Pneumothorax.pptx

lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Introduction & history

3. Pathophysiology 3

4. Pathophysiology The probable cause of pneumothorax is rupture of an apical bleb or bulla Smoking causes a 9-fold increase in the relative risk of a pneumothorax in females A 22-fold increase in male smokers 4

5. Mechanism 5

6. Mechanism In normal people, the pressure in pleural space is negative during the entire respiratory cycle. When a communication develops between pleural space, and intrapulmonary air space or exterior and air will flow into the pleural space until there is no longer a pressure difference or the communication is sealed Compress lungs,blood vessels and heart Decreased cardiac output Impaired venous return Hypotension 6

7. Etiology

8. Etiology

9. Primary spontaneous pneumothora x It occurs in young healthy individuals without underlying lung disease It is due to rupture of apical sub-pleural bleb or bullae Predisposing factors: Smoking. Tall, thin male. Airway inflammation (distal) Structural abnormalities of bronchial tree Genetic contribution 9

10. Secondary spontaneous pneumothorax Common causes. TB Asthma COPD Suppurative pneumonia Cystic fibrosis Rare cause ILD Eosinophilic granuloma Sarcoidosis Lymphangioleiomyomatosis AIDS. 10 Primary lung carcinoma Complication of chemotherapy Connective tissue disease Scleroderma Marfans syndrome Histiocytosis - x Rheumatoid disease Pulmonary infarct Wegener’s granulomatosis …

11. Traumatic pneumothorax Accidental trauma :(non-iatrogenic) Blunt trauma : with fracture ribs. Penetrating trauma : stab wound or gun shot injury. I atrogenic : Positive pressure ventilation : Alveolar rupture  interstitial emphysema  pneumothorax .( B/L PNX ) Interventional procedures : Biopsy, thoraco-centesis , CVP line,trachestomy etc.. 11

12. Clinical Features 12

13. Clinical Features Constant Dyspnea Chest pain ( pleuritic ) Uncommon manifestation Cough Hemoptysis Orthopnea Cyanosis Tachycardia Anxiety, vague presenting symptoms ( eg , general malaise, fatigue)  13

14. 14 C linical types

15. 15 Closed pneumothorax Open pneumothorax Tension pneumothorax The pleural tear Is sealed The pleural tear is open The pleural tear act as a ball & valve mechanism The pleural cavity pressure is < the atmospheric pressure The pleural cavity pressure is = the atmospheric pressure The pleural cavity pressure is > the atmospheric pressure

16. Tension pneumothorax Tension pneumothorax is classically characterized by hypotension and hypoxia.

17. Tension pneumothorax It is life threatening condition. Rapidly progressive breathlessness and circulatory collapse (tachycardia, hypotension & sweating). Jugular venous distention The pleural pressure is more than the atmospheric pressure. Radiological manifestations of large pneumothorax Mediastinal shift, Flattening of the hemidiaphragm & Lung collapse. It is more common with Positive pressure ventilation & Traumatic pneumothorax .

18. Clinical features: IN ICU

19. Clinical features: IN ICU Patients on Mechanical ventilation or cardiopulmonary resuscitation who suddenly deteriorate clinically,with RAPIDLY PROGRESSIVE DYSPNOEA . Cyanosis Marked tachycardia Hypotension The airway pressure alarms are triggered.

20. Physical examination Depend on size of pneumothorax The vital signs usually normal Unilateral Chest movements The trachea may be shifted toward the contralateral side if the pneumothorax is large Tactile fremitus is absent The percussion note is hyperresonant The breath sounds are reduced or absent on the affected side The lower edge of the liver may be shifted inferiorly with a right-side pneumothorax

21. Pneumothorax in erect position Pneumothorax in supine position Air in apicolateral pleural space Air in anteromedial pleural space.

22. Small pneumothorax 22

23. 23 Small pneumothorax

24. LARGE PNEUMOTHORAX 24

25. 25

26. Visceral pleural line 26

27. DD of visceral pleural line Skin fold : Positive mash band (optical edge enhancement). Extend beyond the chest wall. Lung markings extend beyond it.

28. DD of visceral pleural line Scapular edge

29. Tension pneumothorax 29

30. 30

31. CT scanning It is recommended in difficult cases such as patients in whom the lungs are obscured by overlying surgical emphysema To differentiate a pneumothorax from suspected bulla in complex cystic lung disease 31

32. CT can diagnose easily pneumothroax

33. CT can diagnose easily pneumothroax

34. 34 34 CT scanning

35. 35 35 CT scanning Small pneumothorax Subcutaneous emphysema

36. U/S in pneumothorax Ultrasound found to be more sensitive than CXR in diagnosis of pneumothorax .

37. Treatment

38. Treatment Traumatic pneumothorax Intercostal tube drainage for trauma. Aspiration is the technique of choice for iatrogenic pneumothoraces , because recurrence is usually not a factor. Tube thoracostomy is reserved for very symptomatic patients.

39. TREATMENT OPTIONS FOR PSP AND SSP Observation O2 treatment Simple aspiration Small catheter aspiration Chest tube drainage/ICD Thoracoscopy (VAT with blebectomy & VAT with pleurectomy ) Open ( axillary ) thoracotomy 39

40. Observation - PSP Small, closed mildly symptomatic spontaneous pneumothorax do not require hospital admission It should be stressed to patient that they should be return directly to hospital in the event of developing breathlessness. 40

41. Observation - SSP Observation alone is only recommend in patients with small SSP of less than 1 cm depth or isolated apical pneumothorax in asymptomatic patients Hospitalization is recommended in these cases All other cases will require active intervention (aspiration or chest drain insertion) 41

42. Observation - PSP or SSP 42 Marked breathlessness in a patient with a small (<2 cm) PSP may develop tension pneumothorax Observation is inappropriate and active intervention is required If a patient is hospitalised for observation, supplemental high flow ( 10 l/min ) oxygen should be given where feasible.

43. 43 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 should be admitted to hospital and observed for at least 24 hours before discharge.

44. 44 Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been successful A volume of < 2.5 L has been aspirated on the first attempt The aspiration can be done by needle or catheter C atheter aspiration

45. Chemical pleurodesis 45 Goals To prevent pneumothorax recurrence To produce inflammation of pleura and adhesions Indications: Persistent air leak and repeated pneumothorax Bilateral pneumothorax Complicated with bullae Lung dysfunction, cannot tolerate operation.

46. Surgical treatment 46 Indications No response to medical treatment Persistant air leak Hemopneumothorax Bilateral pneumothoraces Recurrent pneumothorax Tension pneumothorax failed to drainage Thickened pleura making lung unable to reexpand Multiple blebs or bullae

47. Thoracoscopy - VATs It is being increasingly used in ot with recurrent psp-ssp Recent studies show VATs may be the procedure of choice and it has much less complication when compared to other open surgery Pleural belbs causes pneumothorax which can be treated by a method called endostapling or suture followed by pleurodeisis 47

48. Axillary (open) thoracotomy Transaxillary minithoracotomy is preferred .when VATs is not available Open thotacotomy with suturing of blebs and pleural abrasion is done Recurrence High risk professions B/L or tension pneumothorax 48 INDICATIONS

49. Recurrence of spontaneous pneumothorax 50% on the same side. 15% on the contralateral side. More common in secondary spontaneous pneumothorax .

50. Tension pneumothorax