Pneumothorax and pneumomediastinum

Pneumothorax and
pneumomediastinum
Dr. Emad Efat
Shebin El kom Chest hospital
June 2017

Definition
Pneumothorax:
Is collection of air within the pleural space with secondary
lung collapse.

Syndromes
Spontaneous pneumothorax:
Pneumothorax in the absence of iatrogenic or traumatic
injury to the chest or lung.
Classified into :
1. 1ry spontaneous pneumothorax: usually occurs at rest
without any prior lung disorders or diseases.
2. 2ry spontaneous pneumothorax: can occur as a complication
of underlying lung disease.
Traumatic pneumothorax:
Results from blunt or penetrating injury that disrupts the
parietal or visceral pleura. Iatrogenic pneumothorax is
secondary to diagnostic or therapeutic medical
intervention

Syndromes
Tension pneumothorax :
Is a life-threatening condition caused by air within the
pleural space that is under pressure; displacing mediastinal
structures and compromising cardiopulmonary function.
Artificial pneumothorax :
It is introduction of measured volume of air into pleura by
needle using device
Indication:-
 Treatment of pulmonary TB in the era before
antituberculous therapy, but now obsolete
 Diagnostically ; in thoracoscopic exam.

Syndromes
Catamenial pneumothorax
 Occurs in conjunction with menstruations & is usually recurrent.
 It is rare phenomenon which the usual way in which the thoracic
endometriosis declares itself
 It generally occurs in women aged 30-40 years.
 It frequently begins 1-3 days after menses onset.
 The majority (90-95% ) affect the Right hemithorax, but isolated
Left side or bilateral pneumothorax has been reported.
 Catamenial pneumothorax is usually treated by:
1. Oral contraceptive or danazol (weak androgen) in few cases to
suppress ovulation.
2. Surgical menopause by hysterectomy with bilateral
oopherectomy
3. Thoracotomy with pleural abrasion or pleurectomy

Syndromes
Pneumomediastinum :
(Air in mediastinal tissue or mediastinal emphysema)
1. 1ry spontaneous Pneumomediastinum : usually
occurs without any prior lung disorders or diseases
2. 2ry spontaneous Pneumomediastinum : can occur as a
complication of underlying lung or mediastinal diseases , most
often any cause of 2ry spontaneous Pneumomediastinum .
Bilateral spontaneous pneumothorax:
Is rare & may be rapidly fatal if occurring , may be due to:
1.Rupture bilateral apical blebs simultaneously
2. Patient with extensive bilateral emphysema or cystic
lung disease

Pathophysiology
If the air enters the pleural cavity from:
 The outside (open pneumothorax)
 from the lung (closed pneumothorax)
Primary spontaneous pneumothoraces (PSP):
Results from apical pleural blebs related to airway
inflammation from cigarette smoking in many patients &
it is dose-dependent.
Secondary spontaneous pneumothoraces (SSP):
Occurs in the presence of lung disease, e.g. COPD . Air
enter the pleural space via distended, damaged, or
compromised alveoli.

Pathophysiology
Tension pneumothorax:
The condition develops from a combination of mechanical
and hypoxic effects.
The injured tissue forms a one-way valve, allowing air to
enter the pleural space and preventing the air from
escaping naturally  the pressure of trapped air  the
ipsilateral lung collapses and the mediastinum shifts
toward the contralateral side  compression of the
contralateral lung and the vasculature entering the Right
atrium of the heart  respiratory insufficiency,
cardiovascular collapse, death if untreated.

Pathophysiology
Pneumomediastinum
 Air escapes into the mediastinum from:
 Rupture of alveoli bordering the mediastinum.
 Esophageal trauma or elevated airway pressures.
 Air may then travel superiorly into the visceral,
retropharyngeal, and subcutaneous spaces of the neck.
From the neck, the subcutaneous compartment is
continuous throughout the body; thus, air can diffuse
widely (Subcutaneous emphysema).
 Mediastinal air can also pass inferiorly into the
retroperitoneum and other extraperitoneal compartments.
 The mediastinal parietal pleura may rupture and cause a
pneumothorax.

