ANATOMY & PHYISIOLOGY

IKA INDRAWATI
14711134

THORAX
 Thorax
➢Part of the body between the neck and abdomen.

➢Consist → thoracic cavity, its contents, and the wall surrounds it,

➢Includes → primary organs of the respiratory and cardiovascular systems.

➢Divided into :

1. Central mediastinum → heart & structures transporting air, blood, and food;

2. Right and left pulmonary cavities → occupied by the lungs.

Boundaries & Regions
BOUNDARIES

• SUPERIOR : jugular notch, sternoclavicular joint, superior

border of clavicle, acromion, spinosus processes of C7
• INFERIOR : xiphoid processes, aostal arch, 11th & 12th ribs,
vertebrae T12

REGIONS

• Thoraxic wall

• Thoraxic cavity
Modern PowerPoint Presentation
Moore,2014
Expand on the following points:
• Provide a brief anatomy review.
• Lungs
• Components of the mediastinum:
• Trachea
• Esophagus
• Main bronchi
MEDIASTINUM
• Heart
• Trachea
• Great Vessels
• Thymus Gland
• Nerves
• Lymph Nodes & Vessels
Moore,2014
• Mediastinum
– Major arteries
• Aorta and branches
• Pulmonary arteries
– Veins
• Superior vena cava
• Pulmonary veins
The Muscles of Thorax
Extrinsic muscles
• Pectoralis major
• Pectoralis minor
• Serratus anterior
Intrinsic muscles
• Intercostales externi
• Intercostales interni
• Intercostales intimi
• Transverses thoracis

Moore,2014
 RIBS / COSTAE
Three types :

• TRUE (vertebrocostal) ribs (1st–7th ribs): attach directly to the ster

num through their own costal cartilages.

• FALSE (vertebrochondral) ribs (8th, 9th, and usually 10th ribs) Thei
r cartilages are connected to the cartilage of the rib above them; th
us their connection with the sternum is indirect.

• FLOATING (vertebral, free) ribs (11th, 12th, and sometimes 10th ribs)
: The rudimentary cartilages of these ribs do not connect even indir
ectly with the sternum; instead they end in the posterior abdominal
musculature. Moore,2014
Intercostal nerve, artery, & vein are found along the inferior border of each rib
ARTERIES & VENAS Moore,2014

• Vena parallel with artery

• Drainage :
V. Intercostalis → V. brachiocephalica
 LYMPH
• Parasternal node -> bronkomediastinalis
trunk

• Diafragmatic node -> parasternal node,

prevertebra, junxtaesophageal,
brachicephalica, lateral aorta

• Nodus intercostalis -> ductus thoracalis

Moore,2014
 NERVES
• Ramus T1-T11 -> Nerve intercostalis ->
cutaneus branch

• Contains :

a. Motoric somatic -> musculus

b. Sensory somatic -> (skin and parietal

pleura)

c. Postganglionic sympathetic

Moore,2014
Segmental Inervation of Anterior Surface of the Trunk

• T2－sternal angle
• T4－ nipple
• T6－xiphoid process
• T8－costal arch
• T10－umbilicus
• T12－midpoint between um
bilicus and symphysis pubi
s

Moore,2014
LUNGS
• Pair of Cone-shaped organs
• Lie in pleural cavity
• Weigh approx 800g
– 90% air
– 10% tissue
• Left lung is narrower
• Right lung is shorter

Moore,2014
PLEURA
• Serous Membrane : Produces fluid
that allows for lubrication
• Attaches lung to inner surface of
thoracic cage
• Failure to function results in
difficult painful breathing

Moore,2014
Moore,2014
 Intra Plural fluid
⚫ It is the fluid that filled pleural cavity

⚫ It is a lubricant fluid which allow the pleura to slide easily

against each other during ventilation.

⚫ Normal amount of fluid equals 20-25 ml in each space

⚫ It is formed and reabsorbed continuously.

⚫ It is produced by parietal circulation (intercostal arteries)

⚫ It is reabsorbed by lymphatic system

⚫ If formation exceeds reabsorptions, pleural effusion will

occurs.
 Intra pleural pressure
⚫ It is the pressure in the space betwe
en the two layers of pleura

⚫ It is usually negative pressure

⚫ Normal value of I.P.P.

