 cm rim of air = to a 50% pneumothorax in volume (approx)

9. Management of Tension Pneumothorax Medical emergency Do not wait for a CXR if the diagnosis is clinically certain / patient seriously compromised or cardiac arrest Immediate decompression - insert large-bore cannula (14- 16 G) into second intercostal space in mid-clavicular line Cannula shoula be left in place untill ICD can be inserted.

10. Intercostal drain inserted in 4th, 5th. 6th intercostal space in midaxillary line should be removed 24 hrs after lung has fully reinflated and bubbling stopped usually 10-14 F in most cases, never clamp a bubbling chest drain

11. Surgical management Aim is to repair the apical hole or bleb and close the pleural space. Indications for cardiothoracic surgical referral Bilateral spontaneous pneumothorax Persistent air leak or failure of lung to re-expand (3–5 days of drainage) Spontaneous haemothorax 1st contralateral and 2nd ipsilateral pneumothorax Professions at risk (e.g. pilots, divers) after first pneumothorax. pneumothorax in pregnancy

12. Plurodesis Talc commonly used, failure rate 10-20% via intercostal drain , placed between the pleural layers to decrease pleural space and prevent fluid build up only as a last resort in older patients with recurrent pneumothorax in whom surgery would be high risk ( severe COPD) in an incompletely re-expanded lung with a persistent air leak, plurodesis may be attempted if surgery is not an option.

13. Advice during discharge Diving- never unless surgically corrected , normal lung function testand a chest CT postoperatively Flying - 1 week from complete resolution smoking cessation F/up in 4 to 6 weeks time Risk of recurrence is around 30% after a 1st pneumothorax, 40% after a 2nd, and > 50% after a 3rd incidence

14. Thank You