The Chest:

Pneumothorax, Hemothorax, Effusions, & Empyema

Bradley J. Phillips, M.D.Burn-Trauma-ICU

Adults & Pediatrics

Pneumothorax

definition, classification,

& management

Pneumothorax (1)

collection of air within the pleural space

• transforms the potential space into a real one

• may lead to various degrees of respiratory compromise

• with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario

• impairs respiratory function

• decreases venous return to the right-side of the heart

Pneumothorax (2)

• General Management

– First: evacuate the air

– Second: address the underlying source

– Third: promote pleural symphysis

Pneumothorax (3)

Classification System

• Spontaneous Pneumothorax– Primary

– Secondary

• Traumatic Pneumothorax– Pulmonary source

– Tracheobronchial source

– Esophageal source

Pneumothorax (4)

• Primary Spontaneous Ptx

– a disease of younger individuals (15 - 35 yrs of age)

– males > females – tall, slim body habitus

– cigarette smoking implicated

– usual cause: parenchymal blebs

• apex of the upper lobe

• superior segment of the lower lobe

Pneumothorax (5)

• Primary Spontaneous Ptx:

“in most instances, the treatment

of a first-occurrence consists of hospitalization,

tube-thoracostomy to closed drainage,

lung-re-expansion against the chest wall,

and

control of any persistent air-leak” [Graeber ‘98]

Pneumothorax (6)

when do you

operate on

a primary spontaneous

pneumothorax ?

Pneumothorax (7)

• Secondary Ptx: due to underlying pulmonary disease

– COPD / Asthma / Cystic Fibrosis

– Immunocompromised Infections• Tb & Cocci• PCP (becoming more common)

– Treatment: Closed Thoracostomy• Water-seal

• Heimlich-Flutter Valve

• V.A.T.S.

Pneumothorax (8)

Traumatic Ptx

• Parenchymal Injury vs. Tracheobronchial vs. Esophageal– Blunt or Penetrating

– Iatrogenic

• central lines / thoracentesis / biopsy

• endotracheal tube placement (esp. dual-lumen tubes !)

• endoscopy / dilational techniques

– Barotrauma

• Ventilation / blast injury / Boerhave’s syndrome

– Operative

Pneumothorax (9)

• The Tension Ptx– “path of least resistance”– life-threatening emergency…how do you treat a tension ptx ??

• The Open Ptx: sucking-chest wound– intrinsic lung compliance creates complete collapse

– 3-sided dressing

– thoracostomy away from the traumatic wound

Pneumothorax (10)

• Treatment Options– Observation: Inpatient vs. Outpatient– Thoracostomy Drainage

• 3rd Interspace / 5th Interspace

• Negative Suction / Water-seal

– V.A.T.S. (becoming the “standard”)

– Muscle-sparing Thoracotomy– Posterolateral & Anterolateral Thoracotomy

Pneumothorax (11)

Questions ?

Pneumothorax (12)

Questions…well, I have some -

1. What is the best diagnostic study ?2. What is the role of “100 % Oxygen” & “Conservative-mgmt” ?3. How would YOU treat a small Ptx (1 cm) in acute trauma ?4. What is the predicted recurrence rate for a spontaneous Ptx ?5. What is a “deep sulcus sign” ?

Pleural Effusions

what are they ?

where do they come from ?

& how do you treat them ?

Definition

the accumulation of excess fluid within the

pleural space in response to injury,

inflammation, or both

may represent a local response to disease

or may just be a manifestation of a systemic illness

Pathogenesis of Effusions

Rate of Fluid Rate of Fluid

Accumulation Removal

1. Altered Pleural Membrane Permeability

2. Decreased Intravascular Oncotic Pressure

3. Increased Capillary Hydrostatic Pressure

4. Lymphatic Obstruction

5. Abnormal Sites of Entry

Clinical Manifestations

• Pain

• Cough

• Dyspnea

• Dullness to Percussion

• Diminished or Absent Vocal Resonance

• Diminished or Absent Tactile Vocal Fremitus

• Friction Rub

Clinical: A Few Points

Large Effusions that prevent contact between the

Visceral & Parietal Pleura during respiration are seldom

associated with pleuritic chest pain.

• Tumors involving the parietal pleura generally produce constant dull pain (Remember Ben Daly, M.D.)

• Large effusions interfere with expansion of the lung and produce dyspnea, shortness of breath, and atelectasis

Radiologic Assessment (1)

• Chest X-Ray: PA & Lateral-Decub blunting of either costophrenic angle is indicative of the

accumulation of between 250 - 500 ml of fluid

• Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening & fibrosis

• Sub-Pulmonic Effusion: accumulation of fluid between the lung & the diaphragm which gives the false impression of an elevated hemi-diaphragm

Radiologic Assessment (2)

• Ultrasound: Helpful in Confirming the Presence of a

Small Pleural Effusion & Identifying Loculations

• C.T. : Extremely Sensitive !!• also helps to view the underlying lung (which may be

obscured by pleural disease)

• can distinguish between Lung Abscess & Empyema

Pleural Fluid Analysis

Thoracentesis = Pneumothorax

Pleural Fluid Analysis

Thoracentesis: Transudate vs. Exudate

1. Gross Appearance

2. Cell Count & Differential

3. Gm Stain, C & S

4. Cytology

5. LDH

6. Protein

7. Glucose, Amylase

Transudate

straw-colored, clear, odorless fluid with a

WBC less than 1000 / ul

• Pleural Membranes are Intact • Secondary to Altered Starling Forces• Low in Protein & other Large Molecules

