![Quantification:
• 1) Light’s index
• % PNEUMOTHORAX=
• [1-(diameter
lung)3/(diameter
hemithorax)3]
• 2) Collin’s method
• 3) Rhea index](https://image.slidesharecdn.com/pneumothorax-200722043519/75/Pneumothorax-24-2048.jpg)
![Quantification
In general,
these are
preferred
COLLIN’S METHOD
% pneumothorax= 4.2+[4.7x(A+B+C)];
A=distance between apex of partially collapsed
lung and apex of thoracic cavity
B=distance between midpoint of upper half of
collapsed lung &lateral chest wall
C= distance between midpoint of lower half of
collapsed lung &lateral chest wall
RHEA METHOD: uses a nomogram that relates the
average intra-pleural distance to the
pneumothorax size(1cm=10%pneumothorax)](https://image.slidesharecdn.com/pneumothorax-200722043519/75/Pneumothorax-25-2048.jpg)
More Related Content
Pneumothorax
- 1.
- 2. DEFINITION: ACCUMULATION OF AIRIN THE PLEURAL SPACE TERM WAS COINED BY ITARD IN 1803 LAENNEC IN 1819
- 3.
- 4. 3 events: •1) Communication between pleura and alveolus • 2) Communication between atmosphere • 3) Gas producing organism in the pleural cavity
- 5. PATHOPHYSIOLOGY: • Effect onpleural pressure: • Normal pleural pressure is negative with respect to alveolar pressure during the entire respiratory cycle with APICOBASAL gradient • Magnitude of pleural pressure gradient is 0.25 cm H2O per cm vertical distance • So if a communication develops between the pleural space and the alveolus/atmosphere, it causes increase in the pleural pressure • Upper lobes > lower lobes
- 6. Effect on pulmonary pressure and bloodgases: Decrease in Vital capacity, FRC, TLC, and DC Decrease in arterial PaO2 – low ventilation- perfusion ratios (airway closure at low lung volumes), anatomic shunts, alveolar hypoventilation Pneumothorax that occupies less than 25% of the hemithorax is not usually associated with significant shunts Compromised pulmonary function before the pneumothorax- significant hypoxemia, alveolar hypoventilation and respiratory acidosis
- 7. Resorption of pleural gases: •By simple diffusion from the pleural space into the venous blood. • Rate of absorption depends on: (a) Pressure gradient for gases between pleural space – venous blood (b) Diffusion properties of gases present in the pleural space (c) Area of contact between the pleural gas and pleura (d) Permeability of the pleural surface (thickened, fibrotic pleura will absorb less)
- 8. PSP (primary spontaneous pneumothorax): Occurs inhealthy individuals with no OBVIOUS lung disease Incidence: Males > Females (3-6:1), Peak age: early 20’s Risk factors: Tobacco smoking Male gender and tall/thin individuals directly related to the amount of cigarette smoking and the years of exposure Lifetime risk is 12% in healthy smoking men as compared to 0.1% in nonsmokers
- 9. Family History Geneticallydetermined Birt-Hogg-Dube syndrome: (mutations in folliculin gene): Autosomal dominant inheritance , characterized by spontaneous pneumothorax, benign skin tumors and renal tumors Others Marfan’s syndrome Homocystinuria Anorexia nervosa
- 10. Pathology implicated: Rupture of subpleuralblebs or bullae on the apical portion of the upper lobes. Airway inflammation/Respiratory bronchiolitis secondary to smoking Pleural porosity • Pathology: (from resected specimens) Eosinophilic pleuritis High prevalence of bronchial anomalies in nonsmokers associated with PSP: M/C was disproportionate bronchial anatomy
- 11. Clinical features: Chest pain •Acute onset - usually localized to the side of pneumothorax • Pleuritic in nature Dyspnea • Acute onset • Usually develops while the patient is at rest
- 12. Physical Examination: (small pneumothoraces <20% areusually not detectable) • Vital signs are usually normal except for tachycardia • Side with pneumothorax is larger than c/l side • Movements decreased on the affected side • Tactile fremitus-absent • Percussion note – HYPERRESONANT • Breath sounds - absent/reduced • With large pneumothorax - tracheal shift to C/L side • With large right sided pneumothorax – lower edge of liver - inferiorly
- 13. Diagnosis: Symptoms and P/Econsistent with pneumothorax Available radiological modalities: 1) CXR: still most common investigation performed 2) USG lung: especially useful in the intensive care units 3) NCCT-chest (in unclear cases) Sensitivity: CT > USG > CXR
- 14. CXR Findings: 1) Visualization ofvisceral pleural line – MUST 2) Convex curve of visceral pleural line ⑊ the contour of chest wall 3) Absence of lung markings distal to pleural line – not necessarily 4) Deep sulcus sign (supine radiograph)
- 15. CXR: • In supineposition: best areas to search for evidence Juxta-cardiac area lateral chest wall and subpulmonic region • 2% radiographic pneumothorax corresponds to 50% pneumothorax by volume • Pooled sensitivity: 40 -52% • Pooled specificity: 99-100%
- 16. Radiological Evidence: Diagnosisestablished by demonstration of pleural line on chest radiograph PA view(outer margin of visceral pleura separated from the parietal pleura by a lucent space devoid of pulmonary vessels)
- 17.
