Pneumothorax

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Pneumothorax

• Sisir Botta
• M3 Gyn-Onc

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Pneumothorax Defined

• Definition What?
• Pneumo- gas Thorax chest cavity
• Analagous to Pleural Effusion
• Pathophysiology How?
• Pleural space
• Baseline (-) pressure space
• Parietal Pleura
• Visceral Pleura
• Normal inspiration
• Diaphragm
• Transmit (-) Pressure
• Pathologic inspiration
• XS gas disrupts transmission of (-) pressure

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Types of Pneumothorax

• Spontaneous Pneumothorax
• Primary - rupture of subpleural bleb
• Jimmy is a tall, wiry, 21-year old male, who
  plays trombone in the marching band.
• Secondary - underlying lung/pleural disease
• 1 emphysema
• Chronic bronchitis, asthma, TB,
• Traumatic Pneumothorax
• Open
• Chest wall is penetrated outside air enters
  pleural space
• Closed
• Chest wall is intact Ex. Fractured rib

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Types of Pneumothorax 2

• Tension Pneumothorax
• Ball-valve mechanism
• Injury to pleura creates a tissue flap that opens
  on inspiration and closes on expiration
• One of our own patients
• Variations
• Hemo-thorax
• Chylo-thorax
• Injury to thoracic duct
• Empyema
• Parapneumonic effusions in community-acquired
  pneumonia

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Symptoms

• Dyspnea
• Pleuritic chest pain
• Nerve endings at pleural capsule
• Sense of impending doom
• Sudden onset
• Tension pneumothorax
• Spontaneous pneumothorax

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Physical Exam - Signs

• Unstable patients vs. Stable patients
• Vital Signs
• Asymmetric chest expansion
• Deviated trachea
• Diminished breath sounds unilaterally
• Hyper-resonance unilaterally
• Decreased tactile fremitus

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Diagnosis

• Unstable patient
• Thoracentesis
• Rapid release of air
• Vital signs stabilize rapidly

• Stable patient
• CXR
• Monitor size by measuring distance from lateral
  lung margin to chest wall
• Be sure that pneumothorax is not expanding

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Imaging

• Plain Radiographs
• Upright PA on inspiration
• Detect other pathologies pneumonia, cardiac,
  etc.
• Partially collapsed lung
• Tension Pneumothorax
• Trachea and mediastinum deviate contralaterally
• Ipsilateral depressed hemi-diaphragm
• Chest CT
• Not routine
• Only to assess the need for surgery (thoracotomy)

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Treatment

• Small pneumothorax
• Resolve over days to weeks
• Supplemental oxygen and observation
• Tension pneumothorax
• Immediate decompression via chest tube or needle
  thoracostomy
• Spontaneous pneumothorax
• Asymptomatic outpatient, f/u with serial CXR
• Symptomatic inpatient, chest tube
• Recurrent pneumothorax CT to evaluate need for
  thoracotomy

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Tube Thoracostomy

• a.k.a. Chest tube

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References

• Roberts Clinical Procedures in Emergency
  Medicine, 4th ed. P. 187-203. 2004, Saunders.
• UpToDate. Stark Imaging of Pneumothorax, April
  7th, 2005.

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Questions??