Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
PNEUMOTHORAX
Dr.JAKEER HUSSAIN
M.D,DNB
PNEUMOTHORAX--intro
Presence of air in da pleural cavity with secondary
collapse of surrounding lung.
occurs due2 loss of ...
PNEUMOTHORAX
 Overdisten of norm lungs results in rupt of subpleu alveoli.
 Air dissect- bronchoalveolar sheath medially...
PNEUMOTHORAX
MAIN PHYSIOLOGICAL EFFECTS
↓vital capacity of lung, ↓PaO2,
↓ TLC, FRC,diffusing capacity of lungs.
↓in PaO2,
i...
PNEUMOTHORAX– X-rays
PNEUMOTHORAX—CT-Scan
PNEUMOTHORAX
CLASSIFICATION
PNEUMOTHORAX
SPONTANEOUS
TRAUMATIC
PNEUMOTHORAX
SPONTANEOUS
PRIMARY
SPONTANEOUS
SECONDARY
SPONTANEOUS
TRAUMATIC
PNEUMOTHORAX
SPONTANEOUS
PRIMARY
SPONTANEOUS
SECONDARY
SPONTANEOUS
TRAUMATIC
IATROGENIC
NON IATROGENIC
PNEUMOTHORAX
SPONTANEOUS
PRIMARY
SPONTANEOUS
SECONDARY
SPONTANEOUS
TRAUMATIC
IATROGENIC
ACCIDENTAL
ARTIFICIAL
NON-IATROGEN...
PRIMARY SPONTANEOUS PNEUMOTHORAX
PRIMARY SPONTANEOUS PNEUMOTHORAX:
PTX without preceding trauma & without underlying
clini...
PRIMARY SPONTANEOUS PNEUMOTHORAX
 familial association. 10%,
mutations in gene encoding folliculin (FLCN)
 BIRT HOGG DUB...
SECONDARY SPONTANEOUS PNEUMOTHORAX
SECONDARY SPONTANEOUS PNEUMOTHORAX:
 occurs in pts č underlying pulmonary structural
p...
SECONDARY SPONTANEOUS PNEUMOTHORAX
SECONDARY SPONTANEOUS PNEUMOTHORAX:
 COPD or emphysema, ASTHMA.
 CYSTIC FIBROSIS. ILD...
IATROGENIC PNEUMOTHORAX
IATROGENIC PNEUMOTHORAX:
medical procedures resulting in traumatic PTX.
IATROGENIC PNEUMOTHORAX
IATROGENIC PNEUMOTHORAX causes:
 Trans-thoracic needle aspiration procedures.
 Thoraco centesis
...
ARTIFICIAL IATROGENIC PTX
ARTIFICIAL IATROGENIC PNEUMOTHORAX:
 Deliberate intro of air inda pleural cavity,by needle.
 d...
TRAUMATIC PNEUMOTHORAX
TRAUMATIC PNEUMOTHORAX:
 stab r gunshot wounds
 blunt chest inj in RTAs
 explosions
TENSION PNEUMOTHORAX
TENSION PNEUMOTHORAX is present when
intrapleural pressure is greater than atmosp press
throughout ex...
TENSION PNEUMOTHORAX
When the pleural pressure is positive
throughout respiratory cycle
“Ball-valve mechanism”
Injury to p...
TENSION PNEUMOTHORAX
SIGNS N SYMPTOMS
 severe dyspnea, tachycardia, profuse diaphoresis
 cyanosis, hypotension, exhibit ...
Rx - TENSION PNEUMOTHORAX
• High flow O2.
• clinical confirmation of PTX- needle aspir 2nd IC
• Immeadiate tube thoracosto...
SIGNS & SYMPTOMS
Clinicalfeatures-Symptoms
Sharp,stabbing unilateral chest pain
exacerbates by deep inspiration,
postural change
 shortne...
SIGNS
PERCUSSION
hyper resonance on affected side.