Causes
1ry Spontaneous pneumothorax
 The male-to-female ratio is about 6:1 .
 most likely to occur during the fall or winter months.
 Occurs most often in persons early in the third decade of
life .
 Occurs from the rupture of subpleural apical
emphysematous blebs or bullae .
 Smoking the risk by more than 22 fold in men and by
nearly 10-fold in women. The risk is directly dose related
to smoking
 PSP is typically observed in tall people due to increased
shear forces in the apex.
 Familial tendency has been noted

Causes
2ry spontaneous pneumothorax
 Occur as a complication of underlying lung disease:
Diseases of the airways: COPD, cystic fibrosis, and status
asthmaticus ,………..etc.
Interstitial lung diseases : (sarcoidosis, fibrosis, tuberous
sclerosis,………..etc)
Infectious diseases : Pneumonia (especially with Staph. Pn,
Klebsiella, Pseudomonas, and Pneumocystis species),
tuberculosis, pertussis, lung abscess ,………..etc.
Malignancies: Sarcoma, lung cancer .
Pneumoconiosis .
Connective tissue diseases .
Chemotherapy for malignancy .
Radiation therapy .

Causes
Iatrogenic pneumothorax
 Transthoracic needle aspiration procedures (most common
cause, accounting for 32-37% of cases)
 Transbronchial lung biopsy, Pleural biopsy, liver biopsy or surgery
 Thoracentesis
 Tracheostomy
 Mechanical ventilation (directly related to peak airway pressures)
, central venous cannulation; hyperbaric oxygen therapy.
 Cardiopulmonary resuscitation
 Subclavian and supraclavicular cannulation
 Intercostal nerve block .
 Unsuccessful attempts to convert an open pneumothorax to a
simple pneumothorax in which the occlusive dressing functions
as a 1-way valve can lead to a tension pneumothorax.

Causes
Traumatic pneumothorax
 Penetrating (Open pneumothorax ) and non penetrating injury .
 Rib fracture .
Thoracic endometriosis :
Leading to catamenial pneumothorax .
Other causes:
 Tall, thin stature in a healthy person or a person with Marfan
syndrome.
 High-risk occupation (e.g., diving, flying) .
 Acupuncture
Tension Pneumothorax
Any condition that leads to pneumothorax can cause a tension
pneumothorax

Causes
Pneumomediastinum
 Acute production of high intrathoracic pressures (usual cause)
 Mechanical ventilation
 Severe cough & Smoking marijuana
 Asthma
 Inhalation of cocaine
 Athletic competition
 Respiratory tract infection
 Decompression of intrathoracic gas
 Violent vomiting may cause vertical tear in the lower 8cm of
esophagus postero-laterally
 Trauma ( traheostomy) or surgical disruption of the
oropharyngeal, esophageal, or respiratory mucosa

Clinical Details
History
 Primary spontaneous pneumothorax usually develops at rest,
and many affected individuals do not seek medical attention for
days after symptoms develop depending on the severity of the
incident.
 The major symptom is chest pain - sharp or stabbing pain,
radiating to ipsilateral shoulder and increasing with inspiration
(pleuritic)
 Secondary spontaneous pneumothorax:
Dyspnea more severe
Anxiety, cough, malaise and Cyanosis
 tension pneumothorax  Sudden chest pain, extreme
dyspnea, consciousness decreased and cyanosis.

Clinical Details
General examination:
General appearances may be normal
Diaphoretic
Splinting chest wall to relieve pleuritic pain .
Cyanotic (with tension pneumothoraces and SSP ) .
With a tension pneumothorax:
 Increasing resistance to providing adequate
ventilation assistance
 Tachycardia, Pulsus paradoxus & Hypotension (key
sign of a tension pneumothorax)
 Jugular venous distension Tracheal deviation (late
finding)
 Abdominal distension

Clinical Details
General examination:
Vital signs:
Tachypnea
Tachycardia (most common finding)
Pulsus paradoxus
Hypotension (with tension pneumothorax)

Clinical Details
Chest
 Ipsilateral diminished chest movement & may be appear
larger with mediastinal and tracheal shift which
suspects tension pneumothorax
 Hyperresonant percussion note.
 Distant or absent breath sounds & tactile focal fremitus
on affected side.
 Hydropneumothorax :- Succusion splashing sound is
produced by rocking the patient. to & fro. The coin test ,
scratch sign is sometime usefully employed.
 In open pneumothorax: Air may be heard passing in and
out of the wound with breathing.

