Dr.

Omar Abd Elkhalek

LECTCHER OF CHEST DISEASES
Al_Azhar University
2024
2
 Pneumothorax:
Introduction
• Pneumo”- gas “Thorax” – chest cavity
• Pneumothorax is defined as air in the
pleural space—that is, between the lung and
the chest wall
• 1ry and 2nd pneumothorax are reported
in the UK at between 5.8/100 000 per year for
women and 16.7/100 000 per year for men.
• Mortality rates in the UK were 0.62/million per
year for women and 1.26/million per year for
men between 1991 and 1995.
 Etiology

Pneumothorax

Spontaneous Traumatic

Primary Secondary Iatrogenic Non iatrogenic

Interventional Positive Penetrating Blunt

procedures. pressure trauma trauma.
ventilation
 TYPES:
• Spontaneous: ― Non Traumatic‖
(primary or secondary)
• Traumatic: (accidental, Artificial)
• May be of 3 types:
-Open
-Closed
- Tension* valvular*
 Spontaneous pneumothoraces
which occur without antecedent trauma or other
obvious cause:

1.Primary spontaneous pneumothoraces

occur in otherwise healthy individuals with

1-Apical emphysematous bleb.

2-Young adults thin tall .

Secondary spontaneous pneumothoraces:
occur as a complication of underlying lung
disease, mostly:
1-commonly chronic obstructive
pulmonary disease (COPD) and Asthma
2- Suppurative lung
3-TB
4-Cystic fibrosis
 Traumatic pneumothoraces:
which occur from direct or indirect trauma to
the chest.
1.Iatrogenic pneumothorax,
which occurs as an intended or inadvertent
consequence of a diagnostic or therapeutic
maneuver.

2. Accidental
 Diagnosis:
• History:
• Examination:
-General examination
-local examination:-
(inspection ,palpation,
percation,Auscultation).
• Investigation:
 TENSION PNEUMOTHORAX
• Injured chest or lung acts as one-way valve

• Air becomes trapped between the lung and chest

wall causing the lung to collapse

• The heart is pushed to the other side causing

blood vessels to kink

• Death will result if not quickly recognized and

treated with needle decompression
• May occur in open and closed chest wounds
TENSION PNEUMOTHORAX
 Tension Pneumothorax

Air between lung

and chest wall

Air collapses lung

and pushes heart to
other side

Blood return to heart

restricted by kinked vessels,
heart unable to pump
 TENSION PNEUMOTHORAX:

• Progressive severe respiratory distress in

setting of unilateral penetrating chest
trauma
• Do not rely on typical signs as breath
sounds, tracheal shift, and
hyperresonance on percussion
• Decompress immediately with 14-
gauge catheter
 OTHER SIGNS AND SYMPTOMS OF
TENSION PNEUMOTHORAX:

• Difficulty breathing
• Chest pain
• Unilateral decreased/absent breath sounds
• Anxiety or agitation
• Increased pulse
• Tracheal deviation
• Jugular venous distention (JVD)
• Cyanosis
TRACHEAL DEVIATION AND JVD

JVD • The trachea is shifted

away from the
collapsed lung
• The jugular veins
Tracheal become engorged
Deviation from restricted blood
return to heart
• LATE SIGNS!
NEEDLE CHEST DECOMPRESSION

