Pneumothorax- CME –

Mohamed Siruhan

Supervisor: Dr. Ian

Outline

• Classification of pneumothorax

• Epidemiology

• Pathophysiology and etiology

• Clinical features

• Radiological features

• Management of spontaneous pneumothorax – case based

• Recommendations on air travel and diving.

• Practice questions

Etiological Classification of pneumothorax

• Spontaneous• Primary: Pneumothorax occurring in persons without clinically apparent lung disease

• Secondary: Pneumothorax occurring in the setting of underlying pulmonary disease

• Traumatic• Penetrating chest injury

• Blunt chest injury

• Iatrogenic Pneumothorax• Transthoracic needle aspiration

• Placement of catheter in subclavian or jugular vein

• Thoracentesis and pleural biopsy

• Mechanical ventilation

Etiology - Secondary spontaneous pneumothorax• Airway disease

• COPD

• Cystic fibrosis

• Asthma

• Infectious lung diseases• Tuberculosis

• Pneumocystis pneumonia

• Necrotizing pneumonia

(anaerobic, Gram negative, staphylococcus)

• Interstitial Lung Disease• Sarcoidosis• Idiopathic Pulmonary fibrosis• Langerhans’ cell granulomatosis• Lymphangioleiomyomatosis• Tuberous sclerosis

• Connective Tissue disease• Rhumatoid arthritis• Ankylosing spondylitis• Polymyosistis and dermatomyositis• Scleroderma• Marfan’s syndrome• Ehlers–Danlos syndrome

• Cancer• Sarcoma

• Lung cancer

• Catamenial pneumothorax – Pneumothorax related to mensturation• Postulated to occur in the setting of endometriosis affecting the lung.

Epidemiology of pneumothorax

Incidence(/100000) Male female

Age group predisposition Recurrence Symptoms

Primary spontaneous 18-28 1.2 – 6 Age 10 -30 yearsRare in >40 years

ThinTallSmoking (up to 20x)

16 – 52% Symptomsless

Secondary spontaneous 6.3 2 60 – 65 years COPD (26/100000)HIV ( PCP)

39 – 47% Most often symptomatic

Catamenial 30 – 40 yrs H/O endometriosis 50% with Hormone therapy

Within 72 hours of onset of menses

Pathophysiology of primary spontaneous pneumothorax (PSP)• Subpleural bullae/blebs/porosities

• 76 -100% on VATS (Video assisted thoracoscopic surgery )1

• All most all the patients undergoing thoracotomy 1

• 79- 96% of patients on contralateral lung, those who were managed by sternotomy.1

• 89% ipsilateral bullae and blebs on CT ( compared to 20% age and smoking matched controls)1

• Subpleural bullae formation remains speculative• Smoking related influx of neutrophils and macrophages• Degredation of elastic fibers• Imbalance in the protease-antiprotease and oxidant-antioxidant systems.1

1. Spontaneous pneumothorax. Sahn SA, Heffner JE N Engl J Med. 2000;342(12):868

Pathophysiology…(PSP)

• Inflammation induced obstruction of the small airways increases alveolar pressure, causes air leak in to interstitium

• Air moves to hilum, causing pneumomediastium.

• As pneumomediastinum causes rise in pressure and rupture of mediastinal parietal pleura, causing pneumothorax.

Pathophysiology…..(PSP)

Reduced FVCIncrease alveolar-

arterial Oxygen gradient

Low ventilation-perfusion ration

(V/Q) and Shunting

Hypoxemia

( Hypercapnia occurs in secondary spontan.

pneumothorax)

Pathophysiology in secondary spontaneous pneumothorax

Alveolar pressure > interstitium pressure (

Alveolar rupture)

Air in the interstitiumtraverses to hilum

and cause pneumomediastinum

Rupture of mediastinal parietal

pleura and pneumothorax

develops

Air from ruptured alveoli

Crosses to pleural cavity via necrosed

lung (eg. PCP)

Pneumothorax

Thoracoscopic images

Subpleural blebs

Air filled spaces between the lung parenchyma and the visceral pleura

Subpleural bullae

Air filled spaces within the lung parenchyma itself

Thoracoscopic images……

Blebs Bullae

• Smoking and the Increased Risk of Contracting Spontaneous Pneumothorax Bense, M.D., FC.C.P.;* Gunar Ekiund, Ph.D., Odont. D. and Lars-Gösta Wiman, M.D., EC.C.P1- CHEST I 92 I 6 I DECEMBER, 1987

1.Smoking and the increased risk of contracting spontaneous pneumothorax.Bense L, Eklund G, Wiman LGChest. 1987;92(6):1009.