Clinical Details
In ventilated patients, the physician may begin to suspect
tension pneumothorax when:
 Sudden onset of tachycardia & hypotension (key sign of
a tension pneumothorax)
 The distressed patient appearing to fight the ventilator
 Sudden decline in O2 saturation
 Increased pleural pressures necessitate an increase in
peak airway pressure in order to deliver the same tidal
volume.
 Decreased expiratory volumes (air leakage into the
pleural space) and increased end-expiratory pressure.

Clinical Details
Clinical feature of Pneumomediastinum:
 None (Physical findings are absent in some patients.)
 Central chest pain, radiating to the neck, back, or shoulders and
exacerbated by deep inspiration, coughing, or supine positioning
& relived by leaning forward & by shallow breathing.
 Neck pain accompanied by Dysphagia & Subcutaneous
emphysema of the chest wall
 Hamman sign “precordial crunching” It result from free air in the
mediastinum moving heart muscle
 Pulsus paradoxus in absence of asthma
 May be cardiac tamponad from air surrounding the heart 
dyspnoea, cyanosis & hypotension
 2ry spontaneous or traumatic types  symptoms & signs of
associated disease ± fever, pleural effusion, or empyema

Investigations - X-ray
X-ray:
 The first investigation performed (confirms pneumothorax)
 A linear shadow of visceral pleura (the pleural line) with lack
of lung markings peripheral to it, indicating collapsed lung.
 Contralateral deviation of mediastinal structures, & rib cage
expansion is evidence of a tension pneumothorax .
 Delayed traumatic pneumothorax can develop in
penetrating chest wound. Obtain serial chest radiographs
every 6 hours in the 1st day of injury to rule this out.
 In tension pneumothorax if a chest x-ray is obtained safely,
findings can include:
 lung collapse at the hilum, diaphragmatic depression
and widened intercostal spaces on the affected side
 Tracheal and mediastinal deviation to the contralateral
side.

 Rotation of CXR can
obscure a pneumothorax .
Rotation can also mimic a
mediastinal shift.
 Expiratory images are
thought to better depicting
minimal (subtle)
pneumothoraces.
 In erect patients: Pleural
gas collects over the apex .

 In the supine position:
 The juxtacardiac area, the
lateral chest wall, and the
subpulmonic region are the best
areas to search for evidence of
pneumothorax.
 The deep sulcus sign: (very wide
and deep costophrenic angle)
 An ipsilateral increased lucency
in the upper quadrant of the
abdomen.
 Double Diaphragm Sign: both
the diaphragmatic dome and
anterior portions of the
diaphragm are visualized

Double Diaphragm Sign
of Pneumothorax. Air in
the right hemithorax
displaces both the
dome (white arrow)
and the anterior
costophrenic angle
(yellow arrow) in this
patient with a large,
right-sided
pneumothorax. There is
also a deep sulcus sign
present (red arrow).

 A large pneumothorax as
being of greater than 2 cm
width at the level of the
hilum.
 The volume of a pneumothorax
approximates to the ratio of
the cube of the lung diameter
to the hemithorax diameter
lateral decubitus studies:
 Should be done with the
suspected side up
 the lung will then 'fall' away
from the chest wall
Rib films are indicated
This chest X-ray shows a large
pneumothorax (P) which is >2 cm
depth at the level of the hilum.

 A bulla or thin wall cyst can be
mistaken for loculated
pneumothorax. The pleural line
caused by pneumothorax is
usually bowed at its center
towards lateral chest wall but
the inner margins of bulla or
cyst is generally concave rather
than convex.
 Pneumothorax with pleural
adhesion may simulate bulla or
lung cyst.
 DD by comparison with previous
chest radiography, lateral
decubitous or CT scanning
A chest radiograph shows RT
bullous formation

A skin fold can be mistaken for a pneumothorax. Unlike
pneumothorax, skin folds usually continue beyond the chest wall,
and lung markings can be seen beyond the apparent pleural line.

Deep sulcus sign (red arrow) in a supine patient in the ICU. The
pneumothorax is subpulmonic.

