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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.
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=
MAIN PHYSIOLOGICAL EFFECTS
↓vital capacity of lung, ↓PaO2,
↓ TLC, FRC,diﬀusing capacity of lungs.
impaired exercise tolerance
↓ in cardiac output
all these more in tension PTX.
SECONDARY SPONTANEOUS PNEUMOTHORAX
SECONDARY SPONTANEOUS PNEUMOTHORAX:
occurs in pts č underlying pulmonary structural
air enters da pleural space via distended,damaged
or compromised alveoli.
presents c serious clinical symptoms.
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.
stab r gunshot wounds
blunt chest inj in RTAs
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.
When the pleural pressure is positive
throughout respiratory cycle
Injury to pleura creates a tissue flap
that opens on inspiration and closes
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.
Rx - TENSION PNEUMOTHORAX
• High flow O2.
• clinical confirmation of PTX- needle aspir 2nd IC
• Immeadiate tube thoracostomy.
Sharp,stabbing unilateral chest pain
exacerbates by deep inspiration,
shortness of breath
mild in PS-PTX, severity on size
in SS-PTX , dyspnea not on size.
cough dry –irritation of da diaphragm.
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
if pt on pressure control mode n
paralysed, ABG shows resp acidosis. As
pt cant increase his resp rate.
ECG pt of tension PTX,
STseg elevation in II, III, Avf, V4-6,
c neg cardiac enzymes. Reversible after
Radiological signs – X ray
A linear shadow of visceral pleura
with lack of lung markings peripheral to
Sharply defined lung edge convex
supine chest X-ray deep sulcus sign.
very dark n deep costophrenic angle.
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
Calculate exact size of PTX, esp smallPTX
can detect occult pneumothorax.
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 xrays., ct scan.
acute care setting as a readily available bedside
tool, especially in ICU and emergency
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.
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
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
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%
admin of o2 accelerates da rate of pleural air
Northfield- rate of absorp on ↑ 4 mes č 02
O2 high conc recomended for hosp pts..
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)
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.
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%
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.
Indications for ICD in SPTX
presence of dyspnea
Intermittent positive pressure ventillation
Prev contralateral pneumothorax
b/l pneumothoraces, or large pneumothorax
Presence of pleural fluid
failed manual aspiration
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
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.
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.
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.
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.
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
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.
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
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.
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,
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.)
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.
Ectopic endometriosis in subpleural area.
Supress da ectopic endometrium using ocps
supress ovulation,, danazol.
GnRH agonists used 2 supress CP,,,Lupron
Thoracoscopy-closure of diaph def, stapling blebs, pleural
abrasions, -- diaphragm mesh (bagan)
Hysterectomy c b/l oopherectomy induce surg menopause
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 .
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, &
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.
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.
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.
Re expansion pulmonary oedema
REEXPANSION PULM EDEMA: rare , potentially fatal
condition that occur after rapid reexpansion of collapsed
lung. Usually in long standing PTX.
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.
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.
last for 24 – 48 hrs only.
Rx supportive, c high flow O2.
try to prevent. (c no negative pressure.)