Respiratory System - Approach to Pneumothorax

Etiopathology, clinical features, diagnosis and management of pneumothorax

1. APPROACH TO
PNEUMOTHORAX
Dr Navdeep Labana MD
Asst. Professor
Dept of Pulmonary Medicine

2. Pneumothorax
✘It refers to air in the pleural cavity
○(i.e. interspersed between the lung and the chest wall)
•Coined first by Itard(1803)&
•First used & described by Laennec(1819)
•Incidence
•18–28/1lakh/annum –Men
•1.2–6/1lakh/annum-Women Ref –BTS 2010

3. 3

4. 4

5. Clinical Features
✘Depends on type, extent and size of Pneumothorax
5

6. 6

7. Radiology
7

8. “
Chest X-
ray

9. 9
Pneumothorax
Erect
Small
Apical lucency
Visceral Line
Large
Apical lucency
>2 cm
Visceral line
Tension
Lung collapse
Medistinal
shift
Low flat
diaphragm
Supine
Deep costophrenicsulcus
Lucent cardiophrenicsulcus
Sharp mediastinalcontour
Double diaphragm

10. 10

11. Inspiration Expiration
11

12. 12

13. D/d-
SKIN FOLD
✘-Extends beyond lung
margin
✘-Positive mash
band(Optical edge
enhancement)
13

14. 14

15. 15
D/d

16. 16

17. Tension Pneumothorax
17

18. 18
Supine Film

19. 19

20. 20

21. 21

22. Ultrasound in Pneumothorax
✘Classic teaching –Ultrasound in not sensitive in pneumothorax
✘But now a days-Ultrasound is more sensitive than Chest xray
✘Negative predictive value 82% and Positive predictive value 100%
22
GalboisA,et al.Pleural ultrasound compared with chest radiographic detection of pneumothorax
resolution after drainage.Chest2010

23. Ultrasound signs in pneumothorax
1.Absence of Lung Sliding
2.Absence of Comet tail artefacts
3.Presence of Lung Pulse
4.Presence of even a single B line rules out pneumothorax
5.M-Mode-Loss of Sea shore sign
6.M Mode-Stratosphere sign or Bar code sign
23

24. 24

25. Normal Lung
25

26. Normal Lung Sliding
26

27. 27

28. “
✘Lung Pulse
28
Lung Pulse is the
rhythmic movement of
the pleura in synchrony
with the cardiac rhythm.

29. 29Normal SeaShoreSign

30. 30

31. 31
GOLD
Standard

32. Pneumothorax
Spontaneous
Primary Secondary
Traumatic
Iatrogenic
Procedure
related
Positive
pressure
ventilation
Others
Blunt trauma
Penetrating
Trauma

33. Primary Spontaneous Pneumothorax
✘Defined as a spontaneous pneumothorax occurring in patients
without a prior known underlying lung disease.
✘Incidence
○7.4-18 /lakh/annum in males
○1.2 -6/lakh/annum in women
✘Clustering of cases in some areas
○Due to Height or atmospheric pollution or changes in
atmospheric pressure
ERS 2015

34. Etiology
•Subpleural bleb (?rupture/ ?leakage)
•Tall Thin Individual
•Familial (HLA A2-B4)
•Autosomal dominant-Incomplete Penetrance
•Britt Hogg Dube Syndrome
•Autosomal dominant-Chr 17
•Pneumothorax + Renal tumor+ Benign Skin tumor
•Catamenial
•Bronchial anatomy abnormalities
34

35. Why more common in smokers??
✘Subpleural bleb rupture is linked to airway inflammation
✘Predominantly in respiratory bronchiole (70-79%)
✘Incidence
Nonsmoker : Light smoker : Moderate smoker : Heavy smoker
1 : 7 : 21 : 102
35

36. Catamenial Pmneumothorax
✘Rare condition -women of reproductive age-in a temporal
relationship with menses.
✘Recurrent episodes of pneumothorax -occur within 72 h
before or after the start of menstruation
✘May try Gonadotrophin relasinghuman analogue for 6-12
months and create iatrogenic amenorrhea as treatment.
1.AlifanoM,
2.JablonskiC,
3.KadiriH,et al.
Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related pneumothorax referred for surgery.Am J RespirCritCare Med2007
ERS 2015

37. Curious Fact
✘30% of women with PSP referred for Surgery had catramenial pneumothorax
✘Most common abnormality found in surgery was not thoracic endometriosis, but
were diaphragmatic defects
✘Defects ranged fro 1 mm to 1cm –resected defects didn’t have endometrium
37
AlifanoM et al.-Catamenial and noncatamenial, endometriosis-related or nonendometriosis-related
pneumothorax referred for surgery.Am J RespirCritCare Med2007
Plu-BureauG,et al.Catamenialpneumothoraxand endometriosis-related pneumothorax: clinical
features and risk factors.Hum Reprod2011