Hydropneumothorax:
 with the patient upright,
there will be an air-fluid
level in the thoracic cavity
 On supine radiographs, a
hydropneumothorax will
be more difficult to see
although a uniform
grayness to the entire
hemithorax with the
absence of vascular
markings suggest the
diagnosis

Radiographic features of Pneumomediastinum
PA Chest X-Ray
Small amounts of air
appear as linear or
curvilinear lucencies
outlining mediastinal
contours and form:
1. Subcutaneous
emphysema
2. Air anterior to
pericardium:
(Pneumoprecardium)
Pneumo-
precardium
subcutaneous
emphysema

PA Chest X-Ray
3. air around
pulmonary
artery and
main
branches:
ring around
artery sign
4. air outlining
major aortic
branches:
tubular
artery sign
Tubular Artery Sign (Red
arrows)
Ring around artery
sign

PA Chest X-Ray
5. continuous diaphragm sign: due to
air trapped posterior to pericardium
6. Spinnaker Sail Sign (angel wing sign)
is seen on neonatal postero-anterior
CXR when thymic lobes are displaced
laterally by air, (Very typical sign in
neonatal age).
Spinnaker Sail
Sign
(angel wing sign)
Continuous diaphragm
sign

PA Chest X-Ray
Naclerio V sign
It is seen as a V-shaped air collection.
One limb of the V is produced by
mediastinal air outlining the left lower
lateral mediastinal border. The other limb
is produced by air between the parietal
pleura and medial left hemidiaphragm.
Lateral Chest X-Ray
Retrosternal air
Lateral Decubitus Chest X-Ray
Air will not move with change in position
Neck Films
Air outlining fascial planes of the neck
Naclerio V sign

HRCT benefits:
1. CT is the most reliable imaging study for the diagnosis, but it is not
recommended for routine use
2. Confirm the diagnosis of pneumothorax in mechanically ventilated
patients
3. Detect underlying emphysema, parenchymal and pleural diseases
4. Determine the exact size of the pneumothorax
Moderate left-sided pneumothorax. (A) Axial and ( B ) coronal CT demonstrating
subpleural blebs ( blue arrow ). Red arrows indicate pneumothorax
Investigations - CT scanning

5. Detect occult (a pneumothorax that is seen only on CT and not a
conventional chest x-ray) pneumothoraces, blebs, bullae, cysts and
pneumomediastinum
a)
Anteroposterior
supine
radiograph
shows no
abnormality.
b)
CT scan shows
the existence of
an occult
pneumothorax
on the right
side.
Tension pneumothorax (green
arrow) and subcutaneous
emphysema (red arrow). CT
shows increased volume of the
right hemithorax, reduction of
ipsilateral pulmonary volume and
shifts the mediastinum to the left

6. Distinguish between a large bulla and a pneumothorax
Chest radiograph shows unilateral hyperlucency affecting the entire right lung
(white arrows). (b) CT demonstrates a large bulla (star) on the right side causing
considerable compression of the mediastinum

CT shows large asymmetric upper lobe bullae. Chest tube is located peripherally in
right pleural space. Note presence of air in pleural space surrounding anterior
bulla on right (arrow) and parallel configuration of bulla wall with chest wall. This is
double-wall sign of pneumothorax.
7. "Double wall" sign described in cases with ruptured bulla causing
pneumothorax (air outlining both sides of the bulla wall parallel to
the chest wall).

Hydropneumothorax:
 The concurrent presence of both
free fluid and air within the pleural
space
 It can occur secondary to various
situations such as thoracocentesis,
thoracic trauma, esophagopleural
fistula, neoplastic processes, post-
traumatic, post-pneumonectomy,
infection, pulmonary infarction,
cystic lung disease, obstructive
lung disease or bronchopleural
fistula.
 CT depicts hydropneumothorax,
with the horizontal air fluid
interface
Axial contrast CT image
demonstrates a right-sided
hydropneumothorax. Note the air
and fluid interface (arrow).

A loculated pneumothorax is a pocket of pleural air
trapped in a localised area. The plain film appearances
may be subtle.
Chest CT revealed a loculated
pneumothorax
chest CT revealed Bilateral
loculated pneumothoraces

Pneumomediastinum: CT findings:
 assess the extent, (i.e., mild, moderate or severe)
 Detect possible aerodigestive tract injuries.
 differentiate between pneumomediastinum and
pneumopericardium
Pneumomediastinum: CT
also shows air
surrounding the
mediastinal structures
(arrows).
Pneumomediastinum. There is air in
the mediastinum surrounding the aorta
and trachea (arrows).

