szd-zps-pleural-disorders-portoroz-2009-31.ppt

Pleural disorders

1. Urgent pleural disorders
Aleš Rozman
University Clinic of Respiratory Diseases and Allergy,
GOLNIK, Slovenia
Portorož – 8th May 2009

2. Pleural emergencies:
• haemorrhage
- haemothorax
• elevated pleural pressure
- tension pneumothorax
- massive pleural effusion

3. 1. Haemothorax
= pleural fluid with Ht > 50% blood Ht
CAUSES:
• chest trauma: penetrating / non – penetrating
(lung blood vessels, chest wall, diaphragm, pleural adhesions,
mediastinum, large vessels, abdomen)
• iatrogenic
(pleural biopsy, subclavian or jugular CVC placement, thoracentesis,
transthoracic or transbronchial NA, esophageal variceal TH,...)
• nonthraumatic
(pleural malignancy, anticoagulant TH, spontaneous rupture of vessel
(AO aneurism), bleeding disorder, thoracic endometriosis,...)

4. 1. Haemothorax
DG:
• CXR
• chest CT – for all patients with severe chest trauma
• thoracentesis
transudate
haemothorax with higher
attenuation (> 35 HU)

5. 1. Haemothorax
TH:
• immediate tube thoracostomy
1.evacuation of blood
2.stop bleeding by apposition of pleural surfaces
3.evaluation of blood loss
4.may decrease incidence of empiema or fibrothorax
5.autotransfusion possible
• thoracotomy (cca 15%)
1.immediate drainage of > 20 ml/kg of blood
2.persistent bleeding > 200 ml/h
3.cardiac tamponade, vascular injury, pleural contamination,
major air leaks,...
•TH of shock, blood and fluid replacement,...

6. 1. Haemothorax
Complications:
1.retention of clotted blood (evacuation if > 30% of
hemiTHX)
2.empyema (3 – 5%)
– shock, contamination, prolongued drainage, abdominal injuries
3.exudative pleural effusion (15 – 30%)
4.fibrothorax (< 1%)

7. 2. Tension PTHX
= air in the pleural space, which pressure exceeds the atmospheric pressure
throughout expiration (inspiration).
CAUSES – any type of PTHX:
1.with mechanical ventilation / NIPPV
2.during cardiopulmonary resuscitation
3.in divers
4.in air travel
5.in spontaneously breathing person at constant pressures (airway,
environment)
6.improper chest tube handling

8. Pneumoscrotum secondary to bilateral tension
pneumothorax
 
Di Capua-Sacoto C, Bahilo-Mateu P, Ramírez-Backhaus M, Gimeno-Argente V, Pontones-
Moreno JL, Jiménez-Cruz JF
 
Servicio de Urología. Hospital Universitario La Fe. Valencia. Spain
 
Actas Urol Esp. 2008;32(7):756-758
 
ABSTRACT
PNEUMOSCROTUM SECONDARY TO BILATERAL TENSION PNEUMOTHORAX
We report a case of pneumoscrotum secondary to a large bilateral tension pneumothorax. Although
pneumoscrotum is an infrequent clinical condition that is generally resolved by means of
conservative management, it may be a symptom of a serious and potentially life-threatening process.
The management of pneumoscrotum should be directed to resolve the underlying cause.
Key words: Pneumoscrotum. Pneumothorax. Complications.

9. 2. Tension PTHX
Patophysiology:
• impaired venous return and decreased cardiac output
• V/Q mismatch - profound hypoxia
Clinical manifestations:
• sudden deterioration
• dyspnoe, cyanosis, tachicardia, profuse sweating
• hypotension, low O
2 saturation, distended neck veins
• subcutaneous emphysema, unilateral hyperinflation
• respiratory acidosis, hypoxemia
• sudden increse in plateau and peak pressures (volume – type vent.)
• sudden drop of tidal volumes (pressure – type vent.)

10. 2. Tension PTHX
hyperinflation
collapsed lung
mediastinal
shift
low
hemidiaphragm

11. TH:
• medical emergency – clinical diagnosis
• do not wait for CXR
• 100% O
2
• observation, auscultation, percussion
• needle & syringe with saline – 2nd anterior ICS
• bubbles? – replace with large - bore needle
• prepare for tube thoracostomy
2. Tension PTHX

12. 3. Massive pleural effusion
CAUSES:
• malignant pleural effusion
PATOPHYSIOLOGY:
• impaired venous return and decreased cardiac output
• V/Q mismatch - profound hypoxia

13. Clinical manifestations:
• gradual deterioration
• dyspnoe, cyanosis, tachicardia
• hypotension, low O
2 saturation, distended neck veins
• unilateral distension of THX, absent respiratory mobility
3. Massive pleural effusion

14. 3. Massive pleural effusion
mediastinal
shift
distension

15. TH:
• thoracentesis for symptomatic relief (500 – 1000 ml)
• consider chest tube and pleurodesis
• avoid rapid evacuation of all pleural fluid (reexpansion
lung edema, PTHX)
3. Massive pleural effusion

16. • Haemothorax and tension pneumothorax can be
iatrogenic.
• Careful monitoring of patients and early recognition of
complications should be a standard after each invasive
procedure.
3. Conclusions

17. Thank you.
University Clinic Golnik,
Slovenia