• Locate 2d intercostal space at

midclavicular line
• Insert 14-gauge catheter-over-needle into
chest cavity over superior edge of rib
• Listen for gush of air and observe for
improvement of symptoms
• Tape catheter in place with cap or valve in
place to prevent re-entry of air
NEEDLE CHEST DECOMPRESSION
NEEDLE CHEST DECOMPRESSION
Percussion
Pleural cavity pressure:
 SIZE OF PNEUMOTHORAX
• The size of a pneumothorax is divided into
“small” or “large” depending on the presence
of a visible rim of <2 cm or >2 cm between the
lung margin and the chest wall.
• The volume of a pneumothorax approximates to
the ratio of the cube of the lung diameter to the
hemithorax diameter,
 primary spontaneous
pneumothorax
• Therapy for the patient with primary
spontaneous pneumothorax has two goals: (a)
to rid the pleural space of its air and
(b) to decrease the likelihood of a recurrence.
1-Observation: If the communication
between the alveoli and the pleural space is
eliminated, the air in the pleural space will be
reabsorbed.
 2- Supplemental Oxygen: The administration
of supplemental oxygen accelerates the rate
of pleural air absorption in experimental and
clinical situations.
3- Aspiration: The initial treatment for most patients
with primary spontaneous pneumothoraces greater
than 15% of the volume of the hemithorax should
probably be simple aspiration. With this procedure, a
16-gauge needle with an internal polyethylene
catheter is inserted into the second anterior intercostal
space at the midclavicular line after local anesthesia.
 4-Tube Thoracostomy: With tube
thoracostomy, the air in the pleural space can
be rapidly evacuated.
The chest tube should be positioned in the
uppermost part of the pleural space, where
residual air accumulates.
5- Tube Thoracostomy with Instillation of a
Sclerosing Agent: Approximately 50% of
patients with an initial primary spontaneous
pneumothorax have a recurrence whether they
are treated with observation or tube
thoracostomy.
6- Autologous Blood Patch for Persistent
Air Leak: In the past few years, there have
been several articles that have reported that
an autologous blood patch is an effective
treatment for a persistent air leak in patients
with spontaneous pneumothorax.
7- Intrapleural Fibrin Glue for
Persistent Air Leak: There has been
one article that suggested that the
intrapleural administration of a large amount
of diluted fibrin glue might be effective in
patients with persistent air leaks.
• 8- Medical Thoracoscopy:
Medical thoracoscopy is performed with
the patient under local anesthesia, usually
combined with conscious sedation. In
contrast, video-assisted thoracoscopic
surgery (VATS) is performed almost
exclusively under general anesthesia with
double-lumen endotracheal intubation,
which allows single-lung ventilation and
the collapse of the lung on the operated
side.
9- Video-Assisted Thoracoscopic Surgery
VATS is effective in the treatment of spontaneous
pneumothorax and the prevention of recurrent
pneumothorax. With VATS, there are two primary
objectives: (a) to treat the bullous disease
responsible for the pneumothorax and (b) to create a
pleurodesis.

10- Open Thoracotomy: The indications

for open thoracotomy are the same as those
for thoracoscopy. If VATS is available,
thoracotomy is recommended only after
thoracoscopy has failed.
 secondary spontaneous
pneumothorax:
• Treatment:
as with primary spontaneous pneumothorax,
are to rid the pleural space of air and to
decrease the likelihood of a recurrence.
Under water seal chest tube in
2nd,3rd,ICS MCL OR 4-6 ICS MAL
Pneumothorax: Special forms
• Hydropneumothorax;

• Pyopneumothorax:
– Air + fluid

– tapping, traumatic, rupture of abscess

– Stony dullness with horizontal level &

hyperresonace above it. Shifting dullness
 Pneumomediastinum
• Air in the mediastinal tissues is referred to as
pneumomediastinum or mediastinal emphysema
 Pneumomediastinum: Causes
• Rise in intrathoracic pressure such as occurs with coughing,
straining→ upper respiratory tract infection, asthma, bronchitis,
whooping cough, obstructive laryngitis, choking on a foreign
body and childbirth.
• Pulmonary barotrauma resulting when a person moves to or
from a higher pressure environment, such as when a SCUBA
diver, a free-diver or an airplane passenger ascends or
descends
• Blunt force or penetrating chest trauma, endobronchial or
esophageal procedures,, mechanical ventilation, or chest
surgery, tracheostomy or other invasive procedures.
• The main symptom is usually severe central chest pain.
• Pain in the neck may be accompanied by dysphagia

• Other symptoms include laboured breathing, voice distortion

(as with helium) and subcutaneous emphysema.

• It is often recognized on auscultation by a "crunching" sound

timed with the cardiac cycle (Hamman's crunch).

• On rare occasions sufficient air under tension surrounds the

heart to cause cardiac tamponade