Investigations - Ultrasonography
Ultrasonography:
 A bedside technique, more sensitive than CXR and Useful in
unstable patients who cannot go outside emergency department.
 In a supine patient, air accumulates in the anterior region of the
chest at the second to fourth intercostal spaces in the mid-
clavicular line. It is the recommended initial area for investigation
in a trauma
Sonographic modes:
 B-mode, or brightness
mode: provides real-time
imaging of structures that
are clearly observable
 M-mode, or motion mode:
determine a structure’s
movement over time.

Sonographic signs:
1. bat sign:
 For the typical supine patient,
Begin by selecting B-mode and
place the probe on the anterior
part of the chest.
 Obtain the bat sign, which is a
basic sonographic landmark.
 It consists of an upper rib, a
lower rib, and the pleural line.
The periosteum of the ribs
represents the wings and the
bright hyperechoic pleural line
in between them represents
the bats’ body

Sonographic signs:
2. Lung Sliding sign:
Between ribs in normal aerated lung, parietal and visceral plura are
seen sliding across one another. the presence of lung sliding rules out
pneumothorax at the location of the probe.

Sonographic signs:
3. seashore sign:
By using M-mode,
two different patterns
are displayed in
normal lung : The
motionless portion
above the pleural line
creates horizontal
“waves”, and the
sliding below it
creates a granular
pattern, the ‘sand’,
this resembles waves
crashing in onto the
sand.

Sonographic signs:
4. Stratosphere/barcode sign:
M-mode only displays one pattern of parallel horizontal lines above
and below the pleural line. This pattern resembles a “barcode”
barcode

Sonographic signs:
5. Z-lines/comet tails/rockets:
 Small, vertical tapering
hyperechoic lines that
diminish distally, caused by
air-fluid interface at the
pleural line.
 Absent when air or
pneumothorax is present
The comet-tail artifact
( yellow arrows): an
ultrasound sign ruling
out pneumothorax.

Sonographic signs:
6. B-lines:
 The B-lines appear in B-mode
ultrasonography as thin,
vertical beams; however,
they are really tiny horizontal
lines tightly stacked on top of
each other at increasing
depth.
 B-lines that occur in a series
of 3 or more have been
termed B+ lines.
 The presence of B-lines is
especially important to rule
out pneumothorax
“B-lines” (white arrows) originating
from pleural line, extending to the
edge of the screen.

Sonographic signs:
7. lung-point sign: Yellow arrow
Indicates the lung point in M-
mode:
 This is the region where the intra-
pleural air (pneumothorax) ends
and normal pleural connection
(seashore sign) begins.
 Note the characteristic streaking of
the barcode/stratosphere sign on
the lower indicating pneumothorax.
 The B-mode image (upper portion
of image) will reveal the absence of
lung sliding on a dynamic
ultrasound scan.

Investigations
Contrast-enhanced esophagogram:
If emesis or retching is the precipitating event, an esophagogram
should be obtained to evaluate Boerhaave syndrome (an esophageal
tear), which has a high mortality rate .
The electrocardiogram (ECG):
Patient with left pneumothorax may shows changes suggesting
antero lateral myocardial infarction ( A right axis deviation, poor R
wave progression, ↓QRS amplitude & precordial T wave inversion ).
Lab Studies
Arterial blood gas
 In patients with severe lung disease
 In those with persistent respiratory distress despite treatment
 ABG analysis may be useful in evaluating the following: Hypoxia,
Hypercarbia and respiratory acidosis

Differential diagnosis
 Pulmonary embolism
 Dissecting aortic aneurysm, rupture
 Esophageal spasm, Perforation, Rupture and Tears.
 Acute pericarditis
 Acute myocardial infarction
 Acute Coronary Syndrome
 Congestive Heart Failure and Pulmonary Edema
 Haemothorax
 Pleural effusion
 ARDS
 Asthma
 Foreign Bodies, Trachea
 Adult Diaphragmatic Injuries