Relative risk of spontaneous pneumothorax for males andfemales based on total population according to daily cigarette consumption.

• Life time relative risk of first spontaneous pneumothorax among smokers• 9 (Women),

• 22(men) 1.

1.Smoking and the increased risk of contracting spontaneous pneumothorax.Bense L, Eklund G, Wiman LGChest. 1987;92(6):1009.

Clinical presentation

• Ipsiliateral pleuritic chest pain• Acute dyspnea• Symptoms usually resolve within 24 hours, even if the pneumothorax

remains untreated and does not resolve1

• Patients with a small pneumothorax (<15%) may have a normal physical examination1.

• Tachycardia is the most common finding1. • Clinical signs: decreased movement of the chest wall, a hyperresonant

percussion note, diminished fremitus, and decreased or absent breath sounds on the affected side.

• Sever tachycardia, Hypotension, cyanosis raise suspicion for tension pneumothorax

1. Spontaneous pneumothorax. Sahn SA, Heffner JE N Engl J Med. 2000;342(12):868

standard PA erect CXR - Radiological features

• Visceral pleural line – necessary to make a definitive diagnosis

• Visceral pleural line parallels the curvature of the chest wall (ie. Convex outwards)• Pneumothorax mimic conditions do not

maintain this spatial relationship. Eg.bullae, artifacts.

• Usually there is absence of lung markings peripheral to pleural line.• Pleural adhesions – lung markings may be

visible beyond the pleural line

Large Bullae

Radiological features CXR…

• Airfluid interface when present confirms presence of pneumothorax.

• Supine CXR - Air collects anteriorly and inferiorly• Deep sulcus sign

• Displaces costopherenic sulcus inferiorly

• Increased lucency of costopherenic sulcus

• Double diaphragm sign

Luftsichel, “air crescent,” sign

• Seen in setting of left upper lobe atelectasis• indirect sign of overinflation

characterized by hyperexpansion of the superior segment of lower lobe on the left side and its insinuation between collapse upper lobe and mediastinum.

• Tension pneumothorax• Shift of mobile

mediastinal structures to the opposite side

• Inversion of hemidiaphragm

• Flatting of heart contour on the side under tension.

Other modalities

• Lateral X-rays

• Expiratory films

• Supine and lateral decubitus X – rays

• Less sensitive and not recommended routinely based on current guidelines

Imaging…

• USG

• Main value in managing supine trauma patients

• CT scan

• This can be regarded as the ‘gold standard’ – able to detect small pneumothorax, estimate size

• Identify aberrant chest drain placement.

• To determine the best treatment for persistent air leaks or to plan a surgical intervention. (ACCP)

• Apex – cupola distance(ACCP) - 2001• a ≥ 3cms small

• a < 3cms large

• Interpleural distance at hilum (BTS) - 2010• b ≥ 2cms small

• b < 2cms large

Size of pneumothorax

Partial Complete without lung collapse Complete with total lung collapse

Size of pneumothorax….. THE SPANISH SOCIETY OF PULMONOLOGY AND THORACIC SURGERY (SEPAR)

CASE 1

• 34yrs/Malay/Male

• No known medical illness

• Ex-smoker 20 pack years ( stopped 4/12, now on e-cigarettes)

• C/O Shortness of breath and left sided pleuritic chest pain x 3 days

O/E

• Mildly tachypnoeic RR 24/min

• Pulse: 78/min BP 147/85 mmHg SpO2 100% NP

• Lungs: Reduced air entry on left side, hyperresonant on percussion.