⚫ -3 mmHg at the end of normal expira

tion.

⚫ -6 mmHg at the end of normal inspir

ation

⚫ -30 mmHg->forced inspiration.

 Pneumothorax
Pneumothorax is a collection of
free air in the chest outside the
lung that causes the lung to
collapse.
 Classification
FISTULE
Open
Closed
Tension

CAUSE
• Spontaneus (primary, SIZE
secondary) Total
• Trauma (Iatrogenic & Partial
Non Iatrogenic)
 PARTIAL TOTAL
Pushing < 50% lung volume Pushing > 50% lung volume
• A spontaneous pneumothorax, also
referred to as a primary pneumothor
ax, occurs in the absence of a traum
atic injury to the chest or a known lu
ng disease
• A secondary (also termed complicat
ed) pneumothorax occurs as a result
of an underlying condition

Moore,2014
 Tension Pneumothorax
• The accumulation of air under pressure in the
pleural space.
• The air enters the pleural cavity → trapped the
re during expiration→ so the air pressure with
in the thorax mounts higher than atmospheric
pressure
• compresses the lung, may displace the media
stinum and its structures (including the lung)
toward the opposite side, and cause cardio-
pulmonary impairment (decrease CO) Choi et al ,2014
Area of Pneumothorax
Kircher & Swartel
A

b B
we defined patients with
pneumothorax size more than 50% as
large or extensive and small or
moderate when smaller than 50%
 RISK FACTORS

Age > 20 - < 40 Smoking Taller Individual Rupture Atmospheric

years Subpleural Bleb / Pressure Change
Bulae

(Choi et al, 2005)

 BLEBS

Pulmonary bleb / bulla : small air sac formed between the lung tissues & pleura,
originating from a pulmonary alveoli enlargement (diameter 1-2 cm) and usually
developed at the apical area
BLEBS
Secondary Spontaneous Pneumothorax
• Secondary spontaneous pneumothorax (SSP), unlike PSP, develops
in patients diagnosed with a pulmonary disorder. The most common
associated etiology is chronic obstructive pulmonary disease (COPD)

(Choi et al, 2005)

 CLINICAL PRESENTATION
• Sudden onset chest pain sharp in nature → more severe in
inhalation (95%)
• Shortness of breath
• Tachypnea
• Tachycardia
• Cyanosis
• Decrease or abscent breath sounds

Daley, 2019
 PHYSICAL EXAMINATION
RESPIRATION
• Respiratory distress or respiratory arrest
• Tachypnea (or bradypnea as a preterminal event)
• Asymmetric lung expansion
• Distant or absent breath sounds
• Hyperresonance on
• Decreased tactile fremitus
• Adventitious lung sounds (crackles, wheeze; an ipsilateral finding)

Daley, 2019
 Daley, 2019

PHYSICAL EXAMINATION
CARDIOVASCULAR
• Tachycardia
• Pulsus paradoxus
• Hypotension
• Jugular venous distention

*Pulsus paradoxus : exaggerated fall in patient’s blood pressure during inspiration by greater than 10 mm Hg. Results from alterations
in the mechanical forces imposed on the chambers of the heart and pulmonary vasculature eg/ pericardial disease, cardiac tamponade.
 Treatment
• A small pneumothorax without underlying lung disease may resolve on its own.
• A large pneumothorax and a pneumothorax associated with underlying lung disease
often require placement of a chest tube to evacuate the air

Daley, 2019
 Emergency Treatment
• bed rest
• oxygen therapy
• observation
• simple aspiration
• closed intercostal tube drainage
• tube thoracostomy.

Ince et al, 2013

 Needle Decompression
Used to relieve tension pneumothorax
Appropriate placement is essential:
- Second intercostal
space, midclavicular
line, over the rib
(preferred site)
- Fifth intercostal space,
midaxillary line, over
the rib (alternate site)
JOURNAL READING
Primary Spontaneus Pneumothorax
PSP definition:

Air entering the pleural space without

provocating factor (trauma, surgery,

medical intervention), without clinically

apparent underlying disease

 Insidence
WORLDWIDE

18 – 28/100.000 1,2 – 6/100.000

FOR MEN FOR WOMEN
 When the pneumothorax is > 20% or patient is symptomatic
MA // CTD should be used to theat PSP
Your Text Here
Not clear which of the 2 should beYouused first
can simply impress your
audience and add a unique zing.

