PNEUMOTHORAX

Xie Can Mao

1st Affiliated Hospital of Sun Yat-sen Universty

1
 Introduction
 The term pneumothorax was first coined by Itard,
a student of Laennec, in 1803
 Laennec described the clinical picture of
pneumothorax in 1819
 He described most pneumothoraces as occurring
in patients with pulmonary tuberculosis, although
he recognised that pneumothoraces also
occurred in otherwise healthy lungs, a condition
he described as “pneumothorax simple”

2
 Introduction
 The modern description of primary
spontaneous pneumothorax occurring in
otherwise healthy people was provided by
Kjaergard in 1932

 Primary pneumothorax remains a

significant global problem
 The incidence is 18-28/100 000 per year
for men and 1.2-6/100 000 per year for
women
3
 Introduction
 Secondary pneumothorax is associated with
underlying lung disease, whereas primary
pneumothorax is not

 By definition, there is no apparent precipitating

event in either
 Hospital admission rates for combined primary
and secondary pneumothorax are reported in
the UK at between 5.8/10 000 per year for
women and 16.7/10 000 per year for men
 Mortality rates in the UK were 0.62/million for
men between 1991 and 1995
4
 Contents
 What is pneumothorax
 Pathogenesis and mechanisms
 Pathophysiology
 Clinical typing
 Clinical manifestation
 Diagnosis and differentiate diagnosis
 Treatment

5
 What is pneumothorax
 Pleural cavity is a latent closed space, in
which there is no air
 The total gas pressure of capillaries is 706
mmHg, 54 mmHg less than atmosphere
 Pneumothorax is defined as air in the
pleural space
 That is, air between the lung and chest
wall, or in other term, air between the
visceral pleura and the parietal pleura

6
Pneumothorax

7
Classification of pneumothorax
 Divided into three types
 Spontaneous
having an unknown cause or occurring as a
consequence of the nature course of a disease
process, such as COPD, tuberculosis
 Traumatic
following any penetrating or non-penetrating chest
trauma, with or without bronchial rupture
 Iatrogenic
occurring as the results of diagnostic or therapeutic
medical procedure. Intentional or a complication

8
Clinical typing of pneumothorax
 Spontaneous pneumothoraces are
subclassified as:
 Primary spontaneous pneumothorax (PSP)
 Healthy people, most young people
 Secondary spontaneous pneumothorax (SSP)
 Underlying diseases
 Chronic obstructive pulmonary disease
(COPD), pulmonary tuberculosis

9
Pathogenesis and mechanisms
 In normal people, the
pressure in pleural space
is negative during the
entire respiratory cycle
 Two opposite forces
result in negative
pressure in pleural space:
 inherent outward pull of
the chest wall and
inherent elastic recoil of
the lung
• The negative pressure will
be disappeared if any
communication develops 10
Pathogenesis and mechanisms
 When a communication
develops between an
alveolus or other
intrapulmonary air space
and pleural space
 air will flow into the
pleural space until there
is no longer a pressure
difference or until the
communication is sealed

11
Pathogenesis and mechanisms
 When a communication  air will enter the pleural
develops through the space until the pressure
chest wall between the gradient is eliminated or
atmosphere and the the communication is
pleural space closed

12
 Pathophysiology
 Pneumothorax:
 Negative pressure eliminated
 The lung recoil-small lung-volume decrease
 V/Q decrease-shunt increase
 Positive pressure
 Compress blood vessels and heart
 decreased cardiac output
 Impaired venous return
 Hypotension
 Shock
 Result in
 A decrease in vital capacity
 A decrease in PaO2

13
 Pathophysiology
 Thoracoscopic studies
 Blebs
 Airfilled spaces between the lung parenchyma and
the visceral pleura
Shows a similar cystic space,
completely surrounded by pl

pleura

14
 Pathophysiology
 Bullae
 Air filled spaces within the lung parenchyma
itself
Surrounded by fibrous tissue

Lung parenchyma

15
 Ble b s
Male ， aged 22
Admission for“explode
dyspnea, left chest pain
for 2 weeks” . Historic
left pneumotorax.

镜下见：左上叶表面见数个直径 0.5 ～ 3cm 肺大疱，部分随

呼吸活动膨大缩小。
Bullae

17
 Pathophysiology
 Blebs and bullae are also known as
emphysema-like changes (ELCs)
 The probable cause of pneumothorax is
rupture of an apical bleb or bulla
 Because the compliance of blebs or bullae
in the apices is lower compared with that
of similar lesions situated in the lower
parts of the lungs