Pneumothorax Treatment
Treatment Based on Risk Stratification
(Patient presentation ):
The following are possible presentations of patients with
pneumothorax:
 Asymptomatic (incidental finding): Treatment decisions are guided
by estimate of long-term recurrence risk.
 Symptomatic but clinically stable:
 The British Thoracic Society (BTS) advocates for simple
aspiration and deferring hospitalization in PSP
 A small-bore catheter or chest tube placement is recommended
by the American College of Chest Physicians (ACCP)
 Clinically fragile: air evacuation and observation; comorbid
conditions may preclude observation
 Life-threatening: must be treated immediately with tube
thoracostomy

Selection of site of patient care
Outpatient care: This can occur in asymptomatic patients
or those with a small pneumothorax and reliable follow-up
Emergency department (ED) care: when Prolonged periods
of observation are inefficient and clinically suboptimal;
manual aspiration and placement of one-way valves are
performed.
Inpatient care: when high flow Oxygen is needed, the
pneumothorax is larger but the patient is stable, or
associated comorbidities ; the average hospital stay is
2-8 days
Intensive care unit (ICU): for patients who are unstable or
intubated

Options for Restoring Air-Free Pleural Space:
1. Observation without oxygen
2. Administering supplemental oxygen
3. Simple aspiration
4. Chest tube placement
5. One-way valve insertion
6. Thoracostomy with continuous suction.

1. Observation without oxygen:
Simple observation is appropriate for asymptomatic
patients with a minimal pneumothorax (<15-20% by
Light criteria; 2-3 cm from apex to cupola by
alternate criteria) with close follow-up, ensuring no
enlargement. Air is reabsorbed spontaneously
2. Supplemental oxygen:
Oxygen administration at 3 L/min nasal canula or
higher flow treats possible hypoxemia and is
associated with a fourfold increase in the rate of
pleural air absorption compared with room air
alone.

3. Simple aspiration:
A more recent ED study supports needle aspiration
as safe and effective as chest tube placement for
PSP, conferring the additional benefits of shorter
length of stay and fewer hospital admissions
4. Chest tube placement:
A tube inserted into the pleural space is connected
to a device with one-way flow for air removal.
Examples of such devices are Heimlich valves or
water seal canisters, and tubes connected to wall
suction devices.

Chest tube :

5. One-way valve insertion (portable system):
The typical goal of inserting one-way valve
systems is to avoid hospital admission and still
treat the spontaneous pneumothorax. One-way
valves may be used during transport of an injured
patient.
A Heimlich valve is a one-way, rubber flutter valve
that allows for complete evacuation of air that is
not under tension
Effective as simple manual needle aspiration or a
conventional chest tube thoracotomy.

One-way valve insertion (portable system):
Heimlich valve

6. Thoracostomy with continuous wall suction:
First time SPS (including chronic obstructive
pulmonary disease [COPD]) and traumatic
pneumothorax typically require this approach.
 A small-bore catheter (eg, 7-14 French) is safe to use
in most patients, whereas a larger chest tube (24
French) is also appropriate initially, and increasing
suction pressure can be used if the lung fails to
inflate.
A larger tube (eg, 28 French) can reduce resistance in
patients who are ventilated and at greater risk for air
leaks.

Prehospital Care:
 Assess the ABCs (airway, breathing ,circulation).
 Evaluate the possibility of a tension pneumothorax.
 Assess the vital signs.
 Perform pulse oximetry.
 A tension pneumothorax is almost always associated with
hypotension.
 Administer oxygen to the patient, ventilate the patient, and
establish an intravenous (IV) line.
 Needle decompression for immediate relief of a tension
pneumothorax.
 Prehospital ultrasonography: could provide diagnostic and
therapeutic benefit when conducted by a proficient examiner
 In open pneumothorax: occlude wound with dressing (3 sides only
to allow air to escape during expiration)

Prehospital Care:
Three sided occlusive
dressing for open
pneumothorax. It can be
made from a good
quality plastic bag and a
roll of tape. The open
side of the plastic is on
the bottom side of the
dressing to encourage
any blood expelled from
the wound to run
downhill and out of the
dressing

Emergency Department Care:
check:
ABCs, Vital signs, Oxygen saturation.
Give oxygen.
Admission to the hospital.
Bedside ultrasonography to look for cardiac
tamponade, massive pulmonary embolus, severe
hypovolemia, and tension pneumothorax

Tension pneumothorax (a medical emergency) :
Is a clinical diagnosis and a high index of suspicion
and knowledge of basic emergency thoracic
decompression are important for all health care
personnel.
Initial management:
Establishing ABCs.
Emergency endotracheal intubation in: Apnea,
profound shock, and inadequate ventilation.
Cover a sucking chest wound.
Volume replenishment in hemorrhagic shock.