AUSCULTATION
diminished breath sounds
decreased vocal resonance
COIN so...
PTX in mech ventillated pt
 sudden onset of tachy, hypotension
 increase in peak airway pressure
 sudden decline in o2 ...
Title
ECG pt of tension PTX,
STseg elevation in II, III, Avf, V4-6,
c neg cardiac enzymes. Reversible after
chest tube.
Radiological signs – X ray
 A linear shadow of visceral pleura
with lack of lung markings peripheral to
the shadow
 Shar...
PNEUMOTHORAX – Xray
PNEUMOTHORAX X-ray supine.
Radiological signs –CT scan
in PSPTX pts CT detects multiple blebs n bullae.
More sensitive for hemithorax, pulm contusion...
X-ray --------- CT-scan
??? PNEUMOTHORAX ,,, ?side
PNEUMOTHORAX – Lt.side
Occult PTX: A PTX identified on a CT
scan dat was not seen on a preceeding
supine chest Xray AP view
Radiological signs - usg
USG used as bedside technique to detect PTX
used in unstable pts, who cant b shift outside
for xr...
Differential diagnosis
ACS
ARDS
ASTHMA,COPD,EMPHYSEMA
CHF, Pulm oedema
Esophagal perforation,tear,rupture
Foreign bo...
Differential diagnosis
Pleural effusion
Pneumonia aspiration, bacterial, viral,
 pulmonary embolism.
Quantification
LIGHTS METHOD
Pneumothorax %
Size of PTX: ratio of lung diameter cubed
to hemithorax diameter cubed
Quantification
Quantification
RHEA METHOD:
it uses a nomogram,
that relates da average
intrapleural distance to
the pneumothorax size.
On this nomogram ...
Quantification
 BTS guidelines…
Distance btw pleura n chestwall…
less than 1cm – small
1-2 cm - moderate
greater than 2 ...
Quantification
 ACCP-measuring distance from da apex
of lung to the top margin of da
visceral pleura (thoracic cupola). O...
TREATMENT
MANAGEMENT
Of PNEUMOTHORAX
treatment
Aim of treatment of primary spont PTX
 to rid da pleural space of its air
 achieve closure of da leak.
 eithe...
treatment
 Observation
 supplemental oxygen
 simple aspiration
 tube thoraco-stomy č/čout sclerosing agent
 medical t...
treatment
The choice of therapy depends on:
 clinical status of da pt
Cause of da pneumothorax
Evidence of concomitant ...
OBSERVATION
OBSERVATION
Rate of spontaneous reabsorbtion is slow,
Kircher n Swartzel- 1.25% of vol was absor every 24 h
so...
O2 Supplementation
SUPPLEMENTAL O2
admin of o2 accelerates da rate of pleural air
absorption .
Northfield- rate of absorp ...
O2 Supplementation
Rate of gas reabsorption depends on:
 press gradient for da gases
btw pleu space to venous blood
 dif...
SIMPLE ASPIRATION
ASPIRATION
initial Rx of pts if PTX > 15%
16 G needle – ( 2nd IC ,M.C.line), (4-5th IC, M.A.line)
use a ...
SIMPLE ASPIRATION
When no more air can be aspirated or the patient suddenly
coughs, the lung most likely has reexpanded
Re...
SIMPLE ASPIRATION
TUBE THORACOSTOMY
TUBE THORACOSTOMY
Air in pleural space canbe rapidly evacuated.
positioned in da uppermost part of pleur...
TUBE THORACOSTOMY
Indications for ICD in SPTX
 tension pneumothorax
 presence of dyspnea
 Intermittent positive pressur...
TUBE THORACOSTOMY
Placement of ICD irritate pleura – partial pleurodesis
thus ↓ recurrence of PTX.
treat c small tubes 14F...
TUBE THORACOSTOMY
TT C Instillation of SCLEROSING AGENTS:
Injec n sclerosin agents ↓recurrence rates of PTX
It create inte...