Your Text Here

You can simply impress your
audience and add a unique zing.

Your Text Here

You can simply impress your
audience and add a unique zing.
Insertion bore catheters (≤ 14 Fr) Aspiration as 1st intervention, when
or chest tubes (16 – 22 Fr) needed. For all PSP without tension

Manual Aspiration vs Chest Tube Drainage

 MATERIAL AND METHODS
This meta analysis followed the PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta Analyses) guidelines
SEARCH STRATEGY
Search : PubMed, EMBASE, Cochrane Library
From the inception (starting point) to 17th March 2018

“spontaneous pneumothorax”, “tube”, “aspiration”,

“intercostal”, “thoracostomy”, “catheter”

*no language restriction

*also search for references of reviews, relevant study
INCLUSION EXCLUSION
criteria criteria
1. Patient > 18 th with 1. Only evolve patient
1st episode of PSP with SSP, Tension, or
with no lung disease Traumatic
2. No concomitant Pneumothorax
disease 2. Retrospective Trials,
3. RCT reviews,
experimental
3. Incomplete /
unavailable data
 Evaluated
Outcome
Primary & Secondary
PRIMARY : IMMEDIATE SUCCESS

MA :
• Complete / nearly complete persisten
lung expansion following MA
CTD :
• complete lung expansion
• absence air leakage
• chest drain removal within 72 hours after
tube placement
 EVALUATED OUTCOME
Complica-
Hospitali-
SECONDARY tion rate +
zation OUTCOME chest
rate surgery

Time of
Hospital recurrence
Stay (weeks)
1 year
recurrence
rate
 Study Selection
• Exclude duplicate studies

• 2 independent researchers → reviewed the titles → likelihood of the study meeting the
inclusion criteria → abstract reviewed

• Then full texts of the studies assessed by 2 researchers → selection

• Disagreement resolved through discussion between both researchersif necessary, the 3rd
would adjudicate.
 Data Synthesis and Analysis
• Inverse variance method :
for continuous variables
• Mantel–Haenszel analysis
: dichotomous variables
• Heterogeneity : I-squared
index (I2)

• P-value <0.10: statistical

significance
• ***based on lack of power
in heterogeneity test
• Fixed effect model was
used
 RESULT
1 Total subjects : 258 (173 MA & 185 CTD)

All studies had comparable baseline demographic criteria 2

3 Blinding method not reported
 Discussion
• MA could decrease hospital stay on PSP pasien w/o underlying lung disease
Principal Finding
• Tube size > 12 Fr of WSD linked to chest tube, increase hospitalization rate for CTD

• Immediate success rate

Comparison
• Hospitalization rate
• 1-year recurrence rate
• 1-week success rate
• Time of recurrence
• Chest surgery rate and complication rate
 PICO
PROBLEM INTERVENTION

PRIMARY SPONTANEUS PNEUMOTHORAX MANUAL ASPIRATION

(PSP)

COMPARISON OUTCOME
CHEST TUBE DRAINATION IMMEDIATE SUCCESS RATE, HOSPITALIZATION
RATE, 1-YEAR RECURRENCE RATE, 1-WEEK
SUCCESS RATE, TIME OF RECURRENCE,CHEST
SURGERY RATE AND COMPLICATION RATE
 Are the result of the study valid?

1. Did the trial adress clearly focused issue?

Yes No

Yes. This meta analysis evaluate the efficacy and complication of

MA vs CTD in PSP patient without underlying lung disease.
2. Did the authors look for the right type of paper?

Yes No
The articles involved in this journals fulfilled the inclusion & exclusion
criteria & the selection is based on the PRISMA guideline.
3. Do you think all the important, relevant studies were
included?