- 18. PITFALLS (CXR): • Bullouslung disease • Large cyst in the lung • PTE 1) Other lung diseases with absent lung markings: 2) Mistaking skin fold to a pleural line - usually skin fold is THICK 3) Mistaking medial border of the scapula for pneumothorax
- 19. Role of CT-chest:Occult Pneumothorax 1) not routinely indicated with PSP – no close correlation between presence of subpleural blebs and recurrence 2) Regarded as - gold standard in detection of small pneumothoraces and in size estimation. 3)Useful in the presence of surgical emphysema and bullous lung disease and 4)For identifying aberrant chest drain placement or additional lung pathology
- 20. USG-chest • Normal LungSliding • Sea-shore sign 2 step approach to diagnose pneumothorax
- 21. Step 1: Pneumothorax andA’-profile • A’-profile is the association of A-line sign with abolition of lung sliding • B-line or lung sliding rule out pneumothorax.
- 22. Step 2: Searchfor Lung Point: • Lung point is pathognomonic • Indicating its volume
- 23. • USG: • 1)Pooled sensitivity: 87-100% • 2) Pooled specificity: 91-100% • 3) Presence of lung sliding definitely rules out pneumothorax with a NPV of 100%, but not specific Pleural symphysis (pleurodesis, fibrosis, adhesions) Loss of lung volume (massive atelectasis, pneumonectomy) • Presence of B-lines, artifact arising from pleura, rules out pneumothorax with NPV of 100%
- 24. Quantification: • 1) Light’sindex • % PNEUMOTHORAX= • [1-(diameter lung)3/(diameter hemithorax)3] • 2) Collin’s method • 3) Rhea index
- 25. Quantification In general, these are preferred COLLIN’SMETHOD % pneumothorax= 4.2+[4.7x(A+B+C)]; A=distance between apex of partially collapsed lung and apex of thoracic cavity B=distance between midpoint of upper half of collapsed lung &lateral chest wall C= distance between midpoint of lower half of collapsed lung &lateral chest wall RHEA METHOD: uses a nomogram that relates the average intra-pleural distance to the pneumothorax size(1cm=10%pneumothorax)
- 26. Continued: 4) BTS guidelines(2010) Lung margin to chest wall Small <2cm Large > or =2cm (At the level of Hilum) 5) ACCP guidelines Lung apex to cupola Small <3cm Large >or = 3cm
- 28. Goals of Managementand Options: • 1) To rid the pleural space of its air • 2) To decrease the likelihood of a recurrence Options: Observation Supplemental oxygen Simple aspiration: shorter hospital stay Tube thoracostomy with/without instillation of sclerosing agent Medical Thoracoscopy with insufflation of talc VATS Open Thoracotomy
- 30. Observation: • Rate ofspontaneous absorption is slow estimated to be 1.25% of the volume of hemithorax q 24hours • So pneumothorax occupying 15% of hemithorax would take 12 days for complete resorption • Pneumothorax < 15% can be considered for observation
- 31. Supplemental Oxygen: Accelerates the rateof pleural air absorption by a factor of 6 It is recommended that hospitalized patients with any type of pneumothorax treated with oxygen at high concentrations The higher the concentration of oxygen used, the faster the resorption of pneumothorax
- 32. Simple Aspiration: • Initialtreatment for most patients with PSP >15% • Site – 2nd anterior ICS at MCL after LA 16-guage needle with an internal polyethylene catheter attach 3-way stopcock and 60ml syringe to catheter manually aspirate until no more can be aspirated (but not >2.5L)
- 33. Repeat Access Do Manual aspiration Noresistance encountered >2.5L No lung expansion Resistance encountered <2.5L Lung expanded Repeat CXR after 4 hours Expansion persists Follow up CXR at 24-72 hoursTube Thoracostomy
- 34. ASPIRATION Simple aspiration canbe used as first line therapy for patients with first time spontaneous pneumothorax(>15% of hemithorax) Advantages- Short hospitalization, no significant recurrence rates at 1yr. Disadvantages- Patients with SSP/ recurrence don’t have good results