1. Urgent needle thoracocentesis:
Performed prior to chest radiographs (is not indicated) and based on
physical examination.
It is both:
Diagnostic (confirming suspicion) and Therapeutic (relieving the
pneumothorax ) .
The procedure :
Insertion of a 14 or 16 gauge catheter over the needle at the second
anterior intercostal space in the midclavicular line (over 3rd rib) or
in the fourth or fifth intercostal space over the superior rib margin
in the anterior axillary line (similar to for chest drain insertion).
The catheter is connected to a 3-way stopcock and a large-volume
syringe. Aspiration is performed.
Leave the catheter in place until the chest tube is placed.

Needle thoracocentesis :

Do NOT x-ray - this is a clinical diagnosis
 Immediate needle decompression.
 Confirm side clinically.
 Inform patient.
 14G cannula .
 2nd intercostal space.
 Listen for hiss.
 Protect with gauze.
 Tape and leave in situ.
 Prepare chest drain for insertion.

Chest tap with 60 ml syringe, 3-way stopcock,
IV extension tube, and 16 gauge needle .

Primary spontaneous pneumothorax :
Stop smoking.
1. Small (involving <15% of hemithorax):
 Observation and oxygen to asymptomatic patient.
 Needle aspiration to symptomatic hemodynamically stable
patient.
2. large (involving >15-20% of hemithorax):
 Drained by aspiration using a pigtail catheter left to low suction or
water seal is recommended.
 Strong suction should not be used with PSP because of delayed
presentation  increased risk of re-expansion pulmonary edema
Follow-up chest radiographs are performed:
If residual pneumothorax is present after 12 hour attach the catheter
to underwater seal.
If not succeed, do tube thoracostomy

Small-bore
(pigtail )
catheter
insertion
Pigtail
catheter
inserted
laterally

Secondary spontaneous pneumothoraces :
1. Admission to hospital for at least 24 h and receive
supplemental oxygen (caution for patients with carbon
dioxide retention)
2. Aspiration is less likely to be successful in SSP but can be
considered in small pneumothoraces (Size 1-2cm) in an
attempt to avoid chest drain insertion.
3. Tube thoracostomy is the procedure of choice in large
pneumothoraces (Size >2cm ) or failed aspiration of small
one.
4. Thoracotomy or video-assisted thoracoscopy: To excise the
bullae.
5. Medical pleurodesis or ambulatory management with a
Heimlich valve: may be appropriate for inoperable patients.

Tube thoracostomy :
Insert a chest tube in the fourth or fifth intercostal space
over the superior rib margin in the anterior axillary line.
Indications: Pneumothorax: open or closed; simple or
tension Hemothorax, Hemopneumothorax, drain a
malignant pleural effusion, drain a empyema. They can
also be placed postoperatively following a thoracotomy,
esophagectomy or cardiac surgery.
For children:
Chest drain insertion in 4th or 5th intercostal space mid-
axillary line.
Drain size: Use a large drain for blood (i.e. 16 gauge for a
5-10 kg child) and a smaller drain for pneumothorax.

Tube thoracostomy :

Video-Assisted Thoracoscopic Surgery (VATS):
Is a minimally invasive surgical technique
Used to diagnose and treat problems in the chest.
VATS can replace a traditional thoracotomy,
which uses one larger incision to gain access to
the chest.
The minimally invasive procedure typically results
in less pain and faster recovery time for the
patient, among other advantages for patients.

 One or more small
incisions are made in
the chest.
 A tiny fiber-optic
camera (called a
thorascope) is inserted
through one incision,
and surgical
instruments are
inserted through this or
other small incisions.
Video-Assisted Thoracoscopic Surgery (VATS):
 The thorascope transmits images of the inside of the chest on a
video monitor, guiding the surgeon in maneuvering the
instruments to complete the procedure.

