Pneumothorax (surgical management)

cardiothoracic surgry
postgraduate

1. Pneumothorax By: MAHMOUD SALLAM CARDIOTHORACIC SURGERY Dept.

2. DEFINITION Pneumothorax is the presence of air in the pleural space Causing partial or complete lung collapse depending on etiology and volume of the pneumothorax and the resultant intrapleural pressure and condition of the underlying lung .

3. Anatomy The pleural space is lined by the visceral and parietal pleurae The visceral pleura is a thin layer (usually one cell thick) intimately covering the outer surface of the lung. It adheres to the lung parenchyma via connective tissue (elastic fibers ). There is therefore no true cleavage plane between the visceral pleura and the lung parenchyma that it envelops. The visceral pleura has no somatic innervation . The parietal pleura is lines the inside of the chest wall, diaphragm, and mediastinum and is attached to these by a fibrous and connective tissue layer known as the endothoracic fascia which is the dissection plane that allows the parietal pleura to be stripped off of the chest wall and other structures. It is thickest along the chest wall, overlying the ribs, and thinnest as it covers the mediastinal structures and beneath the sternum. The parietal pleura is innervated by somatic, sympathetic, and parasympathetic nerve fibers via the intercostal nerves

4. Physiology The elastic and retractive nature of the chest wall and lung pull the parietal and visceral pleurae away from one another, thus creating a negative intrapleural pressure usually in the range of -2 to -5 cm H2O . During inspiration , the outward chest wall and diaphragmatic forces counteracting the normal elastic recoil of the lung parenchyma can create intrapleural pressures of -20 to -35 cm H2O.

5. Gravity also exerts an influence on this negative intrapleural pressure. In the upright position, the apex has a greater negative intrapleural pressure than the base of the lung in the region of the costophrenic sulci (0.25 cm H2O/cm of height). This phenomenon may contribute to some degree to creating increased distention of alveoli in the apex and a greater predisposition to spontaneous pneumothoraces by rupture of apical blebs .

6. Pressure gradient between the gases in the venous blood and those of the arterial system and pleural space usually between 54 and 72 cm H2O, ensures against spontaneous gas formation in the pleural space as long as the intrapleural pressures do not become less than -72 cm H2O. More practically, this also explains how pleural air, such as in the case of a pneumothorax , can be gradually reabsorbed by diffusion into the venous circulation.

7. classification Classified accord to cause Spontaneous Acquired Spontaneous classified accord to underlying lung disease into PSP SSP classified further as depending on the presence or absence of air leak at the time of presentation and intervention open closed

8. incidence Psp male 18-28 female 2-6 /100000/y Ssp male 6.4 female 2/100000/y Recurrence 30% psp 43% ssp 2 nd recurrence rates 67% if 1 st episode not treated properly RF Young age Older < 40 ys CF Increase ht / wt ratio CT evidence of ELCs

9. psp No underlying lung disease The 1ry cause is subpleural bleb rupture Ptn usually had ELCs 81% Typical ptn Tall Thin Young age ( 16-30ys) Smooking

10. psp Mech of bleb formation: Degradation of elastic element ( smoking) Rapid increase in vertical chest diameter in childhood ELCs usually bilat and affect apical segments of UL&LL OTHE FACTORS: Familial inheritance Respiratory bronchiolitis (81% of smokers) Pleural porosity

11. SSP

12. B- Acquired Iatrogenic Transthoracic needle biopsy Subclavian ( percutaneous ) catheterization Central lines Pacemaker insertion Transbronchial lung biopsy Thoracocentesis Chest tube malfunction After laparoscopic surgery Barotrauma Traumatic Blunt trauma Motor vehicle accidents Falls Sports-related Penetrating trauma Gunshot wounds Stab wounds

13. IATROGENIC PNTHX 5 Leading causes TRANSTHORACIC NEEDLE ASPIRATION 24% SCVs puncture 22% Thoracocentesis 22% Pleural biobsy 8% Mechanical ventilation 7% Others Acupuncture Illicit drugs Radiofrequency ablation Intubation git endoscopy

14. Rf for needle aspiration Subpleural lesion Wide cannula < 18fr Wide Trajector angle Lesion > 2cm Several pleural planes Management Coservation Intervention20% Ict 14 fr Simple aspiration IATROGENIC PNTHX

