3. can be
a) Spontaneous
b) Result of iatrogenic injury
c) Trauma to the lung or chest wall
4. Classification
1. Spontaneous
# Primary
- No evidence of overt lung disease
- occurs in males aged 15-30
- air escapes from the lung into the pleural
space through rupture of a small emphysematous
bulla or pleural bleb
- smoking, tall stature & the presence of apical subpleural
blebs are additional risk factors
5. #Secondary
- underlying lung disease
- occurs mainly in males above 55 yrs
- most commonly COPD & TB
- also seen in asthma, lung abscess, pul infarcts,
bronchogenic carcinoma, all forms of fibrotic &
cystic lung disease
9. Closed type
ď¨ Communication b/n airway and the pleural space
seals off as the lung deflates
ď¨ Mean pleural pressure remains negative
ď¨ Spontaneous reabsorption of air & re-expansion of
lung occur over a few days or weeks
ď¨ Infection uncommon
10. Open type
ď¨ Communication b/n pleura & bronchus doesnât
seals off (Bronchopleural fistula)
ď¨ Intra pleural pressure = atm. Pressure
ď¨ Collapsed lung, no re expansion
ď¨ Transmission of infection from the airways into
the pleural space through fistula common
(empyema)
11. Tension type
ď¨ Communication b/n the airway & the pleural
space acts as a one-way valve
ď¨ Allowing air to enter the pleural space during
inspiration but not to escape on expiration
ď¨ Large amt of air accumulates progressively in the
pleural space
ď¨ Intrapleural pressure increases above atm
pressure
12. ď¨ Pressure causes mediastinal shift towards the
opposite side
ď¨ with compression of the opposite lung
ď¨ & impairment of systemic venous return
ď¨ Causing cardiovascular compromise
13.
14. ď¨ Occasionally tension pneumothorax may
occur without mediastinal shift, if malignant
ds or scarring has splinted the mediastinum
15. Clinical features
ď¨ Sudden onset of unliateral pleuritic chest pain
ď¨ Breathlessness
[In pts with a small pneumothorax, physical
examination may be normal ]
17. Inspection & palpation
ď¨ Dyspnoea
ď¨ Accessory muscles of respiration
ď¨ Shift of trachea
ď¨ Shift of mediastinum to opposite side
ď¨ Fullness of chest on the affected side
ď¨ Diminished chest movements
18. ď¨ Marked diminished vocal fremitus on
affected side
ď¨ Reduction in total chest expansion
ď¨ Increase in size of affected hemithorax
ď¨ Diminished expansion of the affected
hemithorax
19. Percussion
ď¨ Hyper-resonant on affected
pneumothorax.
ď¨ Right sided pneumothorax-liver dullness is
obliterated and cardiac dullness is shifted
to the opposite side
22. Investigations
Chest x ray
Shows : increased radiolucency, with absence of
bronchovascular markings
ď¨ extend of mediastinal shift.
ď¨ pleural fluid ,if present .
ď¨ underlying pulmonary disease .
ď¨ (costophrenic angles are clear)
[care must be taken to differentiate b/n a large pre-existing bulla &
a pneumothorax to avoid misdirected attempts at aspiration]
23.
24. CT
Helps to differentiate between large pre
existing emphysematous bullae and
pneumothorax .
30. Secondary pneumothorax
Even a small secondary pneumothorax may
cause respiratory failure, so all such patients require
â
Intercostal tube drainage
[Intercostal drains are inserted in the 4th ,5th or 6th
intercostal space in the midaxillary line ,connected
to an under waterseal]
31. ď¨ Clamping of the drain is potentially dangerous
ď¨ Should be removed 24hrs after the lung has fully
reinflated and bubbling stopped .
ď¨ Continued bubbling after 5 -7 days is an indication
for surgery .
ď¨ All patients should receive supplemental oxygen
32. ď¨ If intercostal tube drainage fails
â
Thoracoscopy (VATS ) or thoracotomy with
stapling of blebs and pleural abrasion is indicated
33. ď¨ If surgery is contraindicated, pleurodesis
should be done .
â
Intrapleural injection of sclerosing agent
34. Tension pneumothorax
ď¨ It is a medical emergency.
ď¨ A large bore needle is inserted into pleural
space through 2nd intercostal space.
ď¨ Needle should be left in place until a
thoracostomy tube can be inserted.
35. Traumatic pneumothorax
ď¨ Supplemental oxygen or aspiration done.
ď¨ Tube thoracostomy , if not improves.
ď¨ If hemo pneumothorax is present, 1 chest
tube should be placed in the superior part to
evacuate air, other should be placed in the
inferior part to remove blood.
36. Recurrent spontaneous
pneumothorax
ď¨ Surgical pleurodesis is recommended in all
patients following a 2nd pneumothorax(even
if ipsilateral)