Documente Academic
Documente Profesional
Documente Cultură
CLINICAL MEDICINE
In a tension pneumothorax, the intrapleural air pressure z Occurs in apparently healthy persons due
exceeds atmospheric pressure throughout expiration and to leak of air through a weak area of the
often during inspiration as well. The mechanism by which a pleura.Itisinitiatedbymarkedvariations
tension pneumothorax develops is probably related to in intra-thoracic pressure as in the
some type of a one-way valve process in which the valve is following:
open during inspiration and closed during expiration. During aeroplane ascent to sub-atmospheric
inspiration, owing to the action of the respiratory muscles, pressure1,4.
the pleural pressure becomes negative, and air moves from
too rapid decompression to
the alveoli into the pleural space. Then, during expiration,
atmospheric pressure of divers or
with the respiratory muscles relaxed, the pleural pressure
caisson workers1, 5.
becomes positive2.
pilots who eject at high altitudes.
* Honorary Affiliate Professor of Medicine, Manipal University, Karnataka; and Visiting Senior Consultant Physician and
Pulmonologist, Fortis Jessa Ram Hospital, New Delhi - 110 005.
** Honorary Professor of Radiology, Yashwantrao Chavan Memorial Hospital, Pimpri, Pune - 411 018, Maharashtra,
*** Bharati Vidyapeeth University Medical College, Dhankawadi, Pune - 411 043, Maharashtra.
ii. Generalised pneumothorax – When the whole 2. Rare
pleuralcavity,i.e.,hemithorax,hasair.
z Broncho-pleural fistula from lung abscess or
C. Classification by ‘Mechanism’: granuloma (tuberculosis)
.
i Open pneumothorax – When there is movement z Fibrocystic disease of the pancreas
of air in and out of the pleural cavity without any z Honeycomb lung
hinderance. This is due to communication between z Hyaline membrane disease
the pleural space and the airways and may lead to
z Oxygen toxicity; Wilson-Mikity syndrome
development of a broncho-pleural fistula (BPF). But
z Perforation of the oesophagus
if the hole through which the air flows is small,
then the intra-pleural pressure during respiration z Pneumonia
couldfluctuate. z Pneumoperitoneum with passage through
diaphragm
ii. Closed pneumothorax – When there is no
z Primary or metastatic neoplasm
movement of air, i.e., air is trapped in the pleural
space because the hole through which air entered z Pulmonary infarction
has been obliterated.
Pathophysiology
iii. Valvular pneumothorax – When air is able to
With reference to the atmospheric pressure, the pleural
enter during inspiration, but is unable to exit
during expiration. This type of pneumothorax space normally has negative pressure during the complete
becomes a medical emergency because the air respiratory cycle. This negative pressure is created by the
chest wall which tends to expand, and the lungs which
pressure keeps on increasing gradually, and the
lung deflates more and more, leading to pressure tend to collapse. As such, the alveolar pressure is more than
effects on the mediastinum and great veins. As the pleural pressure. As a result, if a leak develops between
an alveolus and the potential pleural space, air moves from
an effect, the mediastinum is dispaced and the
great veins become kinked, leading to decreased the alveolus to the pleural space till the pressure equalises
venous return to the heart. This leads to increasing on both sides. As a consequence, the lung volume
decreases, and the thoracic cavity volume increases.
cardiac and respiratory embarrasment At this
stage it is usually termed a ‘tension pneumothorax’ A pneumothorax results in a decrease in the vital capacity
because of the rising pressure which builds up in as also a decrease in the PaO2. A healthy person is likely to
the pleural cavity1. easily cope with this reduction in lung function. But in
D. Classification by ‘Duration’: patients with underlying lung disease, the reduced vital
capacityprogressestorespiratoryinsufficiencywithalveolar
.
i Acute hypoventilation and respiratory acidosis as a result of
ii. Chronic reduced PaO2 and an increase in alveolar-arterial oxygen
difference (AaDO2).