CASE 1.. 34yrs/Male/ex-smoker

CXR – post left chest tubeCXR – on presentation

CXR – post chest tube removal D4 CXR – Post chest tube reinsertion

CASE 1.. 34yrs/Male/ex-smoker

CXR – Post op (VATS)

CT – pre op

CASE 1.. 34yrs/Male/ex-smoker

Management and Outcome

• Diagnosis:• Primary spontaneous pneumothorax

• Management• Chest Tube insertion• Gumco suction D2• Chest tube removal on D4 and reinsertion due to recurrence ( persistant air

leak)• VATS ( Video assisted thoracosopic surgery)

• Outcome• Discharged well on D2 post op.• Lung fully expanded and asymptomatic.

Management issues……..controversies and pitfalls

• General measures ?

• Use of High flow oxygen?

• Will you aspirate or insert chest tube?

• Admit or Discharge?

• Apply suction after Chest tube?

• Will you clamp the chest tube, prior to its removal?

• When will surgical referral needed?

• Surgical options available?

• Chemical pleurodesis as an alternative to surgery?

General measures

• Adequate analgesia – for pneumothorax and to cover for chest drain etc.

• Bed rest - There is no evidence that confining the patient to bed favors air absorption or lung expansion (ACCP)

• Supplemental oxygen:- (Grade B recommendation)• Spontaneous rate of reabsorption 1.25% to 1.8% (50-75 mL) of the total volume/24

hours• Supplemental oxygen increases the rate of absorption by a factor of 41

• It reduces partial pressure of nitrogen in the pleural capillaries. And enhances the reabsorption of air in the pleural cavity.

1.British Medical Journal, 1971, 4, 86-8 T. C. NORTHFIELD

General measures…..

• High Flow Oxygen (for example, 10 L/min), is recommended• Caution in COPD - risk of hypercapnia

• Cessation of smoking.

Oxygen therapy for spontaneous pneumothorax1.

• Group 1 – (12 males, Room air)

• Group 2 - 10 patients received Air and oxygen(16 litres/min) alternatively• 9- 38 hours of oxygen alternate with room air.• FiO2 not measured but estimated to be higher

than 50 -60% and unlikely to be 100%

• Oxygen therapy resulted in a 4 fold increase in the mean rate of absorption(P<0.01).• Pneumothorax < 30% ( 2.2 fold) (P<0.01).• Pneumothorax >30% ( 5.2 fold) (P<0.01).

1.British Medical Journal, 1971, 4, 86-8 T. C. NORTHFIELD

Oxygen therapy for spontaneous pneumothorax1

• The calculated time for full re-expansion with daily oxygen therapy ranged from 3 -8 days, with a mean of 5 days.

1.British Medical Journal, 1971, 4, 86-8 T. C. NORTHFIELD

Light’s index

ACCP 2001 BTS 2010

Drainage Yes • Majority need drainage• Minimally symtptomatic - conservative.

Admission • Most patients need admission• Selected patients may be discharged with small bore

catheter and Heimlich valve if lung has expanded

Admission required

Method of drainage • Under water seal• Heimlich valve

• Needle (14-16 G) aspiration (NA) ( Oneattempt)

• If failed NA small bore chest drain(<14)

Applying suction • If lung fails to reexpand quickly (good consesnsus)• Immediately after under water seal ( some

consensus)

• When persistant air leak is suspected (48hrs)

• Addition of suction too early may cause Reexpansion Pulmonary oedema)

• Not routinely recommended• low pressure High Volume ( -10 to – 20

cmH2O)

Size of chest tube • Chest tube 16 – 24 F• Chest tube 24 – 28 F ( Positive pressure ventilation /

large air leak)• Small bore catheter

Needle (14 – 16 G)Chest Tube ( <14 F)Small bore catheter

ACCP 2001 BTS 2010

Chest Tube removal • Staged manner- Confirm no persisting leak ( No more bubbling)- CXR – Confirm resolution- Stop any suction if applied

• Regardless of clamping, CXR is recommended after 5 – 12 hrs post last evidence of air leak (62% panel members)