 Yes  No
This article satisfy the PRISMA (Preferred Reporting Items
for Systematic Reviews and Meta-Analyses) guidelines
4. Did the review author do enough to assess the qualify
of the included study?
Yes No
This article satisfy the PRISMA guidelines but did not use any
instrument / tools to control bias from each included study.
5. Did the result of the review have been combined, was it
reasonable to do so?
Yes No
 6. What are the overall result of the review?

• No significance difference in immediate success rate (p=0,54).

• Hospitalization rate : no significance difference (p=0,27) in 3 study. In Ho’s
study : p=0,006 (significance).
• Hospital stay : MA related to significantly shoter hospital stay p<0,00001.
• 1 year recurrence rate : no significance difference p=0,96
• Immediate success : MA 61,8%, CTD 62,7%.
• 1 week success : MA 88,8%, CTD 84,5%.
• Both have no or so little influence in the recurrence of spontaneous
pneumothorax
• Chest surgery rate : MA 9,2%, CTD 13,5%
6. What are the overall result of the review?
 7. How large was the treatment effect?

• MA could decrease hospital stay.

• MA result in outcomes comparable with CTD for immediate success rate,
hospitalization rate, 1 year recurrence rate, 1 week success rate, time of
recurrence, chest surgery rate, and complication rate.
7. How large was the treatment effect?
8. Can the result will be applied in your context (for
the local population)?

• MA and CTD both are used already in Indonesia as a treatment for Primary
Spontaneus Pneumothorax eventhough there was no significant guideline
for which one should be used first.
 9. Were all importance outcomes considered?

Yes

• The analysis of several studies proved that MA could decrease hospital stay.
• MA result in outcomes comparable with CTD for immediate success rate, hospitalization
rate, 1 year recurrence rate, 1 week success rate, time of recurrence, chest surgery rate
, and complication rate
 10. Are the benefit worth the harm and
costs?

Yes
• The analysis of several studies proved that MA could decrease hospital stay.
 LIMITATION

1. Relative small sample

2. Limited studies reporting postoperative pain (we could evaluate)
3. Limited by the number of included studies for each outcome, we could not perform a
meta-regression to explore the sources of heterogeneity
4. Publication bias was not detected in the meta-analysis
 LIMITATION
• MA is advantageous in PSP → shorter hospital stay.
• Subgroup analysis : MA provide a lower hospitalization than CTD (tube size of >12 Fr WSD)
• No significant differences between on immediate success rate, 1-year recurrence rate,
1- week success rate, time of recurrence, chest surgery rate / complication rate.
✓ VALIDITAS