18
 Pathophysiology
 It is often hard to assess whether bullae
are the site of leakage, and where the site
of rupture of the visceral pleura is
 Smoking causes a 9-fold increase in the
relative risk of a pneumothorax in females
 A 22-fold increase in male smokers
 With a dose-response relationship
between the number of cigarettes smoked
per day and occurrence of PSP

19
 Clinical typing of pneumothorax

closed communicated tension

Rupture small large valve-like

sealed open in not out
Pressure P or N atmosphere high
After
Aspiration N atmosphere high again

20
 Clinical manifestation
 Symptom
 Depend on whether underlying pulmonary disease or
not
 Depend on the speed of pneumothorax occurred
 Depend on size of pneumothorax
 Depend on the level of intrapleual pressure
 The patient with underlying pulmonary disease
will undergo severe dyspnea
 The healthy person will have minimal symptoms
although having large volume of pneomothorax
21
 Clinical manifestation
 Happened most patients at rest and some
during heavy exercise
 Chest pain-prickling-like, cutting-like
 Having an acute onset
 Air stimulates pleura
 Dyspnea
 Collapsed lung and vital capacity decrease
 Dry cough
 Air stimulates pleura
22
23
 Clinical manifestation
 Tension pneumothorax
 risk factors
 Receiving positive-pressure mechanical
ventilation
 During cardiopulmonary resuscitation
 Undergoing hyperbaric oxygen therapy
 Evolving during the course of spontaneous
pneumothorax

24
Tension pneumothorax

25
 Clinical manifestation
 Tension pneumothorax
 Distressed with rapid labored respiration
 Cyanosis
 Marked tachycardia
 Profuse diaphoresis
 Patient who suddenly deteriorate clinically,
be suspected if the patient with
 Mechanical ventilation
 Cardiopulmonary resuscitation

26
 Clinical manifestation
 Physical examination
 Depend on size of pneumothorax
 Depend on whether pleural effusions or not
 The vital signs usually normal
 The side with pneumothorax is larger than the
contralateral side
 Chest moves less during the respiratory cycle

27
 Clinical manifestation
 Physical examination
 Tactile fremitus is absent
 The percussion note is hypersonant
 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
 The trachea may be shifted toward the
contralateral side if the pneumothorax is large

28
 Clinical stability
Stable patients  Unstable patients
 RR: <24/min
 HR: 60-120/min
 BP: normal
 SO2: >90% (room air) Not fulfilling the
 Patient can speak in definition of stable
whole sentences
between breaths
 All above present
29

Evaluate the severity and make decision for treatment

Imaging- Plane chest X-ray film
 Establishing the
diagnosis
 The characteristics of
pneumothorax
 Pleural line
 No lung markings in
pneumothorax
 The outer margin of
visceral pleura separated
from the parietal pleura
by a lucent gas space
devoid of pulmonary
vessels
30
 Plane chest X-ray film
 In erect patients, pleural
gas collects over the
apex, and the space
between the lung and
chest wall is most notable
there
 In the supine position,
gas migrates along the
broad ventral surface of
lung, making detection on
a frontal radiograph
difficult

31
 Plane chest X-ray film
 It is very important to
differentiate the pleural
line of a pneumothorax
from that of a skinfold,
clothing, tubing, or chest
wall artifact
 Careful inspection of the
film may show that the
artifact extends beyond
the thorax, or that lung
markings are visible
beyond the apparent
pleural line
32
 Plane chest X-ray film
 In the absence of
underlying lung disease,
the pleural line of a
pneumothorax usually
parallels the shape of
chest wall
 Artifactual densities
generally do not parallel
the course of the chest
wall over their entire
length

33
 Plane chest X-ray film
 Quantification of the size
 The size of a pneumothorax, in terms of
volume, is difficult to assess accurately
from a chest radiograph
 The simple method to estimate the size
 Small, a visible rim of < 2 cm between the
lung margin and the chest wall
 Large, a visible rim of ≥2 cm between the lung
margin and chest wall