TUBE THORACOSTOMY
TALC SLURRY: 5 – 10 gms in 250ml of saline intrapleurally
very effective as a slurry via chest tube
talc...
TUBE THORACOSTOMY
TETRACYCLINES.
Minocycline – 600mg in 50-100ml of saline.
Doxycycline – 500 mg in 50 -100ml of saline.
v...
MEDICAL THORACO SCOPY
MEDICAL THORACO SCOPY:
performed ↓local anesthesia, r c conscious sedation.
cost effective than dria...
VATS
VATS performed ↓ GA. c double lumen ET tube.
c single lung ventillation – collapse of operated lung.
AIM to treat bul...
VATS
OPEN THORACO TOMY
THORACOTOMY – ultimate n most eff therapy fot PTX
allows examination of lung for da site of an air leak
...
OPEN THORACO TOMY
potential risk ass c GA,
increased costs, significant pt discomfort.
more severe c lateral r post latera...
recommendations
If PTX small, pt asymptomatic – OBSERVATION
If pt near hospital – high flow O2 supplementation.
If PTX >15...
Rx of SS-PTX
PTX in pts c lung ds is life threatening.
aim is to get rid of air in pleural space, ↓recurrence.
ASPIRATION ...
Rx of SS-PTX
After lung expansion – prevent recurrence of PTX.
VATS (stapling of blebs,pleu abrasion) as recurence rate < ...
CATAMENIAL PNEUMOTHORAX
Recurrent PTX in women in 30 -40 s during periods
with incidence 3 – 6%, occurs within 48- 72hrs.
...
CATAMENIAL PNEUMOTHORAX
Medical rx
Supress da ectopic endometrium using ocps
supress ovulation,, danazol.
GnRH agonists us...
PTX 2 CYSTIC FIBROSIS
SSPTX is frequently seen in pts c CYSTIC FIBROSIS.
Incidence is 6%, c mean age of 1st episode 21.9 y...
PTX 2 CYSTIC FIBROSIS
thoracoscopy if persistant air leak, lung not expands
for 3 days after tube thoracostomy.
As many pt...
PTX 2 Lymphangio leiomyomatosis
LAM rare condition, char by peribronchial,
perivascular,& perilymphatic proliferation of
a...
COMPLICATIONS
TENSION PNEUMOTHORAX
BRONCHO – PLEURAL FISTULA
Re expansion PULM OEDEMA
HEMO THORAX
PYO THORAX.
Title
BRONCHO PLEURAL FISTULA
BRONCHOPLEURAL FISTULA. Rare but serious.
a communication btw pleural space n bronchial tree.
usua...
BRONCHO PLEURAL FISTULA
ACCP guidelines recommend – if leak for 4 days, pt
should be evaluated for Sx, to close airleak n
...
Title
Re expansion pulmonary oedema
REEXPANSION PULM EDEMA: rare , potentially fatal
condition that occur after rapid reexpansio...
Re expansion pulmonary oedema
REPE depends on duration(3days), severity of PTX,
method (suction) &rate of expansion.
 sy...
Title
Pneumothorax ..jack
Pneumothorax ..jack
Pneumothorax ..jack
Pneumothorax ..jack
Pneumothorax ..jack
Pneumothorax ..jack
Prochain SlideShare
Chargement dans…5
×

Pneumothorax ..jack

1 908 vues

Publié le

PULMONOLOGY PNEUMOTHORAX

Publié dans : Santé & Médecine
  • Login to see the comments

Pneumothorax ..jack

  1. 1. PNEUMOTHORAX Dr.JAKEER HUSSAIN M.D,DNB
  2. 2. PNEUMOTHORAX--intro Presence of air in da pleural cavity with secondary collapse of surrounding lung. occurs due2 loss of integrity of either visceral r parietal pleura, r both.  this term was used 1st in doctoral thesis, french physician ITARD, in 1803.  In 5centuryBC, greek physician practised HIPPOCRATIC SUCCUSSION of da chest.
