PNEUMOTHORAX

 

MAIN TOPIC

RESPIRATORY DISEASES

SUB TOPIC : PNEUMOTHORAX

DEFINITION

A Pneumothorax (noo-mo-THOR-acks) is a collapsed lung. Pneumothorax occurs when air leaks into the space between your lungs and chest wall. This air pushes on the outside of your lung and makes it collapse. In most cases, only a portion of the lung collapses.

A Pneumothorax can be caused by a blunt or penetrating chest injury, certain medical procedures involving your lungs, or damage from underlying lung disease. Or it may occur for no obvious reason. Symptoms usually include sudden Chest pain and shortness of breath.

A small, uncomplicated Pneumothorax may quickly heal on its own. When the Pneumothorax is larger, doctors usually insert a flexible tube or needle between your ribs to remove the excess air.

AETIOLOGICAl CLASSIFICATION

A. Traumatic pneumothorax

a. Accidental traumatic Pneumothorax:

It results from: Penetrating trauma, blunt trauma.

b. Iatrogenic Pneumothorax:

It results from procedures such as:

• Thoracocentesis

• Pleural biopsy

• Central vein catheterization

• Percutaneous lung biopsy

• Mechanical ventilation

B. Spontaneous Pneumothorax

It results from without any antecedent trauma to the thorax.

a. Primary spontaneous Pneumothorax: It occurs in the absence of an underlying lung disease. It affects mainly tall, thin individual especially it smokers. It is though to occur from rupture of sub pleural apical blebs in response to high negative in pleural pressure.

b. Secondary spontaneous Pneumothorax: It occur as a complication of underlying lung diseases like COPD, asthma, cystic fibrosis, tuberculosis, pneumonia, staphylococcal lung abscess, lung carcinoma fibrosing alveolitis,etc.

PATHOLOGICAL CLASSIFICATION

1. Closed type: The communication between the lung and pleural space closes spontaneously as the lung deflates and does not re-open. When air is re- absorbed the lung gradually re-expands.

2. Open type: The communication is generally with a bronchus and does not close when the lung collapses. Air pressure in the pleural cavity equals that of atmospheric pressure and the lung does not re-expand. It is usually associated with infection.

3. Tension Pneumothorax: The communication between the pleura and the lung persists and it acts like a one way valve allowing air to enter the pleural space during inspiration and coughing but prevents it from escaping. This usually occurs during mechanical displacement. This must be treated as a medical emergency.

CLINICAL FEATURES

 Closed Pneumothorax :

• Reduced chest examination.

• Hyper-resonant note on percussion.

• Reduced air entry.

• Mediastinal shift to opposite side.

• Decreased Tactile Vocal Fremitus (TVF).

• Decreased Vocal Resonance.

 Open Pneumothorax:

• Crackpot sound on percussion.

• Amphoric breath sounds.

• Voice and cough sound may be heard with metallic echo.

 Tension Pneumothorax

• Displacement of the mediastinum with respiration.

• Dyspnoea.

• Cyanosis.

• Tachycardia.

• Increased respiratory rate.

• Decreased blood pressure.

• Respiratory failure.

General Examination:

 Inspection and palpation

• Dyspnoea

• Accessory muscles of respiration

• Shift of trachea

• Shift of mediastinum to opposite side.

• Fullness of chest on the affected side

• Diminished chest movements

 Percussion

• Hyper-resonant on affected Pneumothorax.

• Right sided Pneumothorax-liver dullness is obliterated and cardiac dullness is shifted to the opposite side.

 Auscultation

• Diminished to absent breath sounds

• Absence of adventitious sounds

• Diminished vocal resonance

• Bronchopleural fistula-amphoric bronchial breathing

RISK FACTORS

Risk factors for Pneumothorax include:

 Sex. In general, men are far more likely to have a Pneumothorax than are women.

 Smoking. The risk increases with the length of time and the number of cigarettes smoked, even without Emphysema.

 Age. The type of Pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is a very tall and underweight man.

 Genetics. Certain types of Pneumothorax appear to run in families.

 Lung disease. Having an underlying lung disease — especially chronic obstructive pulmonary disease (COPD) — makes a collapsed lung more likely.

 Mechanical ventilation. People who need mechanical ventilation to assist their breathing are at higher risk of Pneumothorax.

 A history of Pneumothorax. Anyone who has had one Pneumothorax is at increased risk of another, usually within one to two years of the first episode.

INVESTIGATIONS

i. Chest x-Ray:

• Sharply defined collapsed lung margin

• Underlying lung pathology

• Mediastinal shifting towards opposite side

ii. Investigations to identify underlying disease conditions

iii. Blood, TC, DC, ESR, Hb%

iv. Arterial blood gas analysis: Hypoxemia

v. ECG: To rule out cardiac pathology DIFFERENTIAL DDIAGNOSIS

i. Emphysematous bulae

ii. Pulmonary embolism

iii. Myocardial infarction

iv. Pneumonia

COMPLICATIONS

i. Tension Pneumothorax

ii. Acute respiratory failure

iii. Pyothorax

iv. Pneumomediastinum

v. Subcutaneous emphysema

vi. Failure to re-expansion of lung

vii. Recurrent Pneumothorax

TREATMENT

 General Treatment

I. Bed rest in propped up position

II. O2 inhalation

III. Treat for cough and chest pain

IV. Symptomatic and supportive treatment

V. Stop smoking

 Specific Treatment

The specific treatment depends upon the severity of Pneumothorax and nature of the underlying diseases.

1) Closed type:

a) Small Pneumothorax (<15% of hemi thorax):

• No active measures

• Radiological observation two weekly until re-expansion of the lung is completed.

b) Large Pneumothorax (with breathlessness):

• Water -seal chest tube drain in safely triangle.

• Radiological observation.

• Specific chemotherapy if needed.

• O2 inhalation

2) Tension type

• A large bore needle is interested into the pleural space through second anterior intercostal space followed by water-seal chest tube drainage.

• Radiological observation in every 24 hrs.

• O2 inhalation

3) Open type

• Surgical closure of fistula

• Chest tube with negative suction.

SURGICAL MANAGEMENT

• Supplement oxygen

• Aspiration

• Tube thoracostomy

• Thoracostomy

PHYSIOTHERAPY MANAGEMENT:

Goals:

1. To improve distribution of ventilation.

2. To reinflate atelectatic lung areas.

3. To increase oxygenation.

4. To improve exercise tolerance.

5. Maintain airway clearance.

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