.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
1
Pneumothorax
Objective : To show the definition, etiology and management of
Pneumothorax
Definition
Pneumothorax is the accumulation of air within the pleural space.
Classification of pneumothorax
A. Spontaneous:
a. Primary spontaneous pneumothorax ( idiopathic )
b. Secondary spontaneous pneumothorax ( secondary to any lung disease that
breaches the pleura:
1. Airway disease:
1) Bullous disease including COAD
2) Asthma
3) Cystic fibrosis
4) Hyaline membrane disease
2. Infection:
1) Pneumonia
2) Lung abscess
3) TB
3. Neoplasm ( primary and secondary )
4. Interstitial lung disease:
1) Sarcoidosis
2) Collagen vascular disease
5. Others:
1) Pulmonary embolism
2) Endometriosis
3) Marfan's syndrome
4) Catamenial
B. Acquired: secondary to:
a. Iatrogenic:
1. Central venous line insertion
2. Needle biopsy (transthoracic or transbronchial)
b. Barotrauma
c. Traumatic:
.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
2
1. Blunt trauma
2. Penetrating injury
Pathophysiology
Pneumothorax occurs when air enters the pleural space as a result of disruption of one
of the pleural surfaces and may cross
o Visceral pleura secondary to ruptured pulmonary bleb
o Chest wall parietal pleura secondary to trauma
o Mediastinal parietal pleura secondary to airway or esophageal injury
This leads to:
o Loss of negative intrapleural pressure
o Collapse of the lung
o Positive intrapleural pressure as small as 15-20 mmHg leads to mediastinal shift
Clinical Manifestations
- There may be no symptoms
- Chest pain is the most common presenting symptom, followed by dyspnea
- Less common symptoms include non-productive cough and orthopnea
- Subcutaneous emphysema may be seen.
On examination
- Absent or diminished breath sounds is evident on auscultation
- Hyperresonance on percussion.
Investigations
Plain CXR
-The characteristic radiographic finding is absent bronchovascular markings and a faintly
visible line defining the edge of the lung.
-When the lung collapses almost completely, it is visible as an irregular density attached
to the hilum.
Chest CT - Scan
Other investigations like Sputum examination, arterial blood gas analysis,
bronchoscopy, etc……..
Complications of pneumothorax
1) Pleural effusion in 20% and of these 3% are true hemothorax
2) Respiratory failure, rarely occur in healthy individuals but is frequently encountered in
elderly with COPD
.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
3
3) Empyema especially in pneumothorax secondary to abscess in the lung, TB, or ruptured
esophagus
4) Trapped lung (failure of re-expansion) usually caused by:
a. Epithelialization (fibrothorax)
b. Bronchopleural fistula
c. Endobronchial obstruction that prevents aeration of part of the lung
5) Tension pneumothorax
Treatment
1 - Observation
An initial, small (5% to 20%) asymptomatic pneumothorax can be observed in the
hospital and monitored by daily chest radiography. Reabsorption of the pneumothorax is
facilitated by the administration of supplemental oxygen.
2 - Thoracocentesis ( i.e., needle aspiration )
Its role is controversial.
Small to moderate pneumothorax in a stable patient can be aspirated to hasten re-
expansion of the lung and decrease symptoms
3 - Tube thoracostomy with or without pleurodesis
Tube thoracostomy should be performed in patients with:
- Persistent symptoms
- Unilateral pneumothorax greater than 15% of a hemithorax
- All patients who present with simultaneous bilateral pneumothoraces or previous
pneumonectomy
- Those who fail observation
Complications of tube thoracostomy
1- Pain, when the lung reexpands, the visceral and parietal surfaces reoppose.
2- Reexpansion pulmonary edema involving the ipsilateral lung due to rapid
reexpansion.
3- Trauma of intercostal neurovascular bundle.
4- Laceration of the lung.
5- Intrapulmonary or extrathoracic placement of the chest tube.
6- Infection & even empyema.
7- Trauma of the lung, diaphragm, spleen, liver & heart.
8- Others
4 - Thoracotomy or VATS
Indications for either thoracotomy or VATS in pneumothorax
.أ
م
.
د
.
احمد عبداالمير دفار
(
اختصاصي جراحة الصدر و القلب و االوعية الدموية
)
4
1. Massive air leak preventing re-expansion of the lung.
2. Simultaneous, spontaneous & bilateral pneumothoraces.
3. Persistent air leak (>48 hours for primary spontaneous pneumothorax, >96 hours for
secondary spontaneous pneumothorax).
4. Recurrent pneumothorax.
5. Previous contralateral pneumothorax or pneumonectomy.
6. First episode with occupational hazard for pneumothorax (pilot, scuba diver,
parachutist).
7. Obvious or large bullae or cysts are seen in the collapsed lung.
8. Complete (100%) pneumothorax.
9. Pneumothorax associated with tension.
10. Poor cardiopulmonary reserves.
11. Complications such as empyema or hemothorax.
12. Persons living in remote areas
Tension pneumothorax
It occurs when intrapleural pressure rises sharply. This is due to a valvelike mechanism
that allows air to enter the pleural spaces from the lung parenchyma or airway during
brief episodes of markedly elevated airway pressure, as occurs during cough. Because of
collapse of the lung and shift of the mediastinum, severe respiratory distress may
develop, requiring emergency needle aspiration in the second intercostals space at the
mid-clavicular line, followed by tube thoracostomy drainage. Physical findings of hyper-
resonance, absent breath sounds, and mediastinal shift away from the involved side are
diagnostic. There is also distended neck vein and hypotension.