PNEUMOTHORAX

BY SANTOSH KUMAR MAHATO

FCPS RESIDENT
 CONTENTS
1. INTRODUCTION
2. CLINICAL TYPES AND PATHOPHYSOLOGY
3. CLINICAL FEATURES
4. RADIOLOICAL FINDINGS
5. SURGICAL MANAGEMENTS
6. PHYSIOTHERAPY
7. FOLLOW UP
8. COMPLICATION
 INTRODUCTION
Pneumothorax, sometimes abbreviated to PTX,
(plural: pneumothoraces) refers to the presence of
gas (often air) in the pleural space.
When this collection of gas is constantly enlarging
with resulting compression of mediastinal structures,
it can be life-threatening and is known as a tension
pneumothorax (if no tension is present it is a simple
pneumothorax).
 Pathology
• It is useful to divide pneumothoraces into three
categories :

• primary spontaneous: no underlying lung disease.

• secondary spontaneous: underlying lung disease is
present
• iatrogenic/traumatic
 Primary spontaneous
• A primary spontaneous pneumothorax is one
which occurs in a patient with no known underlying
lung disease. Tall and thin ,young, smoker (<35
year)are more likely to develop a primary
spontaneous pneumothorax.
• sMutation in FLCN Gene in rare cases.
Marfan syndrome
Ehlers-Danlos syndrome
Alpha-1-antitrypsin deficiency
Homocystinuria
 Secondary spontaneous
• When the underlying lung is abnormal, a pneumothorax is
referred to as secondary spontaneous.
• Generally occurs inn elderly patients >45 years
• cystic lung disease
• bullae, blebs
• emphysema, asthma
• pneumocystis jiroveci pneumonia (PJP).
• due to apical lung changes from ankylosing spondylitis 1
• cystic fibrosis
• parenchymal necrosis
• lung abscess, necrotic pneumonia, septic emboli, fungal disease,
tuberculosis
• cavitating neoplasm, metastatic osteogenic sarcoma
• radiation necrosis
 Iatrogenic/traumatic
• Iatrogenic/traumatic causes include –
• Iatrogenic:
• percutaneous biopsy
• barotrauma (e.g. divers), ventilator
• radiofrequency (RF) ablation of lung mass
• endoscopic perforation of the esophagus
• central venous catheter insertion, nasogastric tube placement
• Trauma:
• pulmonary laceration
• tracheobronchial rupture
• acupuncture
• esophageal rupture
 Pneumothorax in covid-19
• Although spontaneous pneumothorax as a form of
coronavirus disease 2019 (COVID-19) presentation
at the emergency department (ED) was unusual, it
was more frequently seen in patients with COVID-
19 compared to patients without COVID-19, and
may be associated with worse outcomes than
spontaneous pneumothorax alone or COVID-19
without spontaneous pneumothorax, according to
the results of a case-control study published in
CHEST.
Types
 Tension pneumothorax
• Tension pneumothorax develop when a lung or
chest wall injury is such that it allows air into the
pleural space but not out of it(a one way valve)
• As a result air accumulates and compress the
lung ,eventually shifting the mediastinum
compressing the contralateral lung, and increasing
intra-thoracic pressure enough to decrease venous
return to the heart causing shock.
 Clinical features
• Tension pneumothorax should be diagnosed
clinically ,before the chest x-ray is obtained
• Difficulty in breathing
• Increased heart rate
• Tachypnea
• Engorged neck veins
• Decreased Blood pressure
• Cyanosis
• Chest wall bulging
• Shifting of trachea to opposite side
• On percussion
.Hyper-resonance of chest wall on affected side
.Decreased vocal fremitus on affected side
.Shifting of cardiac dullness
.Shift of liver dullness
On auscultation
.Absent breathe sound on affected side
.Deceased vocal resonance on affected side
 RADIOLOGICAL FINDINGS
• CHEST XRAYS-
• Hyper-lucency between lung field and thoracic cage
• Sharp border of collapse lung
• Shifting of mediastinum to opposite side
• Absence of Broncho-vascular marking on affected side lung
field.
• Shifting of trachea to opposite side
 CT scan finding
• May be used in case o accult finding or small
pneumothoax
• Intrapleural gas along with loculatted
pneumothoraces
• Ultrasound
• Ultrasound is commonly used in the evaluation of
people who have sustained physical trauma, for
example with the FAST protocol.
• Ultrasound may be more sensitive than chest X-rays
in the identification of pneumothorax after blunt
trauma to the chest.
• Ultrasound may also provide a rapid diagnosis in
other emergency situations, and allow the
quantification of the size of the pneumothorax.
 Treatment and prognosis
• Treatment depends on a number of factors:

• size of the pneumothorax

• symptoms
• background lung disease/respiratory reserve
• Estimating the size of pneumothorax is somewhat
controversial with no international consensus. CT is
considered more accurate than plain radiograph.