34
Estimation of pneumothorax volume

 Light equation
pneumothorax ％＝（ 1
－ L3/HT3 ）） 100
 Kircher equation
Hemithorax pneumothorax ％
(HT)
Thorax area － lung area
Thorax area ×100
 Collins equation
Lung (L) 4.2+[4.7×(A+B+C)]

35
Estimation of pneumothorax volume

 BTS guideline(1993)
 Small
 Moderate
 large
 BTS guideline(2003)
 Lung margin to chest
wall
 small<2cm
 large≥2cm
 ACCP guideline
 Lung apex to chest top
 Small <3cm
 large≥3cm
36
 Plane chest X-ray film
 Since the volume of a pneumothorax
approximates to the ratio of the cube of the lung
diameter to the hemithorax diameter
 A pneumothorax of 1 cm on the PA chest
radiograph occupies about 27% of the
hemithorax volume
 Lung is 9 cm, hemithorax is 10 cm in diameter
 Equation
Volume of pneumothorax = (HT3 – L3) ÷ HT3
= (103 – 93) ÷ 103
= (1000 – 729) ÷1000
= 0.27

37
 Plane chest X-ray film
 A pneumothorax of 2 cm on the PA chest
radiograph occupies about 49% of the
hemithorax volume
 Lung is 8 cm, hemithorax is 10 cm in diameter
 Equation
Volume of pneumothorax = (HT3 – L3) ÷ HT3
= (103 – 83) ÷ 103
= (1000 – 512) ÷1000
= 0.49

38
 CT scanning
 CT scanning is the most robust approach
if accurate size estimates are required
 It is only recommended to 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

39
CT scanning
bullae

pneumothorax

40
 CT scanning

bullae

p pneumothorax
n
e
u
m
o
t 41

h
 CT scanning

pneumothorax

42
 CT scanning
Small pneumothorax

Subcutaneous emphysema
43
 Differentiation
 Asthma and obstructive emphysema
 Repeated wheezing episode
 Dyspnea gradually progress
 In the course of disease, if patients
 Onset of severe dyspnea, cold sweat, dysphoria
 No response to bronchial dilators, antibiotics

 Consider pneumothorax
 Chest X-ray radiograph to conform the
diagnosis

44
 Treatment
 Goals
 To promote lung expansion
 To eliminate the pathogenesis
 To decrease pneumothorax recurrence
 Treatment options according to
 Classification of pneumothorax
 Pathogenesis
 Pneumothorax frequency
 The extension of lung collapse
 Severity of disease
 Complication and concomitant underlying diseases

45
 Observation - PSP
 Observation along is advised for small, closed
mildly symptomatic spontaneous
pneumothoraces
 Patients with small PSP and minimal symptoms
do not require hospital admission
 However, it should be stressed before discharge
that they should be return directly to hospital in
the event of developing breathlessness
 Most patients in this group who fail this
treatment have secondary pneumothoraces

46
 Observation - SSP
 Observation along is only recommend in
patients with small SSP of less than 1 cm
depth or isolated apical pneumothoraces
in asymptomatic patients
 Hospitalisation is recommended in these
cases
 All other cases will require active
intervention ( aspiration or chest drain
insertion)

47
 Observation - PSP or SSP
 Marked breathlessness in a patient with a
small (<2 cm) PSP may herald tension
pneumothorax
 Observation along is inappropriate and
active intervation is required
 If a patient is hospitalised for observation,
supplemental high flow (10 l/min) oxygen
should be given where feasible

48
 Observation - PSP or SSP
 Inhalation of high concentration of oxygen
may reduce the total pressure of gases in
pleural capillaries by reducing the partial
pressure of nitrogen
 This should increase the pressure
gradient between the pleural capillaries
and the pleural cavity
 Thereby increasing absorption of air from
the pleural cavity

49
 Observation - PSP or SSP
 The rate of resolution/reabsorption of
spontaneous pneumothoraces is 1.25 –
1.8% of volume of hemithorax every 24
hours
 The addition of high flow oxygen therapy
has been shown to result in a 4-fold
increase in the rate of peumothorax
reabsorption during the periods of oxygen
supplementation

