Pneumothorax

AN ABNORMAL
COLLECTION OF AIR
IN THE PLEURAL
SPACE BETWEEN
THE LUNG AND THE
CHEST WALL
• 1. Closed Pneumothorax

ØCaused by rupture of small blebs on the visceral pleural space

ØThis condition occurs most commonly in young tall thin male
cigarette smokers between 20-40 years of age
ØSymptoms: Shortness of breath and chest pain are the most
common presenting complaints of pneumothorax.. The patient’s
appearance is highly variable, ranging from acutely ill with
cyanosis and tachypnea to misleadingly healthy.
ØSigns: 1) Hyper resonance but there is no mediastinal shift
Ø 2)decreased breath sounds
Ø3)diminished air entry
Ø4)hypoxia
Ø5)hypercapnia
Management

ØIf the amount of air is small and the patient is

not dyspneic ,the patient is treated conservatively
until spontaneous absorption of the
pneumothorax takes place.
ØIf the patient is dyspneic , a chest tube is inserted
in the 5th intercostal space until expansion of the
lung becomes complete
2.Open Pneumothorax
An opening in the chest wall which allow air entry into the
pleural space, usually caused by penetrating trauma like stabs
or gunshot wounds.
Sucking chest wound makes a new pathway for air to travel
into the chest cavity.
The opening allows air to escape from the lung and decreases
the likelihood of developing tension pneumothorax
• Symptoms
• .chest pain, dyspnea and cyanosis
• .There is absent breath sound with hyperresonance on affected side
and trachea is central
Ø MANAGEMENT:

• It is an emergency condition
• -Immediate application of adhesive external dressing to stop
movement of air through the defect (make it close )
• -The wound is then repaired in theater, and a chest tube is
inserted to drain the air in the pleural cavity
DRESSING OCCULSIVE

CHEST TUBE
3.Tension Pneumothorax

ØIt develops when a “one-way valve “ air leak

occurs from the lung or through the chest wall.
Air is forced into the pleural space ,eventually
completely collapsing of the affected lung
• Through this valvular mechanism
• air will accumulate in the pleural
cavity with increased positive
pressure >> lung collapse on the
affected side with shift of
mediastinum to the other side >>
kinking of the vena cava resulting in
impairment of venous return and
low cardiac output
• and compression to the other lung
leads to significant hypoxia
Ø Clinical picture:

tension pneumothorax is a clinical diagnosis

1. Severe dyspnea and cyanosis

2. There is absent breath sounds with
hyperresonance on affected side, and
trachea and mediastinum are pushed to the
other side
3. Respiratory arrest can occur
4. Hypotension
5. Increase JVD
MANAGEMENT

• - Immediate life-threatening injuries that must be

identified and treated in the primary survey a
clinical diagnosis and treatment should never be
delayed by waiting for radiological confirmation.
• -The pressure should be relieved immediately with
needle decompression (2nd intercostal space
midclavicular ) and later a chest tube should be
inserted (5th intercostal space anterior-axillary )
 Needle decompression

Performed to stabilize
deteriorating patients in the
life threatening situation of
a tension pneumothorax

Chest Tube
Hemothorax

ØAccumulation of blood in the pleural space caused

by injury to:

1- Pulmonary parenchyma or vessels .

2- intercostal vessels or internal thoracic vessels .
3- great vessels with an opening in the pleura .
4- heart with a communicating defect in the
pericardium and pleura .
 SYMPTOMS:
Ø “Massive
Hemothorax”
Ø when blood loss is • -Depending on the rate and
greater than 1500 mL quantity of hemorrhage, varying
degrees of hypovolemic shock will
into the chest cavity be manifested.
or continuing blood • - Respiratory distress, breath
loss more than 200 ml sounds may be diminished and
dullness to percussion.
per hour for at least 4
hours.
Ø Massive Hemothorax
is a serious condition
with mortality rate of
75% .
MANAGEMENT:

1. Correcting the hypovolemic shock (volume

replacement)
2. Tube thoracostomy.
A large-bore tube should be inserted in the 5TH
interspace at the anterior axillary line and
connected to underwater seal drainage and
suction.
3. Thoracotomy if the pleural hemorrhage exceeds
200ml/h
Pericardial Tamponade

defined as :bleeding into pericardial sac ,resulting in constriction of heart

،decreasing inflow and resulting in decreased output.
most common causes: severe chest injury , heart attack ,aortic dissection
, tuberculosis , acute pericarditis
The clinical presentation:
-Tachycardia
-shock
-Becks triad : hypotension, muffled heart sounds, JVD
Diagnosis :Ultrasound(echo)
Management

• Pericardiocentesis
During pericardiocentesis, a doctor inserts a needle
through the chest wall and into the tissue around the
heart.
Once the needle is inside the pericardium, the doctor
inserts a long, thin tube called a catheter. The doctor
uses the catheter to drain excess fluid. The catheter
may come right out after the procedure.

• -If blood returns then median sternotomy to rule out

and treat cardiac injury.
FLAIL CHEST

• When three or more adjacent ribs fracture at two points for each
of them, a segment of the chest wall does not move in continuity
with the rest of the chest but it moves paradoxically; inward
motion with inspiration and outward on expiration

• Crepitus and abnormal chest-wall motion should be noticed

during Primary Survey

• Underlying pulmonary contusion is considered to be the major

cause of respiratory insufficiency with flail chest, and it is
therefore one of the most serious chest wall injuries.
Clinical manifestations:

• Rapid, shallow respirations.

• Tachycardia.
• Movement of the thorax is asymmetric and
uncoordinated.
• inward motion with inspiration and
outward on expiration
• Chest pain.
• Dyspnea.
• Complications:
Respiratory failure due to pulmonary
contusion
DIAGNOSIS:
- Clinically: severe point tenderness, bony crepitus, ecchymosis, and muscle
spasm over the rib being the most common findings.
uImaging: X-ray , CT scan for blunt trauma

vManagement:
1.Fluid management
2.Pain management
3.Ventilation should be maintained with oxygen
4.4..PEEP (positive end –expiratory pressure) intubation
5.Tube thoracostomy in case of hemothorax
Pulmonary contusion

ØIs an injury to lung parenchyma,

leading to edema and blood collecting
in alveolar spaces and loss of normal
lung structure and function and the
presence of gross bruises and
ecchymosis
ØAny chest trauma can lead to
pulmonary contusions
ØMay not be evident initially on
examination but develops in post
traumatic period
ØThe most common potentially lethal
chest injury.
PATIENTS MAY PRESENT WITH:

• 1) Chest pain
• 2) chest-wall bruising.
• 3) Hemoptysis .
• 4) hypoxia ,tachypnea ,dyspnea ,tachycardia.
• 5) Pain on breathing ,Hypoventilation .
• 6) With or without rib fracture.
• In severe cases ecchymosis can be evident over the chest wall
and decrease breath sounds may be present
MANAGEMENT:

àIt is only Supportive Care.

1. Fluid management
2. diuretics to reduce pulmonary venous resistance and
pulmonary capillary hydrostatic pressure.
3. Oxygen administration.
4. Adequate analgesia.
5. PEEP intubation