CHF, Cirrhosis, Nephrotic Syndrome

Hypoalbuminemia, Constrictive Pericarditis, SVC Obstruction, PE

Exudate

• Characterized by Increased Protein & LDH[Pleural Fluid vs. Serum Levels]

• Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic Drainage

Parapneumonic, Infections, Malignancy,

Vasculitic Disease, GI Disease, TB, PE

Criteria for “Exudative Effusion”

criteria value

1. Pleural Protein : Serum Protein > 0.5

2. Pleural LDH : Serum LDH > 0.6

3. Pleural LDH > 200

only need 1 critical value to establish the diagnosis of exudate

a bloody pleural effusionoccurring in a patient without a history of trauma or

pulmonary infarctionis

Indicative of Neoplasm in 90 % of cases!

Because a RBC count as low as 5000 - 10,000 /ul, can cause a pleural effusion

to turn red, the finding of blood-tinged fluid per se has little diagnostic

value (usually from needle trauma)

A True Hemothorax is when the Pleural Fluid Hct exceeds 50 %

of the Peripheral Blood Hct !

Treatment

• Transudative Effusion: focus on the systemic cause

• Exudative Effusion: dependent on the exact sub-type

• Consider Chest Thoracostomy • Gross Pus / Empyema

• pH < 7.2

• Hemothorax

• Complicated Parapneumonic Processes

• Malignant Effusions…but remember the role of pleurodesis!

although pleural diseaseitself is rarely fatal, it may be a

significant cause of patient morbidity

appropriate treatment may produce

dramatic symptomatic relief !

Pleural Effusions

Questions ?

Hemothorax“ the collection of blood between the

visceral and parietal pleura…”

Hemothorax (1)

• Causes of a Spontaneous Hemothorax

– Pulmonary: bullous emphysema, PE, infarction, Tb, AVM’s

– Pleural: torn adhesions, endometriosis

– Neoplastic: primary, metastatic (melanoma)

– Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation

– Thoracic Pathology: ruptured aorta, dissection

– Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum

Hemothorax (2)

The Pathophysiologic Process

• the accumulation of pleural blood forms a stable clot

• overall ventilation & oxygenation becomes impaired

• mechanical compression of the lung parenchyma

• mediastinal shift

• flattening of the hemidiaphragm

Hemothorax (3)

The Pathophysiologic Process

• over time, the clot is partially-absorbed, leaving behind loculated fluid and fibrinous septations

• macro-fibrin deposition begins to provide a structural framework

• this “peel” slowly contracts to entrap the underlying lung

Hemothorax (5)

Goal of Treatment

to remove the pleural blood

and allow for

complete lung re-expansion

Hemothorax (4)

• General Management Options

– thoracentesis: bedside / ultrasound-guided / C.T.-guided

– thoracostomy drainage: the mainstay

– thorascopic surgery: less than 2 wks. & use a 30-degree scope

– thoracotomy: massive hemothorax / instability / chronic hemothorax

– local fibrinolytic therapy: urokinase (1000 IU/ml) in 150cc solution

Hemothorax (6)

• Often, there is an accompanying pneumothorax– Dual Chest Tube Management

• Superior-Apical: Ptx• Diaphragmatic-posterior: Htx• Consider targeted-drainage into a loculated collection

– All tubes to negative suction with protective water-seal– Prophylactic antibiotics may be indicated while the tubes

are in (controversial!!)

– Chest tubes removed: 100 -150 cc’s / day

Hemothorax (6)

Undrained hemothorax increases the risk

of empyema & fibrothorax

• Large collections should be drained slowly to minimize the development of re-expansion-pulmonary-edema[“R.E.E.P.”] (stop after 2 liters…wait 6-8 hrs, then drain out another 1-2 liters, etc)

• Computed tomography is the diagnostic of choice

Hemothorax

Questions ?

Hemothorax

Questions…well, I have some –

1. When do YOU operate on a “Traumatic Hemothorax” ?2. What options exist in trying to drain a hemothorax (chest tube

placement) ?3. What are the reported complications of chest tube placement ?

What is an Empyema ?

Empyema ThoracisAn Accumulation of Pus in the Pleural Cavity

• 1-2 % incidence in the pediatric population

• Up to 18 % in immunocompromised adults

• General Management– Appropriate Antibiotic Coverage

– Thoracostomy Drainage

– Streptokinase / Urokinase

– Surgical Intervention - Decortication

The Stages of Empyema

• Stage I - “Exudative” • sterile pleural fluid develops secondary to inflammation without

fusion of the pleura

• Stage II - “Fibrinopurulent”• a fibrinous peel develops on both pleural surfaces limiting lung

expansion

• Stage III - “Organizing”• in-growth of capillaries & fibroblasts into the fibrinous peel

Empyema: A Pediatric Review

# of Cases# of Positive Cultures

Staph aureusStrep pneumo

0

500# ofCases

# ofPositiveCultures

Staphaureus

Streppneumo

Empyema...

Questions ?

“don’t let it happen !!!”

The Chest:

Pneumothorax, Hemothorax, Effusions, & Empyema

Any Questions…?