15. catamenial pneumothorax pneumothorax that occurs, and recurs, during the first 3 days of menses, may occur in the ovulatory phase Part of TES SITE: pulmonary Pleural Diaph Tracheobronchial( rare)

16. Include: Cataminial pneumothorax Catamnial hemothorax Cataminial hemoptysis Lung nodule Age: 35ys Bilat in pulm and unilat Rt in others AE: unknown may due to diaph. fenestration and ndometrial implants C/P : cough ,dyspnea & chstpain BROWN IMPLANT OR CHOCLATE CYST MANAGMENT catamenial pneumothorax

17. PNEUMOTHORAX WITH PREGNANCY ATMOSPHERIC PNEUMOTHORAX

18. Spontaneous rupture of the esophagus Forcible emesis against closed cricopharengeus Usually lt posterolat . Part near diaphragm

19. Barotrauma pneumothorax Defined as that occurring in a patient receiving positive-pressure ventilation. Often attributed to areas of the lung that become overdistended during mechanical ventilation as other areas are consolidated and poorly ventilated. As a general rule, any barotrauma pneumothorax is an indication for tube thoracostomy

20. Pathological types Simple (closed) pneumothorax . Open pneumothorax . Tension pneumothorax .

21. PRESENTATION Sudden onset of chest pain Shortness of breath Cough

22. The physical findings Tachyardia Hyperresonance to percussion Decreased breath sounds on the affected side. In instances of mild collapse, physical findings can be misleadingly normal, so that if the history suggests pneumothorax and yet the physical examination is normal, a chest radiograph should be obtained

23. True tension pneumothorax - Accompanied by tachycardia, sweating, hypotension, and pallor - That result from mediastinal shift, reduced preload, and intense stimulation of the sympathetic nervous system

24. RADIOGRAPHIC DIAGNOSIS 1- CXR The standard procedure in making the diagnosis. It should be upright and preferably in the posteroanterior projection. It is possible to miss a pneumothorax in a semisupine portable anteroposterior view. If the patient cannot be upright, a lateral decubitus view with the suspect side positioned up may be helpful.

25. A giant bulla can mimic a pneumothorax . Subtle lines demarcate a bulla, which tends to be surrounded by thickened visceral pleura. In addition, a pleural line can frequently be seen with lung markings visible beyond the suspected bulla (double wall sign )

26. British Thoracic Society guidelines for the management of spontaneous pneumothorax , recommend defining pneumothoraces as: small defined as small rim of air around the lung moderate as lung collapsed halfway towards the heart border complete as airless lung, separate from the diaphragm.

27. 2- CT CHEST CT is seldom required for routine diagnosis of SP it can help differentiate between SP and a giant bulla. Controversy exists about the significance of routine chest CT to evaluate for subpleural blebs. However identification of large or multiple subpleural blebs on CT is an indication for early surgical intervention to prevent recurrence.

28. COMPLICATIONS PRESISTENT AIR LEAKE PNEUMOMEDIASTINUM TPT HEMOPNEMOTHORAX RECURRENCE

29. TREATMENT Treatment Options for Pneumothorax Observation Needle aspiration Percutaneous catheter to drainage Water-seal or Pleur-evac type Heimlich valve Tube thoracostomy Water-seal or Pleur-evac Heimlich valve Tube thoracostomy with instillation of pleural irritant Video-assisted thoracic surgery (VATS) Thoracotomy

30. Observation Indication : Small pneumothoraces are those that are less than 3 cm in distance between the apical parietal pleura and the thoracic cupula , with no lateral component. Asymptomatic patients Methods: 24-26 by close monitoring & physical examination. Supplying extra oxygen to such patients theoretically hastens the resolution of the pneumothorax . continuous pulse oximetry . Repeated chest radiography within 6 hours.

