ALOK SINHA

Department of Medicine
Manipal College of Medical Sciences
Pokhara, Nepal
Defined as the presence of air in the pleural
cavity

Negative intrapleural
pressure: ~ 5mm
 PNEUMOTHORAX

Spontaneous: Secondary:
Iatrogenic
traumatic
1. Primary spontaneous P.
2. Secondary spontaneous P.
 Primary spontaneous pneumothoraces

 Do not have overt parenchymal disease

 increased shear forces in the apex
 commonly are smokers & tall young males
 risk much more pronounced in female
smokers

 Genetic factors - Marfan’s syndrome


Defect of connective tissue
High arched palate
 Secondary spontaneous pneumothoraces
(SSP)
occur in the presence of lung disease
COPD
Tuberculosis
sarcoidosis Sub pleural focus
rupturing in pleural cavity
cystic fibrosis
malignancy
idiopathic pulmonary fibrosis
Pneumocystis carinii pneumonia [PCP]) in patients with AIDS
 Iatrogenic pneumothorax
a complication of medical or surgical procedures.
results from
Therapeutic thoracentesis
Positive pressure mechanical ventilation
Pleural biopsy
Central venous catheter insertion
Transbronchial biopsy
routine use of ultrasonography guided diagnostic
thoracentesis is associated with lower rates of
pneumothorax
Intra pleural pressure

(-)
Broncho pleural fistula

Intra pleural pressure

(0)
Intra pleural pressure
(+)
Symptoms:
 Sudden onset (usually after a bout of coughing) of
Chest pain
dyspnoea
 Asymptomatic when small

Signs:
 In sever cases low volume pulse with tachycardia
 Collapse & signs of peripheral circulatory failure

 Cyanosis

(See when there is tension pneumothorax)

Vitals are normal in closed & open pneumothorax
Inspection:
 Dyspnoea with accessory muscles active
 Tracheal shift may be visible – trail’s sign
 Fullness of chest on affected side
 Diminished chest movement
Palpation:
 Trachea & medistinum shifted to opposite
side
 Vocal fremitus – markedly diminished
 Diminished expansion of affected hemithorax

Percussion:
 Hyper resonant note on the affected side
 Liver dullness obliterated: right sided pneumothorax
 Cardiac dullness shifted to opposite side
 Auscultation

Vocal resonance reduced/absent

Breath sounds reduced/absent on affected side
 Hamman's sign: refers to a click on auscultation

in time with the heart sounds, due to movement of

pleural surfaces with a left-sided pneumothorax

In open pneumothorax
Amphoric breath sound due to broncho pleural
fistula may be heard
CXR -diagnostic in most cases
 visible lung edge and absent lung markings
peripherally
 increased lucency & hemidiaphragm depression on
the affected side

CXR appearance may also show features of

underlying lung disease
CT chest may be required
 To differentiate pneumothorax from

bullous disease
 Useful in diagnosing unsuspected

pneumothorax following trauma

 In looking for evidence of underlying

lung disease
Partial pneumothorax
Determined by
1. Degree of breathlessness & lung
collapse
2. Hypoxia
3. Evidence of haemodynamic compromise
4. Presence and severity of any underlying
lung disease
5. Pneumothorax size
Severe breathlessness out of proportion to
pneumothorax size may be a feature of
tension pneumothorax

Secondary pneumothorax has a significant

mortality (10%), and should be managed more
aggressively. Treat also the underlying
disease
Aspiration
Chest Aspiration
Chest Aspiration

Suction apparatus
Inserting a inter coastal drainage tube

1
2
3
4
5
 Aspiration
Indications
Primary pneumothorax Consider aspiration if
patient breathless and/or
pneumothorax large (rim of air > 2 cm on CXR)

Secondary pneumothorax Consider aspiration

patient aged > 50 years (all cases)
with small pneumothorax (rim of air < 2 cm on
CXR)
minimal breathlessness
 Chest drainage

Associated with significant morbidity and

even mortality due to subcutaneous
emphysema

not required in the majority of patients with

primary spontaneous pneumothorax
 Oxygen
All hospitalized patients should receive
high flow (10 l/min) inspired oxygen
(unless CO2 retention is a problem)

Reduces the partial pressure of nitrogen

in blood, encouraging removal of air from
the pleural space and speeding up
resolution of the pneumothorax
 Persistent air leak
Defined as continued bubbling of chest drain 48 hours
after insertion
In indicates:
Inability of lung to expand after the drainage

Broncho pleural fistula - communication with

out side air

Will develop secondary infection and pyopneumothorax

until closed by surgery
 Out-patient follow-up
Repeat CXR to ensure resolution of
pneumothorax and normal appearance of
underlying lungs

Discuss risk of recurrence and emphasize

smoking cessation, if appropriate
 Advise about flying

Patients should not fly for at least 6 weeks.

avoid flying for a longer period, e.g. 1 year
Advise NEVER TO DIVE in the future, unless
patient has undergone a definitive surgical
procedure
 Indications for cardiothoracic
surgical referral
Second ipsilateral pneumothorax
Bilateral spontaneous pneumothorax
Persistent air leak (>5 -7 days of
drainage)
Spontaneous haemothorax
Professions at risk (e.g. pilots, divers)
after first pneumothorax
 Chemical pleurodesis

As an alternative for surgery specially in case of

recurrent pneumothorax
seal the visceral to the parietal pleura to
prevent pleural fluid accumulating.
(already described previously)
Tension pneumothorax
Pneumothorax acts as a one-way valve
Progressive increase in pleural pressure
compresses both lungs and mediastinum
Reduced venous return to the heart,
leading to hypotension and cardiac arrest

not related to pneumothorax size can occur with very

small pneumothoraces in the context of air trapping in
the lung from obstructive lung disease
Patients present with
 Acute respiratory distress & agitation
 Hypotension
 Raised jugular venous pressure
 Tracheal deviation away from the
pneumothorax side
 Reduced air entry on affected side
 May present with cardiac arrest (pulseless electrical
activity)
 Acute deterioration in ventilated patients
 Management
 Give high-flow oxygen
 Insert a needle into second intercostal space
in midclavicular line on side of pneumothorax
Do not wait for a CXR if cardiac arrest has
occurred or the diagnosis is clinically certain
 Hissing air confirms diagnosis. Aspirate air
until the patient is less distressed
 Insert chest drain in mid axillary line
afterwards