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Estimation of pneumothorax volume
Light equation
pneumothorax％＝（1－
L3/HT3） 100
Kircher equation
pneumothorax％
Thorax area－lung area
Thorax area
Collins equation
4.2+[4.7(A+B+C)]
100
Hemithorax (HT)
Lung (L)](https://image.slidesharecdn.com/pneumothorax-ramdhancomlete-170629184045/75/Pneumothorax-26-2048.jpg)
Uploaded byPDT DM CARDIOLOGY
Pneumothorax
The document discusses pneumothorax, including its definition, pathophysiology, etiology, clinical manifestations, investigations, and management. Pneumothorax is defined as the presence of air in the pleural space. It can occur spontaneously due to ruptured blebs or bullae, or due to trauma. Clinical manifestations include dyspnea, chest pain, and decreased breath sounds on examination. Chest x-ray and CT scan are used to diagnose and characterize pneumothorax. Management involves oxygen therapy, needle aspiration, chest tube drainage, and chemical pleurodesis to promote lung re-expansion and prevent recurrence.
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Introduction to pneumothorax, defined as air in pleural space, presented by Dr. Ramdhan Kumar Kamat.
Covers causes like rupture of blebs, smoking risk rates, effects of pressure changes in pleural space.
Types of pneumothorax: spontaneous (primary, secondary) and traumatic (iatrogenic, non-iatrogenic) causes.
Symptoms of pneumothorax include dyspnea, chest pain, and signs of tension pneumothorax.
Examination details based on pneumothorax size, observed changes in vital signs and trachea position.
Utilization of radiology to assess pneumothorax size and characteristics, including various estimation methods.
Ultrasound's sensitivity in pneumothorax diagnosis and CT scan usefulness in complex cases.
Management goals including lung expansion, treatment options based on classification.
Oxygen therapy parameters and detailed approach to simple aspiration for pneumothorax.
Indications for tube drainage, procedure details and management of tube complications.
Purpose and methods for pleurodesis using sclerosing agents to prevent recurrence of pneumothorax.
Discusses pneumothorax complications, including recurrence rates and critical conditions.
Final thoughts on pneumothorax management with a thank you note.
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Pneumothorax
- 1. Pneumothorax DR RAMDHAN KUMARKAMAT PG JLNMCH, BHAGALPUR 1
- 2. 2 WHAT IS PNEUMOTHORAX •Pneumothoraxis defined as presence of air in the pleural space.
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- 4. Pathophysiology • Blebs andbullae are also known as emphysema-like changes (ELCs) • The probable cause of pneumothorax is rupture of an apical bleb or bulla • Because the compliance of blebs or bullae in the apices is lower compared with that of similar lesions situated in the lower parts of the lungs 4
- 5. Pathophysiology • It isoften hard to assess whether bullae are the site of leakage, and where the site of rupture of the visceral pleura is • Smoking causes a 9-fold increase in the relative risk of a pneumothorax in females • A 22-fold increase in male smokers • With a dose-response relationship between the number of cigarettes smoked per day and occurrence of PSP 5
- 6. Mechanism • In normalpeople, the pressure in pleural space is negative during the entire respiratory cycle. • Two opposite forces result in negative pressure in pleural space(outward pull of the chest wall and elastic recoil of the lung) • The negative pressure will be disappeared if any communication develops . 6
- 7. • When acommunication develops between an alveolus or other intrapulmonary air space and pleural space, air will flow into the pleural space until there is no longer a pressure difference or the communication is sealed 7
- 8. Pathophysiology Negative pressure eliminated Thelung recoil-& lung-volume decrease V/Q low –anatomic shunt hypoxia Positive pressure o Compress blood vessels and heart o Decreased cardiac output o Impaired venous return o Hypotension Result in o A decrease in vital capacity o A decrease in PaO2 8
- 9. Etiology Pneumothorax Spontaneous Primary Secondary Traumatic Iatrogenic Interventional procedures. Positive pressure ventilation Noniatrogenic Penetrating trauma Blunt trauma.