  3. 3. PNEUMOTHORAX  Overdisten of norm lungs results in rupt of subpleu alveoli.  Air dissect- bronchoalveolar sheath medially – pneumomediastinum, subcutaneous emphysema,PTX.  peripheral dissection of air = aircontaining space within r below da visceral pleura.  BULLA lined partly by thickened fibrotic pleura n partly by fibrous tissue within lung. BLEB situated within da pleura.  Periph bullae r blebs –distended n rupture in2 pleu space= PNEUMOTHORAX.
  4. 4. PNEUMOTHORAX MAIN PHYSIOLOGICAL EFFECTS ↓vital capacity of lung, ↓PaO2, ↓ TLC, FRC,diffusing capacity of lungs. ↓in PaO2, impaired exercise tolerance ↓ in cardiac output all these more in tension PTX.
  5. 5. PNEUMOTHORAX– X-rays
  6. 6. PNEUMOTHORAX—CT-Scan
  7. 7. PNEUMOTHORAX CLASSIFICATION
  8. 8. PNEUMOTHORAX SPONTANEOUS TRAUMATIC
  9. 9. PNEUMOTHORAX SPONTANEOUS PRIMARY SPONTANEOUS SECONDARY SPONTANEOUS TRAUMATIC
  10. 10. PNEUMOTHORAX SPONTANEOUS PRIMARY SPONTANEOUS SECONDARY SPONTANEOUS TRAUMATIC IATROGENIC NON IATROGENIC
  11. 11. PNEUMOTHORAX SPONTANEOUS PRIMARY SPONTANEOUS SECONDARY SPONTANEOUS TRAUMATIC IATROGENIC ACCIDENTAL ARTIFICIAL NON-IATROGENIC
  12. 12. PRIMARY SPONTANEOUS PNEUMOTHORAX PRIMARY SPONTANEOUS PNEUMOTHORAX: PTX without preceding trauma & without underlying clinical or radiologic evidence of lung disease.  age 18 – 40 years . Incidence 7.4/m,, 1.2/f  tall n thin pts,, apical blebs rupture.  80-90% ass č smoking, x9 folds risk.  changes in atm press, proximity to loud noise,  sharp innerborder of 1st n 2nd rib.
  13. 13. PRIMARY SPONTANEOUS PNEUMOTHORAX  familial association. 10%, mutations in gene encoding folliculin (FLCN)  BIRT HOGG DUBE Syndrome: beningn skin growth, pulmonary cysts, & renal cancers.  specific HLA-A2,B40, antitrypsin phenotypes M1,M2  incresed levels of HYDROXYPROLINE.
  14. 14. SECONDARY SPONTANEOUS PNEUMOTHORAX SECONDARY SPONTANEOUS PNEUMOTHORAX:  occurs in pts č underlying pulmonary structural pathology.  air enters da pleural space via distended,damaged or compromised alveoli.  presents c serious clinical symptoms.
  15. 15. SECONDARY SPONTANEOUS PNEUMOTHORAX SECONDARY SPONTANEOUS PNEUMOTHORAX:  COPD or emphysema, ASTHMA.  CYSTIC FIBROSIS. ILD  BRONCHOGENIC or METASTATIC CARCINOMA  COLLAGEN VASCULAR Ds incl MARFAN SYNDROME.  PNEUMONIA (fungal,HIV,caseating)  CATAMENIAL PNEUMOTHORAX.
  16. 16. IATROGENIC PNEUMOTHORAX IATROGENIC PNEUMOTHORAX: medical procedures resulting in traumatic PTX.
  17. 17. IATROGENIC PNEUMOTHORAX IATROGENIC PNEUMOTHORAX causes:  Trans-thoracic needle aspiration procedures.  Thoraco centesis  CV Catheter insertion (sub,supraclavicular, IJV)  Mechanical ventillation (peak airway pressure)  Pleural & transbronchial lung biopsy.  Tracheostomy.  CPR (if ventillation becomes progressively more diff)
  18. 18. ARTIFICIAL IATROGENIC PTX ARTIFICIAL IATROGENIC PNEUMOTHORAX:  Deliberate intro of air inda pleural cavity,by needle.  devised by FORLANI in 19th cent. MAXWELL BOX  used 2 treat pulm TB, before da ATT.
