Clinical Aspects of Pneumothorax

 Def:
 It means air in the pleural space.
 Causes:
1. Spontaneous: either primary or secondary.
2. Traumatic: either iatrogenic or accidental.

 Spontaneous pneumothorax:
 1ry spontaneous pneumothorax: in young slender patient
with apparently healthy lung.
 2ry spontaneous pneumothorax: in patients with
diseased lung: (COPD , Bronchial asthma)
1) Infections: (Pneumonia, TB, Fungal
infections of the lung).
2) Neoplasms: (Bronchogenic carcinoma, lung metastasis).

 Traumatic pneumothorax:
1. Iatrogenic pneumothorax ;
2. Traumatic pneumothorax:
 Blunt trauma
 Penetrating trauma

 Types of pneumothorax :
1) Open pneumothorax.
2) Closed pneumothorax.
3) Tension pneumothorax.

 Symptoms:
 Classically; acute dyspnea and chest pain.

 Signs:
 General examination: tachypnea and tachycardia.
 Chest examination: the side of pneumothorax will show:
 Inspection diminished movement.
 Percussion increased resonance. (pic. no. 1)
 Palpation diminished expansion. (pic. no. 2)
 Auscultation diminished breath sounds
 
Investigations:

CXR (PA view):
1. Visible lung border and absent lung marking peripherally are diagnostic.
2. Quantification of the pneumothorax.
3. To show an underlying lung disease.
 CT Chest:
 Arterial blood gases: hypoxemia and hypocapnia

 Initial management:
 Conservative treatment: is indicated in healthy adult who is not breathless and volume of
pneumothorax less than 20% of hemithorax.
 Active management: by insertion of intercostal tube (ICT).
1) Aspiration: max 2.5 L of air, preferred in primary pneumothorax.
2) Chest drainage: preferred in secondary pneumothorax. Underwater bottle drainage or Heimlich flutter
valves are used.
3) Oxygen: to speed up the resolution of pneumothorax?.
 Further management:
 Follow-up: repeat CXR.
 Surgery: (VATS or open thoracotomy) to repair the apical hole and close the pleural space.
 Chemical pleurodesis: talc or tetracycline via the chest tube in patients not fit for surgery.

Tension pneumothorax
 Def:
 One-way valve mechanism allowing air to enter the pleural space on each inspiration and preventing
air out during expiration leading to progressive increase of the intrapleural pressure.
 Clinical features:
 Agitation, pale.
 Tachycardia, hypotension and Cyanosis
 Progressive dyspnea (his breathing was now very laboured)
  Raised JVP (examining his neck they noticed engorged veins)
 Tracheal shift to the other side (…and displacement of the trachea t the left of the midline)
 Initial management:
 It must be taken seriously.
 If suspected, give high-flow oxygen and insert a wide-bore needle in the second intercostal space in
midclavicular line. Hiss of escaping air confirms the diagnosis.
 Chest drain to be placed in the fifth intercostal space in the midaxillary line.

Simple pneumothorax Tension pneumothorax