50
 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 with secondary pneumothoraces
treated successfully with simple aspiration
should be admitted to hospital and observed for
at least 24 hours before discharge

51
 Repeated and catheter aspiration
 Repeated aspiration is reasonable for
primary pneumothorax when the first
aspiration has been unsuccessful
 A volume of < 2.5 L has been aspirated on
the first attempt

 The aspiration can be used by needle or

catheter

52
 Catheter aspiration
 Catheter aspiration
of pneumothorax
can be used where
the equipment and
experience is
available

53
 Intercostal tube drainage
Making a small incision
Using a forceps to extend the hole
Inserting a catheter into pleural cavity

Fix the catheter and cover with gauze

54
Intercostal tube drainage

55
 Intercostal tube drainage
 INDICATIONS
 Unstable pneumothorax
 Severe dyspnea
 Large lung collapse
 Open or tension pneumothoraces
 Frequent recurrent pneumothoraces
 Simple aspiration or catheter aspiration
drainage is unsuccessful in controlling
symptoms
56
 Intercostal tube drainage
 Position of intercostal tube
 The chest tube should be positioned in the
uppermost part of the pleural space,
where residual air accumulates
 This procedure permits the air in the
pleural space to be evacuated rapidly

57
 Intercostal tube drainage
 The site of chest
tube insertion is in
the midclavicular
line of second and
third intercostal
 or anterior axillary
line of fifth and
sixth intercostal

58
 Guidewire tube thoracostomy
 Making a small
skin incision
slightly larger than
the diameter of the
chest tube

59
 Guidewire tube thoracostomy
 Introduction of 18-
gauge needle into
the pleural space

60
 Guidewire tube thoracostomy
 Insertion of wire
with “J” end into
the pleural space

61
 Guidewire tube thoracostomy
 With guidewire in
space, the tract is
enlarged by
advancing
progressively
larger dilators over
the wire guide

62
 Guidewire tube thoracostomy
 Introduction the
chest tube inserter/
chest tube
assembly over the
guidewire

63
 Guidewire tube thoracostomy
 The guidewire and
chest tube inserter
have been
removed, leaving
the chest tube
positioned with the
pleural space

64
 Trocar tube thoracostomy
 Insertion of trocar into the pleural space
 Note the position of the hands, the
position of the trocar relative to the ribs

65
 Trocar tube thoracostomy

 Insertion of the chest tube through the

trocar

66
 Operative tube thoracostomy
 The physician’s
index finger is used
to enlarge the
opening and to
explore the pleural
space

Is it brutal?
No! 67
 Operative tube thoracostomy
 Placement of chest
tube intrapleurally
using large
hemostat

68
Drainage system

69
 One bottle system
 Consists of one bottle that serves as both a
collection container and a water seal
 The chest tube is connected to a rigid straw
inserted through a stopper into a sterile bottle
 Enough sterile saline solution is instilled into the
bottle so that the tip of the rigid straw is about 2
cm below the surface of the saline solution
 The bottle’s stopper must have a vent to prevent
pressure from building up when air or fluid
coming from the pleural space enters the bottle

70
One bottle system

71
 One bottle system
 This system works as follow
 When the pleural pressure is positive, the
pressure in the rigid straw becomes positive
 If the pressure inside the rigid straw is greater
than the depth to which the straw is inserted
into the saline solution, air will enter the bottle
 Air will be vented to the atmosphere
 If the pleural pressure is negative, saline will
be drawn from the bottle into the rigid straw
and no extra air will enter the system

72
 Three bottle system
 Three bottle system consists of
 Collection bottle – for collecting pleural fluid
 Water seal bottle – for regulating pressure
 Suction control bottle – connect to the negative
pressure pump, for suction of the air of pleural space,
pres level: -10 - -20 cm H2O

73
 Three bottle system
 When suction is applied to the suction-control
bottle, air enter this bottle through its rigid straw
if the pressure in the bottle is more negative
than the depth to which the straw is submerged

74
 Observation of drainage
 No bubble released
 The lung reexpansion
 The chest tube is obstructed by secretion or blood clot
 The chest tube shift to chest wall, the hole of the
chest tube is located in the chest wall
 If the lung reexpansion, removing the chest tube
24 hours after reexpansion
 Otherwise, the chest tube will be inserted again
or regulated the position