- 10. Primary spontaneous pneumothorax •It occurs in young healthy individuals without underlying lung disease. • It is due to rupture of apical sub-pleural bleb or bullae Predisposing factors: Smoking. Tall, thin male. Airway inflammation (distal) Structural abnormalities of bronchial tree Genetic contribution 10
- 11. Secondary spontaneous pneumothorax Mostcommon cause. TB Asthma COPD Suppurative pneumonia Cystic fibrosis Rare cause ILD Eosinophilic granuloma Sarcoidosis Lymphangioleiomyomatosis AIDS. 11 Primary lung carcinoma Complication of chemotherapy Connective tissue disease Scleroderma Marfans syndrome Histiocytosis- x Rheumatoid disease Pulmonary infarct Wegener’s granulomatosis…
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- 14. Clinical manifestation Dyspnea Chest pain( pleuritic) Uncommon manifestation Cough Hemoptysis Orthopnea Cyanosis Mod tachycardia 14
- 15. Traumatic pneumothorax Accidental trauma:(non-iatrogenic) Blunttrauma: with fracture ribs. Penetrating trauma: stab wound or gun shot injury. Iatrogenic : Positive pressure ventilation: Alveolar rupture interstitial emphysema pneumothorax.(B/L PNX) Interventional procedures: Biopsy, thoraco-centesis, CVP line,trachestomy etc.. 15
- 16. 16 Clinical type ofPNX Pneumothorax Closed pneumothorax Open pneumothorax Tension pneumothorax
- 17. 17 Closed pneumothorax Open pneumothorax Tension pneumothorax The pleural tear Issealed The pleural tear is open The pleural tear act as a ball & valve mechanism The pleural cavity pressure is < the atmospheric pressure The pleural cavity pressure is = the atmospheric pressure The pleural cavity pressure is > the atmospheric pressure
- 18. Clinical manifestation • Tensionpneumothorax o RAPIDLY PROGRESSIVE DYSPNIA. o Cyanosis o Marked tachycardia o Hypotension • Patient who suddenly deteriorate clinically, be suspected in the patient with o Mechanical ventilation (b/l PNX) o Cardiopulmonary resuscitation 18
- 19. Physical examination o Dependon size of pneumothorax o The vital signs usually normal o Unilateral Chest movements o The trachea may be shifted toward the contralateral side if the pneumothorax is large o Tactile fremitus is absent o The percussion note is hyperresonant o The breath sounds are reduced or absent on the affected side o The lower edge of the liver may be shifted inferiorly with a right-side pneumothorax 19
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- 22. Pneumothorax in erect position Pneumothorax insupine position Air in apicolateral pleural space Air in anteromedial pleural space.
- 23. Pneumothorax Erect Small pneumothorax Apical lucency Visceral pleural line Large pneumothorax Apicallucency (>2cm in width) Visceral pleural line Tension pneumothorax Lung collapse Mediastinal shift Low flat diaphragm Supine Deep Costophrenic sulcus Lucent Cardiophrenic sulcus Sharp Mediastinal contour Double diaphragm
- 24. Quantification of thesize T h e s i m p l e m e t h o d t o e s t i m a t e t h e s i z e S 2424
- 25. Quantification of thesize The simple method to estimate the size Small, a visible rim of < 2 cm between the lung margin and the chest wall Large, a visible rim of ≥2 cm between the lung margin and chest wall Light index Measure transverse Diameters of lung and Compare it with diameter hemithorax 2525 Hemithorax (HT) Lung (L)
- 26. 26 Estimation of pneumothoraxvolume Light equation pneumothorax％＝（1－ L3/HT3） 100 Kircher equation pneumothorax％ Thorax area－lung area Thorax area Collins equation 4.2+[4.7(A+B+C)] 100 Hemithorax (HT) Lung (L)
- 27. 27 A pneumothoraxof 2 cm on the PA chest radiograph occupies about 49% of the hemithorax volume Lung is 8 cm, hemithorax is 10 cm in diameter Equation Volume of pneumothorax = (HT3 – L3) ÷ HT3 = (103 – 83) ÷ 103 = (1000 – 512) ÷1000 = 0.49 Plane chest X-ray film
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- 33. DD of visceralpleural line Skin fold: • Positive mash band (optical edge enhancement). • Extend beyond the chest wall. • Lung markings extend beyond it.
- 34. DD of visceralpleural line Scapular edge
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- 42. Double diaphragm sign subpulmonicpneumothorax 43
- 43. CT scanning Itis recommended in difficult cases such as patients in whom the lungs are obscured by overlying surgical emphysema To differentiate a pneumothorax from suspected bulla in complex cystic lung disease 44
- 44. CT can diagnoseeasily pneumothroax
- 45. CT can diagnoseeasily pneumothroax
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- 48. U/S in pneumothorax •Ultrasound found to be more sensitive than CXR in diagnosis of pneumothorax.
- 49. U/S signs of pneumothorax •Loss of lung sliding. • Loss of comet tails. • loss of seashore sign (M mode). • Stratosphere sign or bar code sign(M mode).
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- 55. Stratosphere or barcode sign
- 57. MANAGMENT Goals o Topromote lung expansion o To eliminate the pathogenesis/cause o To decrease pneumothorax recurrence Treatment options according to o Classification of pneumothorax o Pathogenesis o The extension of lung collapse o Severity of disease o Complication and concomitant underlying diseases 61
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- 59. O2 TREATMENT-- PSPor SSP 68 Inhalation of high concentration of {10 l/m} oxygen may reduce the total pressure of gases in pleural capillaries by reducing the partial pressure of nitrogen This should increase the pressure gradient between the pleural capillaries and the pleural cavity Thereby increasing absorption of air from the pleural cavity
- 60. 69 The rateof resolution/reabsorption of spontaneous pneumothorax is 1.25 – 1.8% of volume of hemithorax every 24 hours (ABOUT 50 DAYS TO TAKE if 40% pnx) The addition of high flow oxygen therapy has been shown to result in a 4- fold increase in the rate of pneumothorax reabsorption during the periods of oxygen supplementation
- 61. 70 Simple aspiration Simpleaspiration is recommended as first line treatment for all PSP requiring intervention Simple aspiration is less likely to succeed in secondary pneumothoraces and in this situation, is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients under the age of 50 years Patients should be admitted to hospital and observed for at least 24 hours before discharge.
