For Thoracic Surgeon

1. PNEUMOTHORAX
LT COL SM SHAHADAT HOSSAIN
MCPS,FCPS( Surgery),FCPS(Thoracic Surgery)
Adv Trg on VATS,CNUH,South Korea

2. Pneumothorax
Pneumothorax is the presence of air outside the lung,
within the pleural space.

3. Etiological classification

4. Clinical classification

5. Primary spontaneous pneumothorax
 Common in young people from their mid-teens to late
20s.
 About 75% of cases men are tall and have a family history.
 It is due to leaks from small blebs, vesicles or bullae.
 Typically occur at the apex of the upper lobe or on the
upper border of the lower or middle lobes.

6. Secondary spontaneous pneumothorax
When visceral pleura leaks due to underlying lung disease
 Tuberculosis
 Degenerative or cavitating lung disease
 Emphysema
 Necrosting tumours

7. Closed Pneumothorax
 Communication between airway and the pleural space
seals off as the lung deflates.
 Mean pleural pressure remains-negative.
 Spontaneous reabsorption of air & re-expansion of lung
occur over a few days or weeks.
 Infection uncommon.

8. Open Pneumothorax
 Communication between pleura & bronchus doesn’t seals
off (Bronchopleural fistula).
 Intra pleural pressure = atm. pressure.
 Collapsed lung, no re-expansion.
 Infection into the pleural space is common (empyema).

9. Tension Pneumothorax
 Communication between the airway & the pleural space
acts as a one-way valve.
 Air to enter the pleural space during inspiration but not to
escape on expiration.
 Large amount of air accumulates progressively in the
pleural space.
 Intrapleural pressure increases above atm pressure.

10. Tension Pneumothorax
 Pressure causes mediastinal shift towards the opposite
side.
 Compression of the opposite lung.
 Impairment of systemic venous return &causing
cardiovascular compromise.

11. Risk factors for pneumothorax
 Smoking. Risk increases with time and number of
cigarettes smoked.
 Genetics.
 Lung disease. chronic obstructive pulmonary disease
(COPD).
 Mechanical ventilation.
 Previous pneumothorax.

12. Clinical features
 Sudden onset of unilateral pleuritic chest pain.
 Breathlessness [In pts with a small pneumothorax,
physical examination may be normal].
General examination
 Cyanosis
 Rapid thready pulse.
 Signs of peripheral circulatory failure in severe cases.

13. Inspection & palpation
 Rapid respiratory rate.
 Diminished chest movements.
 Prominent accessory muscles of respiration.
 Shift of trachea.
 Shift apex beat.
 Chest expansion diminished.
 Increase in size of affected hemithorax.
 Marked diminished vocal fremitus on affected side.

14. Percussion &Auscultation
 Hyper-resonant on affected pneumothorax.
 Right sided pneumothorax-liver dullness is obliterated
and cardiac. dullness is shifted to the opposite side.
 Diminished to absent breath sounds.
 Diminished vocal resonance.

15. X-ray chest

16. Risk of recurrent pneumothorax
 Patients who experience a first event, only about one
third experience recurrence.
 Who have a second episode, about one-half go on to
experience a third episode.
 Who have had three episodes will probably go on to have
repeated recurrences.

17. Complications of pneumothorax
 Recurrence
 Tension pneumothorax
 Encysted pneumothorax
 Hydro-pneumothorax
 Broncho-pleural fistula
 Pneumo-mediastinum

18. Treatment
 Asymptomatic; careful observation.
 Symptomatic patient; Intercostal chest drainage.
 Tension pneumothorax; Percutaneous needle insertion
followed by chest drainage.
 If intercostal drainage fails then
 Surgery: Video assisted Thoracic Surgery (VATS) or
thoracotomy.

19. Indications for surgical intervention
●Second ipsilateral pneumothorax.
●First contralateral pneumothorax.
●Bilateral spontaneous pneumothorax.
●Pneumothorax fails to settle despite chest drainage.
●Spontaneous haemothorax: professions at risk (e.g.
pilots, divers).
●Pregnancy.

20. Inserting and management of chest drain
The safest site for insertion of a drain is in the triangle:
Anterior to the mid-axillary line.
Above the level of the nipple.
Below and lateral to the pectoralis major muscle.
Ideally find the fifth space.

21. Technique
 Antiseptic cleaning & draping.
 Adequate local anaesthesia.
 Incision is made in the skin.
 Blunt dissection with artery forceps down through the
muscle layers.
 An oblique tract is created.
 Drain pass over the upper edge of the rib.

22. Technique
 Retaining stitch is secured.
 Vertical mattress suture is inserted for later wound
closure.
 Connect the drain to an underwater seal device which
functions as a one-way valve.
 After completion, check chest radiograph is taken.

23. Insertion of chest drain

24. Insertion of chest drain

25. Complications of ICD
 Bleeding
 Injury
 Surgical emphysema
 Infection
 Neuralgia

26. Chest Drainage System

27. Management
DO
1. Keep the system closed and below chest level. Make
sure all connections are taped and the chest tube is
secured to the chest wall.
2. Ensure that the suction control chamber is filled with
sterile water to the 20-cm level or as prescribed.
3. Assess the amount, color, and consistency of drainage
in the drainage tubing and in the collection chamber.

28. Management
3. Encourage the patient to perform deep breathing,
coughing, and incentive spirometry.
4. Assess vital signs, breath sounds, SpO2, and insertion
site for subcutaneous emphysema.
5. When the chest tube is removed, immediately apply a
sterile occlusive petroleum gauze dressing over the site to
prevent air from entering the pleural space.

29. Management
DON’T
1. Don't let the drainage tubing kink, loop, or interfere
with the patient's movement.
2. Don't clamp a chest tube, except momentarily when
replacing the CDU, assessing for an air leak, or
assessing the patient's tolerance of chest tube removal,
and during chest tube removal.
3. Don't aggressively manipulate the chest tube; don't strip
or milk it.