75
 Complications of intercostal tube
drainage
 Penetration of major organs
 Lung, stomach, spleen, liver, heart and great
vessels
 It occurs more commonly when a sharp metal
trocar is inappropriately applied
 Pleural infection
 Empyema, the rate of 1%
 Surgical emphysema
 Subcutaneous emphysema

76
 Chemical pleurodesis
 Goals
 To prevent pneumothorax recurrence
 To produce inflammation of pleura and
adhesions
 Indications
 Persist air leak and repeated pneumothorax
 Bilateral pneumothoraces
 Complicated with bullae
 Lung dysfunction, not tolerate to operation

77
 Chemical pleurodesis
 Sclerosing agents
 Tetracycline
 Minocycline
 Doxycline
 Talc
 Erythromycin
 The instillation of sclerosing agents into the
pleural space should lead to an aseptic
inflammation with dense adhesions, leading
ultimately to pleural symphysis
78
 Chemical pleurodesis
 Methods
 Via chest tube or by surgical mean
 Administration of intrapleural local anaesthesia, 200 –
400 mg lidocaine intrapleurally injection
 Agents diluted by 60 – 100 ml saline
 Injected to pleural space
 Clamp the tube 1 – 2 hours
 Drainage again
 Observed by chest X-ray film, if air of pleural space is
absorption, remove the chest tube
 If pneumothorax still exist, repeated pleurodesis

79
 Chemical pleurodesis
 Side effct
 Chest pain
 Fever
 Dyspnea
 Acute respiratory distress syndrome
 Acute respiratory failure

80
 Surgical treatment
 Indication
 No response to medical treatment
 Persist air leak
 Hemopneumothorax
 Bilateral pneumothoraces
 Recurrent pneumothorax
 Tension pneumothorax failed to dainage
 Thicken pleura makes lung unable to
reexpansion
 Multiple blebs or bullae
81
Complications of pneumothorax
 Pyopneumothorax
 Caused by aspiration or intercostal chest tube
insertion (iatrogenic)
 Also results from necrotic pneumonia, lung
abscess, or caseous pneumonia
 Chest X-ray shows hydropneumothorax
 The pleural effusion is purulent
 Antibiotics and intercostal drainage
 Surgical mean

82
 Complications
 Hemopneumotorax
 Bleeding in pleural space
 Common cause is rupture of vessels in
adhesions
 When lung reexpansion, bleeding will stop

 When bleeding persists, surgical ligation

will be needed
 Infusion

83
Complications

84
Complications

85
 Complications
 Mediastinal and subcutaneous
emphysema
 Alveoli rupture, the air enter into pulmonary
interstitial, and then goes into mediastinal and
subcutaneous tissues
 After aspiration or intercostal chest tube
insertion, the air enters the subcutaneous by
the needle hole or incision – surgical
emphysema
 Physical exam – crepitus is present
86
 Complications

Pneumocardium
Pneumoperitoneum
Pneumomediastinum Surgical emphysema 87
 Complications

Subcutaneous
emphysema
88
 complications
 Treatment
 Automatic absorption when pneumothorax is
gone
 Inhalation of high concentration of oxygen
 Making a small incision in suprasternal pit for
draining the air from mediastinal and
subcutaneous tissues

89
 Case study
 Female, 20
 Chest pain 3 hours,
and suddenly
dyspnea
 Cyanosis
 Marked tachycardia
 Profuse diaphoresis

90
 Questions
 The diagnosis is  The type of
A. PSP pneumothorax is
B. SSP A. closed
C. pulmonary B. open
embolism C. tension
D. Asthma episode D. hemothorax

91
 Questions
 Which choice is  Which treatment is
right the first step
B. Stable A. oxygen inhalation
C. unstable B. bronchial dilators
C. aspiration
D. chest tube
drainage

92
 Case study
 Male, 70
 Dyspnea 24 hours
 No chest pain
 COPD history 20 ys
 Cyanosis
 Marked tachycardia

93
 Questions
 The diagnosis is  Which treatment
A. AECOPD prefer
B. asthma episode A. oxygen therapy
C. PSP B. aspiration
D. SSP C. chest tube
D. surgical procedure

94
95