  19. 19. TRAUMATIC PNEUMOTHORAX TRAUMATIC PNEUMOTHORAX:  stab r gunshot wounds  blunt chest inj in RTAs  explosions
  20. 20. TENSION PNEUMOTHORAX TENSION PNEUMOTHORAX is present when intrapleural pressure is greater than atmosp press throughout expiration & often during inspiration.  One way value machanism develops..  TPTX can occur after anytype of PTX.  m.c after traumatic PTX. C mech ventillation. during CPR.
  21. 21. TENSION PNEUMOTHORAX When the pleural pressure is positive throughout respiratory cycle “Ball-valve mechanism” Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration
  22. 22. TENSION PNEUMOTHORAX SIGNS N SYMPTOMS  severe dyspnea, tachycardia, profuse diaphoresis  cyanosis, hypotension, exhibit distended neck viens  tracheal deviation,subcutaneous emphysema,  unilateral chest hyperinflation. Widend IC spaces.  ABG – severe hypoximia, resp acidosis.  chest X-ray – mediastinal shift to opp.
  23. 23. Rx - TENSION PNEUMOTHORAX • High flow O2. • clinical confirmation of PTX- needle aspir 2nd IC • Immeadiate tube thoracostomy.
  24. 24. SIGNS & SYMPTOMS
  25. 25. Clinicalfeatures-Symptoms Sharp,stabbing unilateral chest pain exacerbates by deep inspiration, postural change  shortness of breath mild in PS-PTX, severity on size in SS-PTX , dyspnea not on size.  cough dry –irritation of da diaphragm. generalised malaise.
  26. 26. SIGNS PERCUSSION hyper resonance on affected side. AUSCULTATION diminished breath sounds decreased vocal resonance COIN sound scratch sign.
  27. 27. PTX in mech ventillated pt  sudden onset of tachy, hypotension  increase in peak airway pressure  sudden decline in o2 sat.  distressed pt appers to fight c da ventillator.  if pt on pressure control mode n paralysed, ABG shows resp acidosis. As pt cant increase his resp rate.
  28. 28. Title ECG pt of tension PTX, STseg elevation in II, III, Avf, V4-6, c neg cardiac enzymes. Reversible after chest tube.
  29. 29. Radiological signs – X ray  A linear shadow of visceral pleura with lack of lung markings peripheral to the shadow  Sharply defined lung edge convex outwards.  supine chest X-ray deep sulcus sign. very dark n deep costophrenic angle.
  30. 30. PNEUMOTHORAX – Xray
  31. 31. PNEUMOTHORAX X-ray supine.
  32. 32. Radiological signs –CT scan in PSPTX pts CT detects multiple blebs n bullae. More sensitive for hemithorax, pulm contusion Distinguish btw a large bulla and a PTX & underlying emphysema or emphysemalike changes. Calculate exact size of PTX, esp smallPTX can detect occult pneumothorax.
  33. 33. X-ray --------- CT-scan
  34. 34. ??? PNEUMOTHORAX ,,, ?side
  35. 35. PNEUMOTHORAX – Lt.side
  36. 36. Occult PTX: A PTX identified on a CT scan dat was not seen on a preceeding supine chest Xray AP view
  37. 37. Radiological signs - usg USG used as bedside technique to detect PTX used in unstable pts, who cant b shift outside for xrays., ct scan. acute care setting as a readily available bedside tool, especially in ICU and emergency departments
  38. 38. Differential diagnosis ACS ARDS ASTHMA,COPD,EMPHYSEMA CHF, Pulm oedema Esophagal perforation,tear,rupture Foreign bodies, trachea Mediastenitis Myocarditis, MI,Pericarditis,
  39. 39. Differential diagnosis Pleural effusion Pneumonia aspiration, bacterial, viral,  pulmonary embolism.