- 35. Tube Thoracostomy: Potential problems withsmall tubes: 1) More prone for kinking 2) Blockage of the tube 3) Clotting from blood or fluid 4) Greater chances of slippage Rapid evacuation of pleural air Small tubes (<14 F) preferred to large PSP patients can be managed on OP basis
- 36. Tube thoracostomy (afterfailed simple aspiration) Lung expanded and no air leak @24hours yes no continue chest tube for 24 hours. Apply suction (-20cm of H2O) reassess and remove tube Reassess Follow up High-volume low-pressure recommended (15-20L/min)
- 37. Recommendations on Suction and Clamping: Suctionis not routinely recommended 1) Risk of re-expansion pulmonary edema especially with PSP 2) No additional advantage Clamping: 1) Not advised because of risk of tension pneumothorax 2) To detect small pneumothorax – role is controversial
- 38. REPE: Incidence: 14% Risk factors: •1)Duration of pneumothorax prior to drainage (> 3 days) • 2)Severity of pneumothorax (<30% - very rare) • 3)Use of suction ( > -20cm of H2O) and rapid expansion Presentation: 1-24 hours of re-expansion CXR: patchy or diffuse alveolar infiltrates in re-expanded lung
- 39. Pathogenesis: • 1) Increasedpermeability of the pulmonary capillaries damaged by mechanical stress during re-expansion of lung • 2) Reperfusion injury • 3) Decreased surfactant • 4) Decreased Lymphatic flow
- 40. If patient isinitially treated with small tube Lung expanded Not expanded@48 hours yes place a large tube No lung expansion/BPF@4-5 days Other interventions (insertion of addition tube is not recommended)
- 41. Conclusion: • Simple aspiration forPSP and iatrogenic pneumothorax • Tube thoracostomy for SSP and when pleurodesis is indicated.
- 42. Complications of Tubethoracostomy:
- 44.
- 45.
- 47. MEDICAL THORACOSCOPY Medical thoracoscopy is performedunder local anesthesia and is usually combined with sedation Patient lies in lateral decubitus position with hemithorax to be studied facing upwards Two techniques used- single puncture and double puncture Xenon light source is used in both Site of introduction depends upon the location of radiographically detected abnormality The usual site is 6th or 7th ICS between the anterior and mid axillary line Talc insufflation and pleurodesis can be done
- 48. Medical Thoracoscopy vs VATS: • VATS •General Anesthesia • Expensive • Objectives • to treat bullous disease responsible for pneumothorax (endoscopic stapling device) • To create pleurodesis • Recurrence rate- 3% • Medical Thoracoscopy • Local anesthesia • Cost effective • No attempt is made to treat the blebs • Talc is insufflated • Recurrence rates are higher(5%)
- 49. VATS vs Open Thoracotomy: •VATS • General Anesthesia • Recurrence rate- 3% • Open Thoracotomy • Only when VATS is failed • General anesthesia • Recurrence rates are still lower (1.1%) • Some surgeons still prefer mini-thoracotomy to VATS REASONS: • Double lumen intubation is not required • Operating time is short • Good cosmetic result • Less expensive
- 50. Identifying risk of recurrence: more then75% of recurrences occur on the same side Most recurrences occur within FIRST year Recurrence rate: 25-52% Men > Women Age > 60 years Non-smokers < smokers Tall and Thin individuals History of prior recurrence (60% after second recurrence and to > 83% after the third) REMEMBER: 1) No significant relationship between size of original pneumothorax or treatment of original pneumothorax 2) The presence of blebs or bullae on CT-chest does not predict whether the patient will develop a recurrence
- 52. NOTE • Strongly favoredVATS over Conservative management despite Longer length of stay and cost NNT is high Five patients will have to undergo surgical procedure to avoid one recurrence
- 53. JANUARY 30th 2020 • Conservativemanagement is Non-inferior to intervention group • Symptoms resolved as quickly as The symptoms in intervention group • Fewer adverse events • Quite safe • Fewer recurrences during next 12 months than the intervention group