Chest Tube clamping • 53% of panel members would never clamp a chest tube

• Remaining panel members would clamp after 4hrs of last evidence of air leak,

Surgical opinion • Observe for 4 days• After 4 days, need to evaluate for surgery

• 3-5 days of persisting air leak

Preferred Surgical methods

• Thoracoscopy is the preferred management• If Unfit or refuse for surgery chemical pleurodesis

• Open thoracotomy and pleurectomy(recurrence 1%)

• VATS with pleurectomy and pleural abrasion is better tolerated (recurrenc5%)

Agent for pleurodesis • Doxycycline, Talc slurry • Tetracycline, Talc

CASE 2

• 78yrs/Chinese/male

• ex-smoker (80 pack years)

• COPD stage III • recent hospitalization for CAP and

AECOPD

• IHD – 50% LAD ( angiogram)

• Presented with History of cough, chest pain and hemoptysis x 2/7

• O/E:• Tachypnoeic

• Pulse 110/min

• BP: 200/70mmHg

• RR: 30 /min

• Lungs; reduced air entry bilateral, bilateral rhonchi and prolonged expiratory phase.

• ABG: pH 7.4 pco2: 35 Hco3: 27.6 pO2:67

CASE 2… – 78/Male BGx: COPD stage III

CXR on previous admission 1 month ago CXR current

CASE2.. 78yrs/Male BGx COPD stage III -Discussion

•Diagnosis

•Acute Management

• Surgical management – to prevent recurrence

•Medical management – to prevent recurrence

Management and outcome!

• Left side Chest Tube insertion • Suction• Chest tube removal on Day 6 after

full expansion confirmed on CXR

• Plan for pleurodesis after CT scan as patient unfit for surgery

• Outcome: Patient died on Day 8

Cause of death: Acute coronary Syndrome

CASE 3

• 19 years / Male

• No known medical illness

• Non-smoker

• Acute onset Shortness of breath and Right sided chest pain for 2 days

• O/E:

HR: 130/min BP 140/80mm Hg

Tachpnoeic RR: 40/minute

Lungs: Reduced breath sound on Right side with Hyperresonanceon percussion

Chest – X-ray

CXR post chest tube – 6hrs

• Diagnosis:• Tension

Pneumothorax

• Management• Emergency

Chest tube insertion

• Outcome• Discharged

after

Chest X-Ray on arrival

Tension pneumothorax

• Pathophysiology• One-way valve system at the breach permitting air to enter the pleural cavity

during inspiration but preventing egress of air during expiration

• Increase in the intrapleural pressure such that it exceeds atmospheric pressure for much of the respiratory cycle.

• Impaired venous return and reduced cardiac output results in the typical features of hypoxemia and hemodynamic compromise

Management

• Insert Needle at 2nd intercostal space anteriorly, at mid clavicular line,

• Observe for egress of air

• Insert Chest drain, keep the needle until chest drain secured and connected to underwater drainage system.

CASE 4

• A 38-year-old female smoker

• Background Hx Pelvic endometriosis

• Intermittent recurrent Right sided chest pain. Usually occur by Day 2 of menstruation

• Admitted on Day 2 of menses. With shortness of breath and Right sided chest pain.

CASE4 38yrs/Female Bgx.Pneumothorax…

• VATS on the fifth day of menstruation showed numerous brownish oval lesions scattered on the diaphragm – endometrial implantsDIAGNOSIS: CATAMENIAL PNEUMOTHORAX

• Talc poudrage was applied, and treatment with a GNRH analogue was started, 6 month follow up patient asymptomatic

Christoph M. Kronauer, 'Catamenial Pneumothorax', New England Journal of Medicine, 355 (2006), e9.

CASE 5

• 34 yrs / Indonesian / Female

• G4 P2 L1 [21 weeks pregnant]

• BGHx:• PDA under cardio follow up detected

2006 during 3rd pregnancy• ECHO: PDA 0.47cm, Left to Right shunt,

No evidence of Pulm. HTN

• Detected to have ? Lung disease in 2008 not worked up.