38. Clinical Features-PSP
✘Early 20s ( very rare after 40)
✘Pleuritic pain (81%) + Dyspnea (39%)
✘Rare symptom –Horners( due to traction at sympathetic ganglia)
✘Usually at rest (80%)
✘O/E-Tachypnea + Tachycardia (Hemodynamic compromise is rare)
✘Affected side-Decreased movements, Breath sounds, VF and VR with
Hyperresonance
Rarely may have shift of mediastinum to opposite side
BenseL,Etal.Onset of symptoms in spontaneous pneumothorax: correlations to physical activity.EurJ
RespirDis1987

39. Recurrence rate
✘ERS 2018 (Stephen et al) systematic review
○a 32% PSP recurrence rate,
○with greatest risk in the first year.
○Female sex -with higher risk
○Widely accepted Lights Reference (Ipsilateral)
■-Recurrence rate 52.5% ( 1
st
year) -62% (second year) -83% (third
year)
■Contralateral -10%
39

40. Management (ERS 2015, BTS 2010)
✘More towards conservative side
✘Because tension poneumothorax extremely rare
✘Principle
○intrapleuralair does not necessarily require a therapeutic
intervention, and that management depends on the clinical
symptoms and not on the size of the pneumothorax
40
HenryM,et alBTS guidelines for the management of spontaneous pneumothorax.Thorax2003;58:Suppl. 2,ii39–ii52

41. 41

42. ERS 2015 conclusion
✘Needle aspiration is effective for the initial management of spontaneous
pneumothorax.
✘Following aspiration, patients may be discharged, avoiding hospital admission
✘Failure with aspiration occurs at a frequency of 25–50% in PSP
✘After a failed aspiration there is no evidence to support a second aspiration over
chest drain insertion.
✘Smaller bore (11–13 French) tubes seemed to perform better than larger drains
(20–28 French)
42

43. Pneumothorax distance measurement
43

44. Conservative Management
✘Rate of absorption of air –1.25% of total hemithoracicvolume/day
✘Average duration of hospital stay –4 days
OXYGEN in Pneumothorax
3L/mtvia nasal cannula ( higher if there is hypoxemnia)
Oxygentherapy reduces the partial pressure of nitrogen in the alveolus
compared with the pleural cavity, and a diffusion gradient for
nitrogen accelerates resolution
44

45. Suction or No Suction
✘Initial Suction –No much role
✘Lung re-expansion is achieved in up to 70% of patients with chest tube
drainage alone by day 3 without suction
✘May be tried in a small proportion with air leak
45
1.VoisinF,etal.Ambulatory management of large spontaneous pneumothoraxwith pigtail catheters.Ann EmergMed2014;64:222–228.
LaiSM,et al.Outpatient treatment of primary spontaneous pneumothoraxusing a small-bore chest drain with a Heimlich valve: the experience of a Singapore emergency
department.EurJ EmergMed2012;19:400–404

46. Indications of Definitive Management of Primary
Spontaneous Pneumothorax
✘Second episode of PSP
✘Persisting airleak >3-5 days
✘Hemopneumothorax
✘Bilateral pneumothorax
✘Professions at high risk
46

47. Recurrence rate –Definite Management
47

48. Pleurodesis –Aseptic Inflammation-Adhesion
✘Agents
○Talc (5-10g)
○Iodine
○Tetracycline
○Minocycline
○Bleomycin
○Erythromycin
✘Via Chest tube or surgical method
✘Intrapleural Lignocaine –
✘Agents diluted by 60-100ml saline
✘Inject to pleural Space
✘Clamp tube for 2-4 hours
✘If still persists-can repeat procedure48

49. Secondary Spontaneous Pneumothorax
✘Due to a preexisting lung disease
✘Incidence 6.3/lakh in males and 2/lakh in females (Lights) (No
other large scale studies)
✘As age increases incidence increases
✘Mean time of expansion 5d
✘Recurrence Rate 40-50% (Hefnner et al 2004 CHEST)49

50. 50
Causes ERS 2010

51. Management
✘All patients with SSP should be admitted to hospital for at least 24 h
and receive supplemental oxygen in compliance with the BTS guidelines
on the use of oxygen. (D)
✘Most patients will require the insertion of a small-bore chest drain. (B)
✘All patients will require early referral to a chest physician. (D)
✘Those with a persistent air leak should be discussed with a thoracic
surgeon at 48 h. (B)
51

52. 52

53. 53

55. ✘Pneumothorax ex vaco–Due to acute bronchial obstruction
✘Pneumothorax with maximum duration of airleak –PCP in AIDS
55

56. thanks!
Any questions?
56