PNEUMOTHORAX
 
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PNEUMOTHORAX

 

DEFINITION:

Air or gas in the pleural cavity separating the visceral from the parietal pleura.

EPIDEMIOLOGY:

  • prevalence: 9/100,000/year
  • age of onset:
    • any
  • risk factors:
    • for spontaneous pneumothorax
      • M > F (6:1)
      • body habitus - tall and thin
      • smokers
      • 5% of hospitalized asthmatic patients
      • familial in some cases

DIFFERENTIAL DIAGNOSIS:

1. Spontaneous Pneumothorax

  • 1. Primary (Idiopathic)
  • 2. Secondary
  • 1. Respiratory
    • asthma
    • congenital cyst or bleb
    • cystic fibrosis
    • empyema
    • foreign body
    • interstitial pneumonitis
    • pulmonary abscess
    • pulmonary embolism
    • pulmonary fibrosis
    • pulmonary alveolar proteinosis
    • PNEUMOTHORAX
  • 2. Others
    • biliary cirrhosis
    • catamenial
    • collagen vascular disease (Ehlers-Danlos, Marfan)
    • hydatid disease
    • lymphangiomyomatosis
    • neoplasms (Histiocytosis X, Lymphoma, metastases)
    • Sarcoidosis
    • Tuberculosis
    • Tuberous Sclerosis

    • 2. Traumatic Pneumothorax

  • 1. Iatrogenic
    • acupuncture
    • bronchoscopy
    • central line placement
    • mechanical ventilation with PEEP
    • pleural biopsy
    • thoracentesis
    • tracheostomy
  • 2. Chest Trauma
    • Penetrating Trauma
    • Nonpenetrating Trauma

    • CLINICAL FEATURES:

    1. Respiratory Manifestations

    1. Symptoms

    • abrupt onset of:
      • chest pain (90% of patients)
      • dyspnea

    2. Signs

    • ipsilateral to the leak:
      • decreased breath sounds
      • absent tactile fremitus
      • hyperresonant (tympanic) percussion note
    • tracheal deviation to the contralateral side

    3. Complications

  • 1. Respiratory Distress +/-
    • cyanosis
    • arrest
  • 2. Pneumomediastinum +/-
    • subcutaneous emphysema
    • tamponade of the great vessels (distended neck veins, hypotension, shock)
  • 3. Tension Pneumothorax
    • shock with hypotension, tachycardia, and diaphoresis
    • tracheal deviation towards the contralateral side
  • 4. Pneumopericardium
    • shock with muffled heart sounds and poor pulses
  • 5. Upon Re-Expansion
    • persistent bronchopleural fistula
    • pulmonary edema (in 10% following re-expansion)
  • 6. Others
    • pyopneumothorax (purulent effusion)
    • hemopneumothorax (bloody effusion)
    • hydropneumothorax (serous effusion)
  • 7. Catamenial Pneumothorax
    • a pneumothorax due to the passage of intra-abdominal air through a diaphragmatic defect

    • 2. Other Manifestations

    • systemic manifestations of underlying disorders

    INVESTIGATIONS:

    1. Imaging Studies

    1. Chest X-Ray

  • 1. Pneumothorax
    • air in the pleural cavity is diagnostic
  • 2. Pneumomediastinum
    • sharp hyperlucent cardiac border
  • 3. Tension Pneumothorax
    • contralateral deviation of the larynx, trachea, and heart
  • 4. Underlying Lung Disorder
    • interstitial lung disease

    • 2. CT (Chest)

    • to rule out underlying lung disease, i.e., blebs

    2. Others

    1. Pulmonary Function Tests

    • decreased vital capacity

    2. Blood Gas

    • hypoxia (due to a V/Q mismatch)

    3. ECG

    • QRS axis shift and precordial T-wave inversion if L-sided leak

    MANAGEMENT:

    1. Supportive

    • if the patient is hemodynamically stable, is clinically stable and has a pneumothorax <15% of the hemithorax - reassure the the air will be reabsorbed from the pleural space (at a rate of 1.25% volume of the hemithorax per 24 hours such that a 15% pneumothorax would take about 10 days to resolve)
    • recurrence rate is about 50% with 75% recurring on the ipsilateral side and within 2 years of the initial pneumothorax
    • the pneumothorax complicating asthma (usually <5% of the hemi-thorax) resolve spontaneously
    • treat pleural pain with analgesics
    • administration of 100% oxygen will increase the rate of resorption of nitrogen from the pleural space

    2. Chest Tube Thoracotomy

    • indications for:
      • severe dyspnea or chest pain
      • pneumothorax >15-25% of the hemithorax
      • mechanically ventilated
      • tension pneumothorax

    3. Surgical Management

    1. Open Thoracotomy

    • indications for:
      • recurrent episodes of ipsilateral pneumothorax
      • lungs remain unexpanded after 5-7 days of chest tube drainage to prevent formation of a bronchopleural fistula
      • correction of underlying lung disorder, i.e., blebs
      • +/- chemical pleurodesis
        • introduction of a sclerosing agents into the pleural cavity (i.e., silver nitrate, tetracycline) to obliterate the pleural space

    4. Tension Pneumothorax

    • administer 100% oxygen
    • insert a large-bore needle into the pleural cavity through the
    • 2nd anterior intercostal space
    • chest tube placement

     

     

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