- 54. • Study opinion: •When to opt conservative management in PSP with large pneumothorax? • 1) Hemodynamically stable • 2) Patient is informed and agrees to the approach • 3) Readily available for OPD follow up • 4) Not planning for air travel or scuba diving
- 55. Advice: 1) SMOKING CESSATION2) RETURN TO WORK AND RESUME NORMAL PHYSICAL ACTIVITY ONCE ALL SYMPTOMS HAVE SUBSIDED 3) AIR TRAVEL: NO EVIDENCE THAT AIR TRAVEL PER SE PRECIPITATES RECURRENCE CAN TRAVEL AFTER 1 WEEK OF FULL RESOLUTION 4) DIVING: SHOULD BE DISCOURAGED PERMANENTLY UNLESS A VERY SECURE DEFINITIVE PREVENTION STRATEGY HAS BEEN PERFORMED EXAMPLE: SURGICAL PLEURECTOMY
- 56. Secondary Spontaneous Pneumothorax: • SSP occuras a complication of Underlying lung disease • M/C: COPD and tuberculosis • More serious d/t underlying already compromised lung function • High recurrence rate (40- 80%)
- 57. C/F and P/E: •1) Dyspnea frequently out of proportion to size of pneumothorax • 2) Chest pain • 3) Physical Examination is less helpful: Already have hyperinflated lungs Decreased vocal fremitus Hyper-resonant percussion notes and Distant breath sounds over both lung fields • 4) So threshold should be lower in a patient of COPD presenting with SOB especially associated with chest pain
- 58. Management: • Aspiration –not recommended • Nearly every patient – hospitalized for at least 24 hours – tube thoracostomy • Tube thoracostomy – less efficacious Mean time for lung to expand is – 5 days In 20% - lung remains unexpanded • Prevention of recurrence is most important • If lung does not expand after 72 hours or there is PAL > 3 days option: VATS > medical thoracoscopy
- 59. Accepted indications forsurgical advice:
- 60. Unfit or RefusesFurther Invasive Procedures: • Medical Pleurodesis
- 62. Indications of Pleurodesisin Pneumothorax: • 1) PSP with any one of the following: second episode of PSP PAL: > 3-5 days Haemopneumothorax B/L pneumothorax Professions at risk : aircraft personnel, divers • 2) SSP
- 65. Agents for Pleurodesis: Chemicalagents: • Talc • Iodopovidone • Antimicrobials: Tetracyclines (tetracycline, minocycline, doxycycline) • Cytotoxic agents: (bleomycin, mitoxantrone, mitomycin, carboplatin) • Bevacizumab • Silver nitrate • Sodium hydroxide • 50% glucose
- 71. Pneumothorax secondary to AIDS: Ominous prognostically Highmortality Very likely to have a recurrent pneumothorax or C/L pneumothorax • Etiologies: • 1) PCP – m/c (CD4+ < 200) • 2) H/O receiving nebulized pentamidine prophylaxis • 3) Bacterial pneumonia • 4) Pulmonary Tuberculosis • 5) Pulmonary cryptococcosis • Management: • Difficult to treat: Necrotizing inflammation • Early ICTD and surgical referral • Appropriate treatment for PCP and HIV • Definitive Treatment - VATS
- 72. Pneumothorax in CysticFibrosis: • High prevalence and mortality with advanced stage of disease • Chronic airway inflammation Important risk factors: • 1) FEV1 < 30% of predicted (risk increases by 50%) • 2) Presence of Pseudomonas aeruginosa, Burkholderia cepacian or Aspergillus in the airways • 3) Use of Dornase alfa (Bronchospasm – acute decline in FEV1)
- 73. Management: • 1) Chesttube alone has a recurrence of about – 37% - 50% • 2) Recurrent pneumothorax + fit for surgery - TOC is partial pleurectomy • 3) Unfit for surgery: Pleurodesis Pleural procedures including pleurodesis do not have significant adverse effect on outcome of subsequent transplantation
- 74. Tension Pneumothorax: Emergency •Intrapleural pressure > atmospheric pressure in E + I • Sudden deterioration: reduced CO with hypoxemia PPV YES Alveolar rupture NO One way valve process
- 75. • Barotrauma: • 1)PEEP > 10 cm of H2O • 2) Mean airway pressure > 30 • 3) Peak inspiratory pressure > 50 • 4) PEEP especially when combined with VCV • 5) Plateau pressure > 35 • 6) Lung compliance < 30mL/cm H2O NOTE: monitor plateau pressure in VCV Decreasing tidal volume if on pressure support