Iatrogenic pneumothorax:
Aspiration is the technique of choice, because recurrence is
usually not a factor. Tube thoracostomy is reserved for
very symptomatic patients.
Traumatic pneumothorax:
In general, traumatic pneumothoraces should be treated
with insertion of a chest tube.
A subset of patients who have a small (<15-20%),
minimally symptomatic pneumothorax may be
admitted, observed closely, and monitored by using
serial chest radiographs. administration of 100% oxygen
promotes resolution.

Catamenial pneumothorax:
Oral contraceptives carry a high success rate
May also (rarely) be treated surgically
Pneumomediastinum:
 Most patients with pneumomediastinum should be observed for
signs of serious complications (e.g., pneumothorax, tension
pneumothorax, mediastinitis).
 If the pneumomediastinum occurred from the inhalation of
cocaine or smoking of marijuana, observation in the ED for
progression may be indicated.
 A follow-up chest radiograph should be obtained in 12-24 hours to
detect any progression or complication, such as pneumothorax. If
no progression occurs at 24 hours and if no evidence of
mediastinitis exists, the patient may be discharged.

Surgical strategies:
 Open thoracotomy and pleurectomy.
Video-assisted thoracoscopic surgery (VATS) with pleurectomy
and pleural abrasion.
Indications for surgical assistance:
 Repeated episodes of pneumothorax
 The lung remains unexpanded after 5 days
 Persistent air leak for more than 7 days
 Contralateral pneumothorax
 Bilateral pneumothorax
 A high-risk occupation (e.g., diver, pilot)
 In acquired immunodeficiency syndrome (AIDS) patients
 Lymphangiomyomatosis, a condition at a high risk of pneumothorax

Drug treatment:
 Local Anesthetics (Lidocaine hydrochloride): Used for analgesia,
for thoracentesis and chest tube placement.
 Opiate Analgesics (Fentanyl citrate and Morphine): Used for
pain control, ensures patient comfort, and promotes pulmonary
toilet.
 Benzodiazepines (Midazolam and Lorazepam ): Used for
conscious sedation,in premedication before pleurodesis,
sclerotherapy or placement of a thoracostomy tube.
 Antibiotics (Doxycycline and Cefazolin): In patients with
repeated pneumothoraces who are not good candidates for
surgery, pleurodesis (or sclerotherapy) may be necessary.
 Prophylactic antibiotics are not recommended for the
placement of chest tubes in non-traumatic causes.

Pneumothorax-Complications
Pneumothorax complications include the following:
Hypoxemic respiratory failure
Respiratory or cardiac arrest
Hemopneumothorax
Bronchopulmonary fistula
Pulmonary edema (following lung reexpansion)
Empyema
Pneumomediastinum
Pneumopericardium
Pneumoperitoneum
Pyopneumothorax
Complications of surgical procedures: Infection of the
pleural space, Persistent air leak and Pain at the site of
chest tube insertion

Recurrent Pneumothorax
Recurrent Pneumothorax:
 the recurrence rate for primary pneumothorax is more than 20%
after the first episode and even greater after the second episode
and tends to be more likely in women, tall men and smokers
 Causes of recurrent spontaneous pneumothorax are:
 Cystic fibrosis
 Lung cysts
 Emphysematous bulla / apical subpleural bleb
 Rupture of bronchogenic carcinoma / esophageal carcinoma
 Honeycomb lung
 Catamenial pneumothorax (associated with menstruation)
 AIDS

Recurrent Pneumothorax
Available treatment options include:
 Medical treatment:
 Medical chemical plerurodesis: should only be used if a patient
is either unwilling or unable to undergo surgery
 Surgical treatment:
 Video-assisted thoracoscopic surgery (VATS) with (partial)
pleurectomy or talc poudrage
 A thoracotomy with partial or complete pleurectomy

Pneumothorax - Prevention of Recurrent
Strategies for the prevention of recurrent include:
Prompt recognition and treatment of bronchopulmonary
infections
When subclavian vein cannulation is required, use the
supraclavicular approach rather than the infraclavicular
approach when possible
The incidence of iatrogenic tension pneumothorax may
be decreased with prophylactic insertion of a chest tube
in patients with a simple pneumothorax that requires
positive pressure ventilation
Pleurodesis decreases the risk of recurrence of
spontaneous pneumothorax
Thoracotomy or VATS to excise the bullae

Pneumothorax and pneumomediastinum

Pneumothorax and pneumomediastinum

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