  40. 40. Quantification LIGHTS METHOD Pneumothorax % Size of PTX: ratio of lung diameter cubed to hemithorax diameter cubed
  41. 41. Quantification
  42. 42. Quantification
  43. 43. RHEA METHOD: it uses a nomogram, that relates da average intrapleural distance to the pneumothorax size. On this nomogram there is 10% pneumothorax for every cm of intrapleural distance.
  44. 44. Quantification  BTS guidelines… Distance btw pleura n chestwall… less than 1cm – small 1-2 cm - moderate greater than 2 – large.
  45. 45. Quantification  ACCP-measuring distance from da apex of lung to the top margin of da visceral pleura (thoracic cupola). On xray small PTX – less than 3cm. large PTX – greater than 3cm.
  46. 46. TREATMENT
  47. 47. MANAGEMENT Of PNEUMOTHORAX
  48. 48. treatment Aim of treatment of primary spont PTX  to rid da pleural space of its air  achieve closure of da leak.  either prevent r reduce this risk.  to decrease da likelihood of a recurrance.
  49. 49. treatment  Observation  supplemental oxygen  simple aspiration  tube thoraco-stomy č/čout sclerosing agent  medical thoraco-scopy č da insufflation of talc  video assisted thoraco-scopy č staplin of blebs Instillation of sclerosing agent or pleural abrasion Open thoraco-tomy
  50. 50. treatment The choice of therapy depends on:  clinical status of da pt Cause of da pneumothorax Evidence of concomitant lung ds Prior history of pneumothorax, r risk of recurrence Availability of specific therapeutic options experience n prefered techniques of da physician
  51. 51. OBSERVATION OBSERVATION Rate of spontaneous reabsorbtion is slow, Kircher n Swartzel- 1.25% of vol was absor every 24 h so PTX occup 15% of hemithorax take 12 days recomended only for pts č PTX less than 15% asymptomatic, unilateral.
  52. 52. O2 Supplementation SUPPLEMENTAL O2 admin of o2 accelerates da rate of pleural air absorption . Northfield- rate of absorp on ↑ 4 mes č 02 O2 high conc recomended for hosp pts..
  53. 53. O2 Supplementation Rate of gas reabsorption depends on:  press gradient for da gases btw pleu space to venous blood  diffusion properties of da gases  area of contact btw pleural gas n pleura  permeability of da pleural surface… (thickend,fibro c pleura will absorb ↓normal pleura)
  54. 54. SIMPLE ASPIRATION ASPIRATION initial Rx of pts if PTX > 15% 16 G needle – ( 2nd IC ,M.C.line), (4-5th IC, M.A.line) use a 3 way, This procedure is done in emergency in tension ptx , to relive pressure. As emergency decompression.
  55. 55. SIMPLE ASPIRATION When no more air can be aspirated or the patient suddenly coughs, the lung most likely has reexpanded Remove the catheter, and massage the insertion site with sterile gauze to seal the channel into the pleural space . Devanand et all- metaanalysis –simple aspiration is adv than ICD – shorter hospitalization. Noppen – recurr rate c aspiration is 19%
  56. 56. SIMPLE ASPIRATION
  57. 57. TUBE THORACOSTOMY TUBE THORACOSTOMY Air in pleural space canbe rapidly evacuated. positioned in da uppermost part of pleural space. mc site is 2nd IC space in Mid-Clavicular line. now- 4,5th IC space btw ant n post axillary lines.