✓ IMPORTANCE

✓ APPLICABILITY
 REFERENCES
Andrivet P, Djedaini K, Teboul JL, Brochard L, Dreyfuss D. Spontaneous pneumothorax. Comparison of thoracic drainage v
s immediate or delayed needle aspiration. Chest 1995;108:335–9.
Ayed AK, Chandrasekaran C, Sukumar M. Aspiration versus tube drainage in primary spontaneous pneumothorax: a rand
omised study. EurRespir J 2006;27:477–82.
Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J. Management of spontaneous pneumothorax: an American
College of Chest Physicians Delphi consensus statement. Chest 2001;119: 590–602.
British Thoracic Society Research Committee. Comparison of simple aspiration with intercostal drainage in the managem
ent of spontaneous pneumothorax. Thorax 1993;48:430–1.
Carson-Chahhoud KV, Wakai A, van Agteren JE, Smith BJ, McCabe G, Brinn MP et al. Simple aspiration versus intercostal t
ube drainage for primary spontaneous pneumothorax in adults. Cochrane Database Syst Rev 2017;9:CD004479
Chee CB, Abisheganaden J, Yeo JK, Lee P, Huan PY, Poh SC et al. Persistent air-leak in spontaneous pneumothorax–clinical
course and outcome. Respir Med 1998;92:757–61.
Cho S, Lee EB. Management of primary and secondary pneumothorax using a small-bore thoracic catheter. Interact Cardi
oVasc Thorac Surg 2010;11:146–9
 REFERENCES
Desmettre T, Meurice J-C, Mauny F, Woronoff M-C, Tiffet O, Schmidt J et al. [Comparison of simple aspiration versus stan
dard drainage in the treatment of large primary spontaneous pneumothorax]. Rev Mal Respir 2011;28:336–43.
Devanand A, Koh MS, Ong TH, Low SY, Phua GC, Tan KL et al. Simple aspiration versus chest-tube insertion in the manage
ment of primary spontaneous pneumothorax: a systematic review. Respir Med 2004;98: 579–90.
Dickersin K, Berlin JA. Meta-analysis: state-of-the-science. Epidemiol Rev 1992;14:154–76.
Fleiss JL. Analysis of data from multiclinic trials. Control Clin Trials 1986; 7:267–75.
Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Epidemiology of pneumothorax in England. Thorax 2000;55:
666–71.
Harvey J, Prescott RJ. Simple aspiration versus intercostal tube drainage for spontaneous pneumothorax in patients with
normal lungs. British Thoracic Society Research Committee. BMJ 1994;309:1338–9.
Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003;58(Suppl 2
):ii39–52.
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD et al. The Cochrane Collaboration’s tool for assessing ris
k of bias in randomised trials. BMJ 2011;343:d5928.
Ho KK, Ong ME, Koh MS, Wong E, Raghuram J. A randomized controlled trial comparing minichest tube and needle aspira
tion in outpatient management of primary spontaneous pneumothorax. Am J Emerg Med 2011;29:1152–7.
 REFERENCES
Kepka S, Dalphin JC, Parmentier AL, Pretalli JB, Gantelet M, Bernard N et al. Primary spontaneous pneumothorax admitte
d in emergency unit: does first episode differ from recurrence? A cross-sectional study. Can Respir J 2017;2017
:2729548.
Korczynski P, Go´ rska K, Nasiłowski J, Chazan R, Krenke R. Comparison of small bore catheter aspiration and chest tube d
rainage in the management of spontaneous pneumothorax. Adv Exp Med Biol 2015;866:15–23.
Ma WL, Zhang X, Song R, Lu HY. [Effects of pleural drainage using central venous catheter and simple aspiration in treatm
ent of spontaneous pneumothorax: a clinical comparative study]. Zhonghua Yi Xue Za Zhi 2007;87:1749–51.
Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst
1959;22:719–48.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M et al. Preferred reporting items for systematic review a
nd meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.
Noppen M, Alexander P, Driesen P, Slabbynck H, Verstraeten A. Manual aspiration versus chest tube drainage in first epis
odes of primary spontaneous pneumothorax: a multicenter, prospective, randomized pilot study. Am J Respir C
rit Care Med 2002;165:1240–4.
Parlak M, Uil SM, van den Berg JW. A prospective, randomised trial of pneumothorax therapy: manual aspiration versus c
onventional chest tube drainage. Respir Med 2012;106:1600–5.
 REFERENCES
Thelle A, Gjerdevik M, SueChu M, Hagen OM, Bakke P. Randomised comparison of needle aspiration and chest tube drai
nage in spontaneous pneumothorax. Eur Respir J 2017;49, pii: 1601296.
Tschopp JM, Bintcliffe O, Astoul P, Canalis E, Driesen P, Janssen J et al. ERS task force statement: diagnosis and treatment
of primary spontaneous pneumothorax. Eur Respir J 2015;46:321–35.
Vohra HA, Adamson L, Weeden DF. Does video-assisted thoracoscopic pleurectomy result in better outcomes than open
pleurectomy for primary spontaneous pneumothorax? Interact CardioVasc Thorac Surg 2008;7:673–7.
Wait MA, Estrera A. Changing clinical spectrum of spontaneous pneumothorax. Am J Surg 1992;164:528–31.
Wang C, Lyu M, Zhou J, Liu Y, Ji Y. Chest tube drainage versus needle aspiration for primary spontaneous pneumothorax:
which is better? J Thorac Dis 2017;9:4027–38.
Wang J, Zhang L, Ma J, Yang Y, Jia H, Ma X. Is intramedullary nailing better than the use of volar locking plates for fracture
s of the distal radius? A meta-analysis of randomized controlled trials. J Hand Surg Eur Vol 2016;41:543–52.
Zehtabchi S, Rios CL. Management of emergency department patients with primary spontaneous pneumothorax: needle
aspiration or tube thoracostomy? Ann Emerg Med 2008;51:91–100, 100.e1.
THANK YOU