- 62. 71 Repeated aspirationis reasonable for primary pneumothorax when the first aspiration has been unsuccessful A volume of < 2.5 L has been aspirated on the first attempt The aspiration can be done by needle or catheter Catheter aspiration
- 63. Intercostal tube drainage •INDICATIONS o Tension pneumothorax o Severe dyspnea o Large/complete pneumothorax o Intermittent positive pressure ventilation pneumothorax o Recurrent pneumothorax o Bilateral pneumothorax o Presence of pleural fluid o Simple aspiration or catheter aspiration drainage is unsuccessful in controlling symptoms 72
- 64. 7373 A commonsite of chest tube insertion is in the 2nd ICS in mid-clavicular line. An alternative site now commonly used is midaxillary line of 4th and 5th intercostal space for cosmetic reason and also for when pleural effusion. Intercostal tube drainage
- 65. Trocar tube thoracostomy 74 Insertion of trocar into the pleural space.
- 66. Trocar tube thoracostomy 75 Insertion of the chest tube through the trocar
- 67. Observation of drainage 77 No bubble released ◦ The lung re-expansion ◦ The chest tube is obstructed by secretion or blood clot ◦ The chest tube shift to chest wall, the hole of the chest tube is located in the chest wall If the lung re expanded, removing the chest tube 24 hours after re expansion. Otherwise, the chest tube will be inserted again or regulated the position.
- 68. Complications of intercostaltube drainage 78 Penetration of major organs ◦ Lung, stomach, spleen, liver, heart and great vessels ◦ It occurs more commonly when a sharp metal trocar is inappropriately applied Pleural infection ◦ Empyema, the rate of 1% Surgical emphysema ◦ Subcutaneous emphysema
- 69. Chemical pleurodesis 79 Goals ◦To prevent pneumothorax recurrence ◦ To produce inflammation of pleura and adhesions Indications ◦ Persist air leak and repeated pneumothorax ◦ Bilateral pneumothorax ◦ Complicated with bullae ◦ Lung dysfunction, not tolerate to operation
- 70. Chemical pleurodesis 80 Sclerosingagents ◦ Tetracycline ◦ Doxycycline ◦ Talc ◦ Erythromycin ◦ 10% povidine iodine The instillation of sclerosing agents into the pleural space lead to an aseptic inflammation with dense adhesions.
- 71. Chemical pleurodesis 81 Methods ◦Via chest tube or by surgical mean ◦ Administration of intrapleural local anaesthesia, 200 – 300 mg lidocaine intrapleurally injection ◦ Agents diluted by 60 – 100 ml saline ◦ Injected to pleural space ◦ Clamp the tube 4hours ◦ Drainage again ◦ Observed by chest X-ray film, if air of pleural space is absorbed, remove the chest tube ◦ If pneumothorax still exist, repeated pleurodesis.
- 72. Chemical pleurodesis 82 82 Sideeffect ◦ Chest pain ◦ Fever ◦ Dyspnea ◦ Acute respiratory distress syndrome ◦ Acute respiratory failure
- 73. Surgical treatment 83 Indications ◦No response to medical treatment ◦ Persistant air leak ◦ Hemopneumothorax ◦ Bilateral pneumothoraces ◦ Recurrent pneumothorax ◦ Tension pneumothorax failed to drainage ◦ Thickened pleura making lung unable to reexpand ◦ Multiple blebs or bullae
- 74. Complications of pneumothorax Recurrenceof spontaneous pneumothorax Tension pneumothorax Hydropneumothorax Encysted pneumothorax Failure of expansion of the collapsed lung Re-expansion pulmonary edema Broncho-pleural fistula Pneumomediastinum
- 75. Recurrence of spontaneous pneumothorax •50% on the same side. • 15% on the contralateral side. More common in • secondary spontaneous pneumothorax.
- 76. Tension pneumothorax • Itis life threatening condition. • The pleural pressure is more than the atmospheric pressure. Radiological manifestations of large pneumothorax • Mediastinal shift, • Flattening of the hemidiaphragm & • Lung collapse. Associated with clinical manifestations of rapidly progressive breathlessness and circulatory collapse (tachycardia, hypotension & sweating). It is more common with • Positive pressure ventilation & • Traumatic pneumothorax.
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- 78. Hydropneumothorax • Due torupture of pleural adhesions. • Bronchopleural fistula.
- 79. Encysted pneumothorax • Dueto pleural adhesions.
- 80. Failure of re-expansionof the collapsed lung • Due to pleural adhesions. • Or tracheobronchial injury.
- 81. 93 Mediastinal andsubcutaneous emphysema ◦ Alveoli rupture, the air enter into pulmonary interstitial, and then goes into mediastinal and subcutaneous tissues. ◦ After aspiration or intercostal chest tube insertion, the air enters the subcutaneous by the needle hole or incision – surgical emphysema ◦ Physical exam – crepitus is present. Subcutaneous emphysema
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