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The presence of air or gas

in the pleural cavity


(ie, the potential space
between the visceral and
parietal pleura of the lung),
which can impair
oxygenation and/or
ventilation.
Pneumothorax occurs at
any ages, including
neonates and children.

This condition is medical


emergency that can cause
death, especially in
children.
There is much national and
international controversy
surrounding the right
initial treatment of
pneumothorax
A-14 years and 8 month girl,
presented to pediatric dept.
Wahidin Sudirohusodo Hospital
on November 13th, 2012
with main complaint was
shortness of breath
Aloanamnesis: From her mother
Main complaint: shortness breath (sudden onset)
experienced since six hours prior to the admission.

Sudden onset chest pain


Paroxysmal cough for one week
Frequent cough for three month but no dyspnea
No fever and seizure
History of frequent fever for three months
Nausea and vomiting two times
Her appetite was decreased
Defecation and micturition were normal
Body weight decreased for the last three months
Bed time sweating for the last one month
Contact with adult tuberculosis patients was denied
History of chest trauma was denied
There was no contact history with suddenly died poultry
General condition:
Severely ill, under nourish, and conscious child (GCS 15).
Vital sign:
BP 90/60 mmHg. PR 120x/min. RR 60x/min. BT 37.8 0C
Body weight 13 kg. Body length 96 cm.
Inspection :
distressed and sweating. No pale and cyanotic, nostril breathing.
Assymetrical chest movement, retraction on suprasternal & subcostal
Palpation :
found crepitations on the left lung.
Percussion :
hyper-resonance over the collapse lung.
Auscultation :
Breath sounds are reduced or absent over the affected area (left side).
Crackles are found on the right lung, there is no wheezing appearance.
Complete blood count:

WBC 9.560 /mm3


RBC 4.54 x106 /mm3
HGB 12.7 g/dl3
HCT 38.3 %
MCV 84.4 fl
MCH 28.0 pg
MCHC 33.2 g/dl
PLT 317.000 /mm3
Blood gas analysis:
pH 7.454 Result:
PO2 61.2 mmHg Fully compensated
PCO2 30.8 mmHg respiratory alkalosis.
SO2 92.2 %
HCO3 21.2 mmol/L
BE -1.9 mmol/L
Blood glucose level 108 mg/dl
SGOT 14 U/L
SGPT 8 U/L
HBsAg negative
Anti HCV negative
BT 800 minutes
CT 200 minutes
PT 10.9 second
APTT 27.3 second
Electrolytes:
Sodium 144 mmol/l
Potassium 4.1 mmol/l
Chloride 112 mmol/l
AP X-ray result:

Pneumothorax sinistra
Lung tumor suspected

Advice : Thorax CT scan


CT Scan Thorax result:

Pneumothorax sinistra with


lung colaps
Infected bronchiectasis dextra
Chronic active of duplex
tuberculosis
Spontaneous pneumothorax sinistra
Under nourish
Supporting therapy:
O2 2 L/min via nasal canule
IVFD Dextrose 5% 30 gtt/min
Medicamentosa:
Ceftriaxon injection 2 x 1 g/iv
Ketorolac injection 2 x 10 mg/iv
Ranitidine injection 2 x 25 mg/iv
Usual diet:
Calorie 2000 gr
Protein 75 gr
Consult to surgical dept. for WSD procedure
Tuberculin test
Acid-fast Bacilli from sputum
Nov 14th Nov 15th Nov 16th Nov 17th
(2nd day) (3rd day) (4th day) (5th day)

Vital Sign RR : 50 x/m, PR : 140 RR: 36 x/min Normal Normal

Cough, Dyspnea was Cough with sputum (+),


Complaint Cough, Dyspneu Cough (-)
decreased Dyspnea (-)

Nasal flare (+), Supra- Appetite was improve,


Nasal flare (+), Subcostal Symetric chest wall
sternal retraction (+), Nasal flare (-), Supra-
& Suprasternal retraction movement, sonor on
Asymmetrical chest sternal retraction
Physical (+), Asymmetrical chest right & left chest, WSD
movement improving, minimal, Asymmetrical
examination movement, hypersonor (+), Crepitation (+),
hypersonor in the right chest movement (-) Left
in the right chest, BS ronchi +/+
chest, BS decreased on lung BS improving,
decrease on left chest
left chest still audible crackels on both lung

O2 2 l/min, IVFD D5%, O2 2 l/min, IVFD D5%, IVFD D5%, IVFD D5%,
Ceftriaxon 2x1g/iv, Ceftriaxon 2x1g/iv, Ceftriaxon 2x1g/iv, Ceftriaxon 2x1g/iv,
Ketorolac 2x10mg/iv, Ketorolac 2x10mg/iv, Ketorolac 2x10mg/iv, Ketorolac 2x10mg/iv,
Therapy
Ranitidine 2x25mg/iv, Ranitidine 2x25mg/iv, Ranitidine 2x25mg/iv, Ranitidine 2x25mg/iv,
stop oral intake Usual diet ATD day 1, Usual diet ATD day 2, Usual diet
Planning: WSD 1st day WSD attached 2nd day WSD attached 3rd day WSD attached