• Presented with Shortness of breath for 10/7 and cough x 3/7

• O/E

• Mildy tachpneoic, RR 24/min

• Speaking in full sentences

• Pulse: 88/min

• BP: 130/70 mmHg

• sPO2: 97% Room air

• Lungs: Reduced air entry on the right side with hyperresonant on right side

BASELINE - 2008 On presentation

CASE 5. 34yrs/Indonesian

• Diagnosis• Secondary spontaneous pneumothorax• Community Acquired Pneumonia• To work up for underlying Chronic Lung

Disease – TRO TB

• Treatment• Chest drain in ED• High flow oxygen• Monitoring in HDW• Fetal well being monitoring.• Gumco suction 5cm H2o from day 2• Subcutaneous emphysema -• Persisting air leak• Discharged on Day 10 with pneumostat

• Early review in Clinic Day 16

Day 8 admission

CASE 5. 34yrs/Indonesian / 24 weeks pregnant–second presentation

• Shortness of breath x 1/7

• After dressing change and dislodged Chest drain

• O/E

• Mildly tachypneoic

• HR: 90/min BP: 130/80mmHg

• SpO2: 96% (NP 3Lt)

• Lungs: Reduced air entry right side. With hyperresonance

Managment

• Chest drain with Gumco suction (5cmH2O)

• No evidence of Air leak on Day 4

• Persisting Pneumothorax on Day 5

• CT scan once delivery and definitive surgical management.

Air travel advice – BTS (September 2011)1

1. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendationsBritish Thoracic Society Air Travel Working GroupSeptember 2011 Volume 66 Supplement 1

International Air Transport Association (IATA) –20131

6 days or less after full inflation ( Assessment by doctor with aviation medicine experience)

If general condition is adequate, early transportation with ―Heimlich type drain and a doctor or nurse escort is acceptable

Spontaneous pneumothorax non-surgical means

7 days after full inflation

traumatic pneumothorax 14 days after full inflation

Chest surgery like – pleurectomy, lobectomy, open lung biopsy

Allow if ≥ 11 days and uncomplicated recoveryIf ≤ 10 days , need assessment by doctor with aviation medicine experience

1.Medical Manual ISBN 978-92-9252-195-0 © 2013 International Air Transport Association. Montreal—Geneva

Recommendation on diving-BTS 2003 guideline1

• Barotrauma: is caused by compression or expansion of gas filled spaces during descent or ascent, respectively• Expansion of the lungs during ascent may cause lung rupture leading to

pneumothorax, pneumomediastinum, and arterial gas embolism.

Lung bullae or cysts increase risk of barotrauma and are contraindications to diving.1

Previous spontaneous pneumothorax is a contraindication unless treated by bilateral surgical thoracotomy and pleurectomy and associated with normal lung function and thoracic CT scan performed after surgery.1

Previous traumatic pneumothorax may not be a contraindication if healed and associated with normal lung function, including flow-volume loop and thoracic CT scan1

1.British Thoracic Society guidelines on respiratory aspects of fitness for diving British Thoracic Society Fitness to Dive Group, a Subgroup of the British Thoracic Society Standards of Care Committee Thorax 2003;58:3–13

Practice question

• Q1 – 38 y/o male presented with difficulty in breathing. 5 days duration. Intermittent chest discomfort. No fever or productive cough . He smokes for 10 pack years. He was seen in the local klinik kesihatan which the attending doctor thought was a tension pneumothorax. Inserted a urgent needle decompression. He was subsequently refer to ED because of worsening SOB with no repeated CXR.

What is your action plan

ABCDE - > oxygen - > urgent CXR, gases. -> manage as per 2 pneumothorax.

What could have occur

? Iatrogenic pneumothorax

• Question 2 – 38 year old man admitted with intermittent fever for 1 months duration & progressive worsening in effort tolerance.

• CXR showed

• Q3 – 40 year old co-pilot came to ED complaining worsening shortness of breath 2 days duration. Deny symptoms of infection. (pls get a cxrshowing very small pneumothorax)

How are you going to manage him ?

Answer – counsel & refer to CTC

• 24 year old young man came with sudden onset of shortness of breath. He is a active young man who leads his football team in the school & national level

• Does he need a chest drainage ? Or surgical intervention in view of his possible professional involvement in football ?