Aetiological factors6,1
1. Common
Clinical manifestations of tension
pneumothorax
z Iatrogenic, e.g., insertion of a central venous
catheter while managing a patient in shock. Symptoms of pneumothorax will depend on its type and
extent. Usually, the patient experiences severe pain. Often,
z Mediastinal emphysema
a small pneumothorax is asymptomatic. But when there is
z Spontaneous (ruptured bulla) progressive dyspnoea with pain and tightness in the affected
z Trauma side of the chest, then the possibility of tension
3. Diminished air entry. Physical findings – are those of any large pneumothorax4.
4. “Anvil-clink” heard on tapping two coins on the chest. 1. In primary spontaneous pneumothorax, there is
moderate tachycardia, and the vital signs are usually
5. Tinklingrales(crepitations).
normal.
All these findings are suggestive of the presence of positive
2. In tension pneumothorax:
intra-pleuralpressure.
z Pulse rate > 140.
Many a times, it is a spontaneous pneumothorax which
z Hypotension.
progresses to become a tension pneumothorax. In a hospital
z Cyanosis.
setting, it could occur in patients with the following:
z The side of chest with pneumothorax is larger in
1. Ventilatory support.
comparison to the contralateral side.
2. Cardio-pulmonary resuscitation.
z Trachea is shifted to the contralateral side.
3. Pneumothorax secondary to trauma or infection2.
z The intercostal spaces are widened and appear
bulged-out on the affected side.
Striking clinical features
z Movement — i.e., excursion of chest wall — is
1. Anxious and distressed look, restlessness with rapid decreased on the side with pneumothorax.
laboured breathing (respiratory distress).
z Tactilefremitusisabsent.
2. Weak, rapid pulse; and cold, clammy skin of shock as a z Breath sounds are absent or reduced due to
result of increasing intra-pleural pressure which diminished air entry.
progressively impairs the venous return to the heart1.
z Percussion note is hyper-resonant.
3. Cyanosis – is unusual in the younger patients except z “Anvil clink” (produced by tapping two coins on
when severe tension pneumothorax is present. But in the chest) is heard.
older patients with chronic bronchitis and
z In left-sided pneumothorax, the metallic tinkle may
emphysema, cyanosis may occur even with a small
be synchronous with cardiac contractions (‘clicking’
pneumothorax1.
pneumothorax)8.
4. Profuse diaphoresis.
z With a right-sided pneumothorax, the lower edge
5. Marked tachycardia1. ofliverisshiftedinferiorly.
Physical signs in the chest depend essentially on the degree All these signs are conclusive of the presence of positive
of pulmonary collapse, and whether or not there is an intra-pleuralpressure.
associated pleural effusion1. Both chest pain and dyspnoea
3. Surgical emphysema9: Some air escapes into the tissue
are present in about 64% patients with primary spontaneous
planes of the chest wall after most wounds of the chest
pneumothorax. Chest pain is present in about 90% patients.
– surgical or traumatic – but it is generally slight in
It is acute in onset, and is localised to the side of the
extentandisrapidlyre-absorbed.Itdiffersinnorespect
pneumothorax.
from mediastinal emphysema, and should it increase,
Surgical emphysema over the neck or chest wall it demands intrathoracic exploration, as a penetrating
Radiological appearances
On a roentgenogram of the chest, a pneumothorax is
classically seen as an area of ‘absent’ lung markings between
the bony thoracic cage and the edge of the lung.
1. A shallow pneumothorax could be missed on a cursory
viewing of the chest film, but is well seen in a film
taken in full expiration, or a lateral decubitus film with
the affected side uppermost.
TO Prevention of recurrence
ATMOSPHERE
OR SUCTION Prevention is important since recurrences could seriously
PUMP
affect the quality of life of a patient and even endanger it.
In cases where recurrences have occurred more than three
times,itisadvisabletogoinforpleurodesis17,i.e.,adhering
the lung to the chest wall by artificial means. For this, there
are two methods:
1. Surgical:
a
. A trusted method is to do a pleurectomy wherein
theparietalpleuraispeeledoff.Thereafter,alllung
cysts which are larger than a marble are excised
and sutured at the base7.
Diamicron MR