31. Our practice is to monitor patients in the hospital for a minimum of 24 hours. Even though some patients with stable radiographic features may be discharged from the hospital with follow-up within 12 to 24 hours,24 the potential for catastrophic consequences from a missed tension pneumothorax is a great risk. Small pneumothoraces usually resolve without intervention, but recurrence is possible. If chest radiography reveals that the SP is enlarging, immediate intervention is crucial.. The results of observational therapy have been under question

32. Needle or small-catheter aspiration In mild to moderate spontaneous pneumothorax ,it may hasten the resolution if a persistent leak is absent. The British Thoracic Society, recommends it as a primary treatment option for primary spontaneous pneumothorax . American College of Chest Physicians, found that there is increasing support in America for initial aspiration of clinically stable patients with small pneumothoraces .

33. Seldinger technique Tech: which uses a small, single-lumen central line placed over the superior rib edge in the second interspace in the midclavicular line. A three-way stopcock and large syringe are used to aspirate until resistance is felt usually signifying full lung expansion Chest radiography is then performed to confirm the findings, and the catheter is Removed Complications of aspiration: bleeding possible lung injury

34. Tube Thoracostomy Tube thoracostomy is recommended for patients with large or symptomatic SP and for most patients with SSPs Tech: Through the fifth intercostal space in the midaxillary line Apical placement speeds resolution, and a subcutaneous track prevents “sucking air” during removal. 28 French is preferable &directed toward apex The chest tube is left in place between 24 and 48 hours Tube thoracostomy successfully resolves PSP in approximately 90% of patients for the first occurrence, 50% for the first recurrence, and 15% after a second recurrence. For this reason , tube thoracostomy is recommended only for definitive management of PSP for the first event

35. If an air leak persists, a Heimlich valve can be placed. The patient can then be discharged for outpatient management.

36. Pleurodesis After tube thoracostomy , chemical pleurodesis may help prevent SP recurrence. Sclerosing agents are instilled to create pleural symphysis . Agents : sterile talc. doxycycline solution & bleomycin . Blood . Because adult respiratory distress syndrome may be triggered by high doses of talc, use should be limited to 5 g. Talc has the potential to induce malignant transformation after decades of use, but thus far, this has not been demonstrated in humans.

37. Nonetheless, our agent of preference is doxycycline to sclerose benign pleural processes. A total of 500 mg of doxycycline combined with lidocaine is infused through the chest tube, and The patient’s position is shifted from side to side to distribute the sclerosant . Suction is then placed for 48 hours. Recurrence of SP in patients treated with bedside pleurodesis is high, ranging from 8% to 40%.38,40,41 In our institution, this treatment is reserved for patients who are not considered good operative candidates, most commonly patients with SSP

38. Indication Large or/& Persistent air leak Recurrent pneumothorax First episode in a patient with prior pneumonectomy First episode with occupational hazard Airplane pilot Diver history of bilateral SP Heamo-pneumothorax with bleeding in ICT >3ml/kg/h SURGICAL MANAGEMENT

39. Approaches of surgeries : Video-assisted thoracoscopic surgery (VATS) is the surgical procedure of choice for SP limited lateral or axillary incision bilateral pneumothoraces (concurrent or separate) can be considered for bilateral treatment via median sternotomy . Bilateral VATS procedures at a single sitting may also be considered.

40. The entire lung is carefully inspected, with particular attention to the apex and superior segments , as these are typical bullae locations. Saline flood ing of the hemithorax during gentle lung inflation can help locate a ruptured bleb. Some surgeons resect the apex of the lung even if no bleb is located, although our practice is to perform lung resection only when a bleb is identified . Intraoperative pleurodesis should be performed in addition to blebectomy . Mechanical pleurodesis is our most common method and is performed with use of a Bovie scratch pad with aggressive abrasion of the parietal pleura . chemical sclerosing agents, such as talc, at the time of surgery with good results and minimal impairment of pulmonary function over time.

41. Another effective method of obtaining pleural symphysis is parietal pleurectomy , by either VATS or open techniques. One should make every effort to control air leak before leaving the operating room. Apical chest tube placement is crucial to full lung expansion. Postoperatively, we prefer 48 hours of suction before removal. VATS successfully resolves SP and prevents recurrence in more than 90% of patients. Whereas some studies show that recurrence of SP is slightly higher with VATS compared with thoracotomy , this small increment does not justify the discomfort and lost work days in this generally young population. Thoracotomy is reserved for VATS failures and complex giant bleb resections not amenable to VATS.

42. THANK YOU SUBISTON&SPENCER 8 TH EDITION SHILDS THORACIC SURGER