Cardiothoracic Surgery

Pneumothorax

CLASSIFICATION

• Primary spontaneous• Secondary spontaneous• Traumatic• Tension• Definition- injury to the lung resulting in

release of air into the intrapleural space(between the parietal and visceral pleura)

Primary spontaneous

• Tall thin people• Age; 20-30 years old• Smokers- occurrence increases directly with

the number of cigarettes smoked per day• Familial• Presentation

– Sudden onset SOB– Associated with chest pain

Secondary spontaneous

• Underlying pulmonary pathology• Most commonly seen in COPD patients• Other causes include

– Sarcoidosis– Tuberculosis– Cystic fibrosis– Malignancy– Idiopathic pulmonary fibrosis

Traumatic pneumothorax

• Penetrating versus blunt chest trauma

Tension pneumothorax

• Surgical emergency• Definition-a build up of positive pressure

within the hemithorax-mediastinal shift.• One way valve mechanism- air enters

alveoli but can’t escape as the lung tissue collapses around the hole in the pleura.

Examination

Decreased or absent breath sounds on affected sideHyperresonanceDecreased tactile fremitusHypotensionTachycardia>130TachypnoeaCyanosisDistended jugular venous pulsationTracheal deviation to contralateral side

Mediastinal shift

• Pressure on unaffected lung interferes with gas exchange leading to hypoxaemia

• Pressure on the heart reduces venous return to the heart reducing cardiac output.

• Leads to cardiorespiratory failure

Investigations

• Chest X ray- should never be performed when suspecting tension pneumothorax

• ABG-hypoxaemia

• Imaging to distinguish Bullae at apex from pnemothotax- in emergency setting U/S or CT if not an emergency

Management of spontaneous pneumothorax

• Observation with follow up X-ray

• Tube thoracostomy

Management of tension pneumothorax

• Immediately insert a large bore cannula into 2nd intercostal space in midclavicular line

• Hissing sound will be heard

• Follow by inserting a chest drain

Insertion of chest drain

• NB remember surgical principles ie aseptic technique– Paint with Bethadine– Drape the surrounding area– Triangle of safety is

• 1) anterior to the midaxillary line• 2) above the level of the nipple• 3)below and lateral to the pec major

– 5th intercostal space in midaxillary line

Insertion of chest drain

• Sharp dissection of skin• Blunt dissection through the remaining

tissue as far as the parietal pleura• The tract should be just above the lower

rib to avoid the neurovascular bundle aiming toward the apex.

• Insert finger into cavity and use this to guide the trocar

Insertion of chest drain

• Remove the trocar and the tube is carefully and securely positioned using a purse string suture.

• Tube is then connected to an underwater seal and bubbling of the water is observed.

• Request a chest x ray to determine correct positioning of the tube and reinflation of the lung

Definitive surgical management

• Indications– Recurrent pneumothorax for any reason– Patients with– high risk occupations eg pilots, divers.

Definitive surgical management

• Surgical options– Pleurodesis- tube thoracostomy with

preferred agent being talc – Thorocotomy with pleurectomy– VATS- video assisted thorascopic surgical

biopsy with talc insufflation

Classification

• Primary spontaneous

• Secondary spontaneous

• Traumatic

• Tension