Pneumothorax

IN THE NAME OF ALLAH

22/2/2021

DISEASES OF THE PLEURA, DIAPHRAGM AND CHEST WALL

OBJECTIVES
To know the
epidemiology ,
etiology,
pathogenesis ,
clinical presentation
investigation ,
diagnosis ,
treatment
,complication ,
prognosis


Pleural effusion

Appearance of fluidand features
Type of fluid
Predominant cells in fluid
Other diagnostic features

Pleura fluid

Cause Appearance
Tuberculosis Serous, usually amber-coloured
Serous, often blood-stained Malignant disease

Cardiac failure
Pulmonary infarction
Rheumatoid disease
SLE
Acute pancreatitis
Obstruction of thoracic duct Milky

Clinical assessment

Symptoms (pain on inspiration and coughing)
signs of pleurisy (a pleural rub) often precede the development of an effusion.
The onset may be insidious.
Breathlessness severity depends on the size and rate of accumulation.


Investigations

Imaging
The erect PA chest film .
200 mL of fluid is required ,
ultrasound or CT smaller effusions.
Pleural fluid localised below the lower lobe ('subpulmonary effusion').
Fluid localised within an oblique fissure.
Ultrasonography is more accurate than plain chest radiography.
To distinguish pleural fluid from pleural thickening.
CT better than either plain radiography or ultrasound,.

Light's criteria for distinguishing pleural transudate from exudate

Pleural fluid is an exudate if one or more of the following criteria are met:
Pleural fluid protein:serum protein ratio > 0.5
Pleural fluid LDH:serum LDH ratio > 0.6
Pleural fluid LDH > two-thirds of the upper limit of normal serum LDH .
Pleural aspiration and biopsy

Empyema

This is a collection of pus in the pleural space.
The pus may be thin or so thick.
Microscopically, neutrophil leucocytes are present in large numbers.
An empyema may involve the whole pleural space or only part of it ('loculated' or 'encysted' empyema) and is usually unilateral.


Aetiology

A secondary to infection in a neighbouring structure.
'Para-pneumonic' effusion become secondarily infected.
infection of a haemothorax .
Empyema remains a significant cause of morbidity and mortality.

Aspiration of fluid

Ultrasound or CT is used to identify the optimal site using a wide-bore needle.
features suggesting empyema
1-fluid is thick and turbid pus.
2-Biochemistery
fluid glucose low
LDH very high
fluid pH low
However, pH measurement should be avoided if pus is thick.
3- Baceriology pus is culture.

The pleural biopsy for histology and culture.

Management

Treatment of non-tuberculous empyema
When the patient is acutely ill and the pus ia drained
a wide-bore intercostal tube .
The tube should be put on suction .
Antibiotic
directed against the organism causing the empyema should be given for 2-4 weeks.
Empirical antibiotic treatment (e.g. intravenous co-amoxiclav or cefuroxime with metronidazole).
surgical intervention :If the intercostal tube is not providing adequate drainage.



Pneumothorax

The presence of air in the pleural space.

Types

Spontaneous

Primary

Secondary

Traumatic

Primary

• No evidence of overt lung disease.

Air escapes from the lung
into the pleural space through rupture of a small pleural bleb,
or the pulmonary end of a pleural adhesion

Secondary

• Underlying lung disease,
COPD
Tuberculosis;
Asthma,
Lung abscess,
Pulmonary infarcts,
Bronchogenic carcinoma,
All forms of fibrotic


Traumatic
Iatrogenic (e.g. following thoracic surgery or biopsy) or chest wall injury

Spontaneous pneumothorax

Clinical features
The primary spontaneous peaks in males aged 15-30 years.
Secondary spontaneous pneumothorax occurs mainly in males > 55 years.
The most common symptoms:
1- sudden-onset unilateral pleuritic chest pain.
2- breathlessness.
3-Sever breathlessness in those with underlying chest disease, and may not resolve spontaneously.
Examination
• may be normal in patients with a small pneumothorax.
• A decreased or absent breath sounds in larger pneumothorax .
3 - The combination of absent breath sounds and resonant percussion note.

Types of spontaneous pneumothorax.

1-Closed type.
2-Open type. 3-Tension (valvular) type.

Types of spontaneous pneumothorax. A Closed type. B Open type. C Tension (valvular) type

Clinical features

The sudden-onset unilateralpleuritic chest pain .
breathlessness.
severe breathlessness in those with underlying chest disease .
Small pneumothorax,
may be normal physical examination.
Larger pneumothorax
results in decreased or absent breath
sounds


Tension pneumothorax
rapidly progressive breathlessness.
tachycardia.
hypotension.
cyanosis and tracheal displacement.

treatment& Investigation

Chest Xray.
CT chest.
Treatment
Small asymptomatic in healthy need observation .
Larger need aspiration.
Tension ,elderly,sever lyng diseases need intercostal chest tube.

Investigations

The chest X-ray.
CT is useful in distinguishing bullae from pleural air.
Management
Primary pneumothorax
the lung edge is less than 2 cm from the chest wall.
the patient is not breathless.
normally resolves without intervention.
A moderate or large spontaneous primary pneumothorax : In young patients
percutaneous needle aspiration of air
secondary pneumothorax may cause respiratory distress.
In patients with significant underlying chronic lung disease
the success rate of aspiration is much lower,
intercostal tube drainage
H0SPITAL ADMISSION particularly in those over 50 years old and those with respiratory compromise.

Recurrent spontaneous pneumothorax

After primary spontaneous pneumothorax, recurrence occurs within a year in approximately 25% of patients, .
Surgical pleurodesis
a second pneumothorax
first episode of secondary pneumothorax if low respiratory reserve.

DISEASES OF THE DIAPHRAGM ANDCHEST WALL

Disorders of the diaphragm
Congenital disorders
Diaphragmatic hernias
Eventration of the diaphragm


Acquired disorders
Elevation of a hemidiaphragm cause by
• Phrenic nerve paralysis
• • Eventration of the diaphragm
• • Decrease in volume of onelung (e.g. lobectomy,unilateral pulmonaryfibrosis)
• • Severe pleuritic pain
• • Pulmonary infarction
• • Subphrenic abscess
• • Large volume of gas in the stomach or colon
• • Large tumours or cysts of the liver

Chest wall deformity

Kyphosis
Kyphoscoliosis
Pectus excavatum funnel
Pectus carinatum pigeon

Malignant diseases of pleura

Mesothelioma
As pleural effusion


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