Laboratory Tuberculin test (done) CBC Thorax X-ray control Planning: Stop WSD
Chest X-ray control:
Pneumothorax
Laboratory Tuberculin test (+) sinistra dissapear
- -
result induration 30 mm Specific bilateral
pneumonia infection
Nov 18th Nov 19th Nov 20th Nov 21th
(6th day) (7th day) (8th day) (9th day)

Vital Sign Normal Normal Normal Normal

Complaint - - - -

Active, retraction (-), Active, retraction (-), Active, retraction (-), Active, retraction (-),
Physical chest movement normal, chest movement normal, chest movement normal, chest movement normal,
examination BS normal, crackles on BS normal, crackles on BS normal, crackles on BS normal, crackles on
both lung both lung both lung both lung

IVFD D5%, IVFD D5%, IVFD D5%, IVFD D5%,


Ceftriaxon 2x1g/iv, Ceftriaxon 2x1g/iv, Ceftriaxon 2x1g/iv, Ceftriaxon 2x1g/iv,
Therapy Ketorolac 2x10mg/iv, Ketorolac 2x10mg/iv, Ketorolac 2x10mg/iv, Ketorolac 2x10mg/iv,
Ranitidine 2x25mg/iv, Ranitidine 2x25mg/iv, Ranitidine 2x25mg/iv, Ranitidine 2x25mg/iv,
ATD day 3, Usual diet ATD day 4, Usual diet ATD day 5, Usual diet ATD day 6, Usual diet

Laboratory - - - -

Laboratory
- - - -
result
Nov 22th Nov 23th Nov 24th Nov 25th
(10th day) (11th day) (12th day) (13th day)

Vital Sign Normal Normal Normal Normal

Her mother ask for


discharge from hospital
Complaint - - -
and continue oral
therapy at home

Active, retraction (-),


Physical chest movement normal,
- - -
examination BS normal, crackles on
both lung

IVFD stop,
Stop intravenous drug
Therapy - - -
ATD day 7
Usual diet

Laboratory - - - -

Laboratory
- - - -
result
Left secondary spontaneous pneumothorax
Lung tuberculosis
Under nourish
Qua ad vitam : ad bonam
Qua ad sanationam : ad bonam
Pair of spongy, air-filled organs.
Located on either side of the chest
Trachea conduct inhaled air into the lungs through its bronchi
The bronchi than divide into smaller branches called bronchioles
Finally become microscopic air sac called alveoli
The lung covered by a thin tissue layer called pleura
The presence of air or gas
in the pleural cavity
(ie, the potential space
between the visceral and
parietal pleura of the lung),
which can impair
oxygenation and/or
ventilation.
It is every pneumothorax
that occurs suddenly.
This type of pneumothorax
can be classified into two
types; primary
pneumothorax and
secondary pneumothorax.
It is one that occurs
without an apparent cause
and in the absence of
significant lung disease.
It is one that occurs in the
presence of existing
lung pathology
(i.e. Lung tuberculosis)
It is every pneumothorax
that resulted from trauma,
either blunt or penetreting
trauma, which cause
tearing of the pleura, chest
wall and lung. So that air
enters directly into the
pleural cavity.
PNEUMOTHORAX

SPONTANEOUS TRAUMATIC
Tension
Primary Non Iatrogenic
Pneumothorax
Secondary Iatrogenic
18 per 100,000 men / year
6 per 100,000 women / year

Secondary spontaneous
pneumothorax is a rare case
and its occurs at any age
(neonates, children, adult)
British Thoracic Society 2012

Sudden chest pain


Sudden shortness of breath
Respiratory failure x
British Thoracic Society 2012

The clinical results are dependent on


the degree of collapse lung on the affected area

1. Amount of air in pleural cavity


2. Size of collapse lung
3. Tension Pneumothorax
British Thoracic Society 2012

Inspection asymmetricaly chest movement


Percussion hyper-resonance
Auscultation decrease breath sounds
Circulatory collapse due to Tension pneumothorax x
Amount of air in pleural cavity and
Size of collapse lung

% estimate size of pneumothorax


A + B + C (cm) x 10
10 cm
3

8 cm

6 cm
Amount of air in pleural cavity
Size of collapse lung

If lateral edge of lung is


>2cms from thoracic cage at
level of the hilum, then this
> 2 cm
implies pneumothorax is at
least 50% (large).
Small pneumothorax is
equivalent to <30%.
Tension Pneumothorax Sign
A case of pneumothorax in a 14 year old
girl, was reported. Diagnosis was based
on history taking, physical and supporting
examinations. The management of this
patient is to remove the trap air with water
sealed drainage procedure. As mention
that the patient has a tuberculosis
infection, anti tuberculosis therapy was
prescribed. Intervention evaluated base
on improvement of the clinical symptoms.
The prognosis of the patient was good.
After 72 hours
Pair of spongy, air-filled organs
Thoracic cavity

This space is defined by:


Sternum anterior
Thoracic vertebrae posterior
Ribs lateral
Diaphragm inferior

Chest wall composed of


ribs, sternum, thoracic
vertebrae interlaced with
intercostal muscle

The diaphragm is the floor


of the thoracic cavity
Thoracic cavity
Right lung
Left lung
Mediastinum
Heart
Aorta and great
vessels
Esophagus
Trachea
Thymus
Breathing: inspiration

Brain signals the phrenic nerve


Phrenic nerve stimulates the
diaphragm (muscle) to contract
When diaphragm contracts, it
moves down, making the
thoracic cavity larger
(keep this in mind as we discuss physics)
Physics of gases

Air is made up of gas molecules


Gas molecules in a container collide and create a force
Pressure is the amount of the force created by the gas
molecules moving and colliding
Physics of gases: Boyles law

When the volume of a container increases,


the pressure decreases
When the volume of a container decreases,
the pressure increases

If youre trying to squeeze as many people in a car as possible, they will


be under much higher pressure in a VW Beetle than the same number of
people would be in a bus.
Physics of Gases
If two areas of different pressure communicate, gas will move
from the area of higher pressure to the area of lower pressure
This movement of air causes wind when a high pressure
system is near a low pressure system in the atmosphere
Physics of Gases
Another example
Inflated balloon = HIGH PRESSURE (POSITIVE)
Atmosphere = LOW PRESSURE (NEGATIVE)
Pop the balloon, and air rushes from an area of high
pressure inside the balloon to the low pressure in the
atmosphere
Breathing: inspiration
When the diaphragm contracts, it moves
down, increasing the volume of the thoracic
cavity. When the volume increases, the
pressure inside decreases.
Air moves from an area of higher pressure,
(the atmosphere), to an area of lower
pressure (the lungs).
Pressure within the lungs is called
intrapulmonary pressure.
Breathing: exhalation
Exhalation occurs when the phrenic
nerve stimulus stops
The diaphragm relaxes and moves up
in the chest
This reduces the volume of the
thoracic cavity
When volume decreases, intra-
pulmonary pressure increases.
Air flows out of the lungs to the
lower atmospheric pressure
Breathing
Remember, this is normally an unconscious process
Lungs naturally recoil, so exhalation restores the lungs to
their resting position
However, in respiratory distress, particularly with airway
obstruction, exhalation can create increased work of
breathing as the abdominal muscles try to force air out of
the lungs
Pleural anatomy

Lungs are surrounded by thin tissue


called the pleura, a continuous
membrane that folds over itself.

Parietal pleura lines the chest wall


Visceral pleura covers the lung
(called the pulmonary pleura)
Pleural anatomy
Normally, two membranes are separated by the lubricating
pleural fluid. Fluid reduces friction, allowing the pleura to slide
easily during breathing.

Ribs

Intercostal
muscles

Lung Pleura Pleura


Visceral Parietal

Normal Pleural Fluid Quantity:


Approx. 25 ml per lung
Pleural physiology
The area between the pleura is called the pleural space
(sometimes referred to as potential space)
Normally, vacuum (negative pressure) in the pleural space keeps
the two pleura together & allows the lung to expand and contract.
During inspiration, the intrapleural pressure is approximately
-8cmH20 (below atmosphere)
During exhalation, intrapleural pressure is approximately -4cmH20
Pressures
Intrapulmonary pressure rises and falls with breathing
Equalizes to the atmospheric pressure at end-exhalation
(defined as 0 cmH2O because other pressures are compared
to it as a baseline)
Intrapleural pressure also fluctuates with breathing ~4
cmH2O less than the intrapulmonary pressure
The pressure difference of 4 cmH2O across the alveolar wall
creates the force that keeps the stretched lungs adherent to
the chest wall
When pressures are disrupted

Intrapleural pressure: -8cmH20

If air or fluid enters the pleural


space between two pleura, the
-4cmH20 pressure gradient
that normally keeps the lung
against the chest wall
disappears & the lung collapse.

Intrapulmonary pressure: -4cmH20


Conditions requiring chest drainage
Air between the pleura is a pneumothorax

Visceral pleura Pleural space

Parietal pleura
Conditions requiring chest drainage
Blood in the pleural space is a hemothorax
Conditions requiring chest drainage
Transudate or exudate in the pleural space is a pleural effusion
Conditions requiring chest drainage: tension pneumothorax

Tension pneumothorax occurs


when a closed pneumothorax
creates positive pressure in the
pleural space that continues to
build
That pressure is then
transmitted to the mediastinum
(heart and great vessels)
Conditions requiring chest drainage: mediastinal shift

Mediastinal shift occurs when


the pressure gets so high that it
pushes the heart and great
vessels into the unaffected side
Mediastinal shift These structures are
compressed from external
pressure and cannot expand to
accept blood flow
Conditions requiring chest drainage: mediastinal
shift

Mediastinal shift can quickly lead to cardiovascular collapse


The vena cava and the right side of the heart cannot accept
venous return
With no venous return, there is no cardiac output
No cardiac output = not able to sustain life !!

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