- 76. Clinical Manifestations: Clinical diagnosis Patient appears distressedwith rapid labored breathing Diaphoresis Cyanosis Marked tachycardia Hypotension O/E: Distended neck veins, hypoxemia, hypotension, tracheal deviation to opposite side of pneumothorax, unilateral chest hyperinflation and subcutaneous emphysema
- 77. Diagnosis: ABG- hypoxemia,respiratory acidosis CXR 1) Mediastinal shift to the opposite side 2) Diaphragmatic depression 3) Rib cage expansion 4) Subcutaneous emphysema USG • NOTE: Degree of lung collapse is an unreliable sign for or against the presence of a tension pneumothorax
- 78. Tension pneumothoraxmay also develop because of • Improper connection of one-way valve to chest tube • Malposition of the chest tube
- 79. Management: Tension pneumothorax Hypoxia High concentration of O2 Needleaspiration Definitive Tube thoracostomy (silicon catheter)
- 80. Iatrogenic Pneumothorax: • Incidence ishigh and likely to increase • Particularly high in ICU • Particularly with ARDS • Substantial morbidity • At present, m/c/c is transthoracic needle aspiration CVC (IJV > subclavian line) and thoracentesis follow
- 81. Two primary factors relatedare 1.Depth of the lesion Lesions in the LL Greater lesion depth Lesion size < 2cm Needle trajectory < 45 degree 2.Severity of the underlying lung With emphysema, 3 times increased risk of having chest tube drainage
- 82. Preventive Measures? • 1) Lungbiopsy tract plug • 2) Use of fibrin glue as a sealant • 3) 2-4ml of normal saline into the whole puncture access during extraction of trocar needle • 4) Use of USG guidance for CVC and thoracentesis • 5) Using newer ventilatory modes which ventilate with lower peak inspiratory pressures and lower mean airway pressures The presence of mediastinal emphysema may precede development of pneumothorax
- 84. Treatment: How does it Differ? •Asymptomatic to varying degree of symptoms • No/mild symptoms + < 40% of hemithorax – observation + O2 • More symptomatic or > 40% or enlarging size – evacuate the air • In general, most patients should be treated with aspiration • Only if lung doesn’t expand – Chest tube • Recurrence is not likely – need not try to create pleurodesis • when pneumothorax occurs in PPV – immediate chest tube prevents tension • Chest tube at least for 48 hours after air-leak stops if patient continues to receive mechanical ventilation
- 85. Catamenial Pneumothorax: • Usuallyin third or fourth decade of life • Recurrent pneumothorax that occurs within 72 hours of onset of menses • Classically develop chest pain, dyspnea and sometimes hemoptysis • Usually right sided (90%) • Association – Pelvic endometriosis • High recurrence rate (In fact HIGHEST) – 50-100% • Diagnosis – not difficult if possibility is considered
- 86. • Thoracic Endometrial Syndrome Catamenialpneumothorax Catamenial haemothorax Catamenial haemoptysis Lung nodules (purple/brown)
- 87. • Pathogenesis: Air gainedaccess to peritoneal cavity during menstruation, entered pleural cavity through diaphragmatic defects Leakage of air from lung owing to subpleural endometrial implants
- 88. MANAGEMENT: Management Thoracic surgical techniques Diaphragmatic resection orplication of fenestrations Mesh/Patch over fenestrations Electrocoagulation of endometrial deposits and pleurodesis Hormonal therapy GnRH analogues Danazol Surgical menopause
- 89. Take Home Message: •The role of observation in large but mildly symptomatic PSP is gaining momentum and yet to be incorporated into new guidelines • Patients in profession with high risk of recurrence of PSP should undergo definitive therapy at first presentation • Heimlich flutter valve can be used to mobilize patient with prolonged chest tube drainage • With SSP, chemical pleurodesis is indicated only if patient is unfit for operative interventions or is reluctant • Tension pneumothorax is a medical emergency • Catamenial pneumothorax should be suspected in any young female with recurrent pneumothoraces • Imaging modalities include CXR/USG and CT
- 90.