  58. 58. TUBE THORACOSTOMY Indications for ICD in SPTX  tension pneumothorax  presence of dyspnea  Intermittent positive pressure ventillation  Prev contralateral pneumothorax  b/l pneumothoraces, or large pneumothorax  Presence of pleural fluid  failed manual aspiration
  59. 59. TUBE THORACOSTOMY Placement of ICD irritate pleura – partial pleurodesis thus ↓ recurrence of PTX. treat c small tubes 14F as insertion less traumatic. if lung not expanded in 48hrs –large tubes be placed
  60. 60. TUBE THORACOSTOMY TT C Instillation of SCLEROSING AGENTS: Injec n sclerosin agents ↓recurrence rates of PTX It create intense inflam reaction – obliterate pl space. Agents – quinacrine, talc slurry, olive oil, bleomycin silver nitrate, tetracycline. best are – TALC SLURRY, TETRACYCLINE derivatives. injected as soon as lung has reexpanded.
  61. 61. TUBE THORACOSTOMY TALC SLURRY: 5 – 10 gms in 250ml of saline intrapleurally very effective as a slurry via chest tube talc poudrage during thoracoscopy. meta analysis shows success rate of 91%. can be performed easily at bedside. inhomogeniety in distru – loculation n incomple symphysis. ↑incidence of ARDS, size of talc particles (↓15mm), dose(↑5g) ass c higher incidence of ARDS.
  62. 62. TUBE THORACOSTOMY TETRACYCLINES. Minocycline – 600mg in 50-100ml of saline. Doxycycline – 500 mg in 50 -100ml of saline. very effective, c less recurrence rate. injected as lung re expanded, n position da pt so dat tetracycline comes incontact c apical pleura very painful intrapleural injection.
  63. 63. MEDICAL THORACO SCOPY MEDICAL THORACO SCOPY: performed ↓local anesthesia, r c conscious sedation. cost effective than drianage alone. Tschopp et all –recurrance rate is 7.5% MT c talc recurrance rate is 5%. in MT blebs were not treated.
  64. 64. VATS VATS performed ↓ GA. c double lumen ET tube. c single lung ventillation – collapse of operated lung. AIM to treat bullous ds responsible for PTX to create pleurodesis. bullae r treated c an endoscopic stapling device. very less recurrence rate than electrocoagulation, r ligation c Roeder loop
  65. 65. VATS
  66. 66. OPEN THORACO TOMY THORACOTOMY – ultimate n most eff therapy fot PTX allows examination of lung for da site of an air leak lysis of prev adhesions – (loculated PTX) enables release of fibrotic peel pleura is scarified, ---↓↓recurance rate. recurrance rate is < 2%. thoracotomy recom only after failed thoracoscopy.
  67. 67. OPEN THORACO TOMY potential risk ass c GA, increased costs, significant pt discomfort. more severe c lateral r post lateral thoracotomy c muscle division n rib spreading. nowadays smaller incisions –muscle sparing thoracotomies mini axillary thoracotomy performed. open thoracotomy still remains valuable option for complicated cases
  68. 68. recommendations If PTX small, pt asymptomatic – OBSERVATION If pt near hospital – high flow O2 supplementation. If PTX >15% - aspiration – if successful- discharge pt. if unsuccessful – plan thoraco scopy if both medical n VATS avail – VATS prefered (blebs) if rec PTX- thoracoscopy – in pilots, divers - fatal PTX if no thoracoscopy - tube thoracostomy c doxy.
  69. 69. Rx of SS-PTX PTX in pts c lung ds is life threatening. aim is to get rid of air in pleural space, ↓recurrence. ASPIRATION is NOT recommended. every pt – hospitalised, plan TUBE THOROCO STOMY. in SS PTX, tube thoracostomy less effecttive, than PS PTX delayed lung expansion n persistant air leaks. in COPD meantime 5days for lung expansion. in 20% SS PTX pts air leak lasts for 7 days,
  70. 70. Rx of SS-PTX After lung expansion – prevent recurrence of PTX. VATS (stapling of blebs,pleu abrasion) as recurence rate < 5%. medical thoracoscopy c talc insufflation. mini thoracotomy good alternative to thoracoscopy. BTS guidelines: Open thoracotomy & repair. thoracoscopy reserved for pts c poor lung funct, not fit. intrapleural inj of doxy through chest tube ↓50 to 30%. (only if above procedures not available.)