• British Thoracic Society (BTS) guidelines (2010):

measured from chest wall to lung edge at the level
of the hilum 12
• <2 cm: small
• ≥2 cm: large
• American College of Chest Physicians guidelines
(2001): measured from thoracic cupola to lung apex
• <3 cm: small
• BTS guidelines for the treatment of pneumothorax;
local protocols may differ:

• asymptomatic small rim pneumothorax: no treatment

with follow-up radiology to confirm resolution
• pneumothorax with mild symptoms (no underlying
lung condition): needle aspiration in the first instance
• pneumothorax in a patient with background chronic
lung disease or significant symptoms: intercostal drain
insertion (small drain using the Seldinger technique)
 Management of tension pneumothorax
• It is life threatening condition should be managed
immediately
• Needle decompression is done at the second
intercostal space in the mid clavicular line above the
rib with an needle(14-16G). It results in re-
expansion of the collapsed lung. However, the risk
of lung re-expanding quickly increases the risk of
pulmonary edema. Following needle
decompression, a chest tube is usually placed, and
an immediate CXR is done to assess the resolution
of the pneumothorax.
 Surgical management
• Chest tube is usually kept though safety triangle and
under water seal
 Following insertion of the chest drain it is essential to
• check the underwater seal oscillates during respiration
• order a repeat chest x-ray to confirm the position of the tube and the
degree of lung re-expansion and exclude any complications
• advise the patient to keep the underwater bottle upright and below
the drain insertion site.
• ensure regular analgesia is prescribed whilst the chest drain is in
place
• ensure all sharps disposed of in accordance with the Trust policy
• document the procedure in the patient’s medical and nursing records
 Indication of chest tube in pneumothorax
• Consider if Chest drain is required. Follow the BTS 2010
Algorithm
1. persistent or recurrent pneumothorax after simple
aspiration
2. tension pneumothorax should always be treated with a
chest drain after initial relief with a small bore cannula or
needle
3. in any ventilated patient with a pneumothorax
4. large secondary spontaneous pneumothorax (>2cm)
5. iatrogenic eg. following insertion of a central venous
catheter
 When to remove chest tube
• Stable clinical condition
• Wide-open lung in X-ray of the tube thoracostomy
• Discharge of less than 200 cc in twenty-four hours
• No air leak
• Bubbling movement has ceased
• Lung is fully expanded in chest x-ray
• Air leak should not exist either during suction or
coughing.
 Other treatment modalities
. Chemical pleurodesis, such as talc, tetracycline
. Thoracotomy followed by pleurectomy
. Video-assisted thoracoscopic surgery (VATS)
. Lobectomy
 Physiotherapy
Goals
• To improve distribution of ventilation
• To re-inflate the atelectatic lung areas
• To increase oxygenation
• To improve exercise tolerance
• Maintain airway clearance
 Follow up
• Patients should be advised to return to hospital If
increasing breathless develop
• All patient should be followed up by respiratory
physician with full resolution( CXR 2-4 week post
discharge)
• Air travel should be avoided until more than 1 week
after full resolution
• Diving should be permanently avoided unless the
patient has undergone b/l surgical pleurectomy
complications
 reference
1.Management of spontaneous pneumothorax: British
Thoracic Society pleural disease guideline 2010
2. Laws D, Neville E, Duff J. British Thoracic Society guidelines
for the insertion of a chest drain.
3. Collop NA, Kim S, Sahn SA. Analysis of tube thoracostomy
performed by pulmonologists at a teaching hospital
4. American association of respiratory care.
5.Miró Ò, Llorens P, Jiménez S, et al; on behalf of the Spanish
Investigators on Emergency Situations Team (SIESTA) Network.
Frequency, risk factors, clinical characteristics and outcomes
of spontaneous pneumothorax in patients with Covid-19: a
case-control, emergency medicine-based multicenter study.
Published online November 20, 2020. CHEST.
THANK YOU