  71. 71. CATAMENIAL PNEUMOTHORAX Recurrent PTX in women in 30 -40 s during periods with incidence 3 – 6%, occurs within 48- 72hrs. c/o chestpain, dyspnea. ass c mental n physical stress. 90% on rt side, but b/l, lt side PTX also occurs. diaphragm defects, Ectopic endometriosis in subpleural area.
  72. 72. CATAMENIAL PNEUMOTHORAX Medical rx Supress da ectopic endometrium using ocps supress ovulation,, danazol. GnRH agonists used 2 supress CP,,,Lupron Surgical rx Thoracoscopy-closure of diaph def, stapling blebs, pleural abrasions, -- diaphragm mesh (bagan) Hysterectomy c b/l oopherectomy induce surg menopause
  73. 73. PTX 2 CYSTIC FIBROSIS SSPTX is frequently seen in pts c CYSTIC FIBROSIS. Incidence is 6%, c mean age of 1st episode 21.9 yr Freq seen in pts c severe resp impairement, ↑age. FEV1 < 40% seen in 75% of pts c PTX. ↑press, vol in alveoli due2 mucous pluggin n inflam of prox airways leadin to rupture inda pleural space. Rx to prevent recurrence.. initially stabalised c tube thoracostomy .
  74. 74. PTX 2 CYSTIC FIBROSIS thoracoscopy if persistant air leak, lung not expands for 3 days after tube thoracostomy. As many pts require lung transplantation, procedure of choice is VATS c staplin of blebs, & pleural abrasion.
  75. 75. PTX 2 Lymphangio leiomyomatosis LAM rare condition, char by peribronchial, perivascular,& perilymphatic proliferation of abnormal smooth muscle cells. affects women of child bearing age. Incidence 66%. presents c progressive dyspnea, chylothorax, recurrent SPTX, hemoptysis…. Rx VATS,c stapling of blebs, n pleural abrasion.
  76. 76. COMPLICATIONS TENSION PNEUMOTHORAX BRONCHO – PLEURAL FISTULA Re expansion PULM OEDEMA HEMO THORAX PYO THORAX.
  77. 77. Title
  78. 78. BRONCHO PLEURAL FISTULA BRONCHOPLEURAL FISTULA. Rare but serious. a communication btw pleural space n bronchial tree. usually airleak seals within 24-48 hrs. only 3- 5% have persistant air leak. pts c COPD, cystic fibrosis- ↑risk of persistant BPF.
  79. 79. BRONCHO PLEURAL FISTULA ACCP guidelines recommend – if leak for 4 days, pt should be evaluated for Sx, to close airleak n perform pleurodesis to prevent recurrence. THORACO SCOPY preff - to prevent recurrence. Pts not fit for Sx - BPF localised by bronchoscopic baloon cath occlusion, n injected to seal airleak. fibrin glue, liquid bioadhesive, sterile gelatin sponge, lead shot, & autologous blood patch.
  80. 80. Title
  81. 81. Re expansion pulmonary oedema REEXPANSION PULM EDEMA: rare , potentially fatal condition that occur after rapid reexpansion of collapsed lung. Usually in long standing PTX. usually unilateral. due to ↑permeability of pulm capillaries that r damaged by mechanical stress during re expansion of lung. reperfusion inj due 2 free radicals, decreased surfactant. ischemic reperfusion inj, airway obstruc on, ↓lymp flow.
  82. 82. Re expansion pulmonary oedema REPE depends on duration(3days), severity of PTX, method (suction) &rate of expansion.  symptoms- severe cough, chest pain.within an hr. hypoximia,tachypnea,tachycardia, hypotension. last for 24 – 48 hrs only.  Rx supportive, c high flow O2. try to prevent. (c no negative pressure.)
  83. 83. Title

×