PNEUMOTHOR

AX

Shintya Nanda Carita

Dina Fauziah
Supervisor : dr. Ali Haedar, Sp.EM

BACKGROUND
Definition: Pneumothorax is defined as accumulation of air in
the pleural space with secondary lung collapse (Al-Qudah,
2006).
Pneumothoraces can be classified according to their cause
and clinical presentation: Spontaneous, traumatic, or
iatrogenic (Al-Qudah, 2006).
Spontaneous pneumothorax (SP) can be a medical
emergency requiring early diagnosis and treatment to
prevent subsequent respiratory failure and death
(Saiphoklang, 2013).
Spontaneous Pneumothorax clasified into 2 types: PSP and
SSP The distinction between PSP and SSP should be made at
theSaiphoklang
time of
diagnosis
to guide
management
N , Kanitsap
A . 2013. Prevalence,
clinical appropriate
manifestations and mortality
rate in patients with
spontaneous pneumothorax in Thammasat University Hospital. J Med Assoc Thai. Oct;96(10):1290-7.
Etiology:
Secondary pneumothorax develops in patients with
Al-Qudah, Abdullah. 2006. Treatment Options of Spontaneous Pneumothorax. Indian J Chest Dis Allied Sci
2006; 48:
191-200.
known
clinical
and/or radiographic lung disease (Al-Qudah,
1

BACKGROUND
Causes of secondary SP were pulmonary tuberculosis (19/34,
55.9%), chronic obstructive pulmonary disease (14/34,
41.2%), and pneumonia (8/34, 23.5%) (Saiphoklang, 2013).
Mortality and Morbidity Rate: Studey in Thailand use one
hundred patients with SP were identified (66 primary, 34
secondary SP), for a prevalence of 76.3 per 100,000 hospital
admissions. There were 12 deaths (12%), 11 with secondary
SP (Saiphoklang, 2013).
The size of the pneumothorax determines the rate of
resolution and is a relative indication for active intervention
(BTS guideline,2010).
Needle (14e16 G) aspiration (NA) is as effective as large-bore
(>20 F) chest drains and may be associated with reduced
Saiphoklang N , Kanitsap
. 2013. Prevalence,
clinical manifestations
and mortality rate in patients with
hospitalisation
and Alength
of stay.
(BTS guideline,2010).
spontaneous pneumothorax in Thammasat University Hospital. J Med Assoc Thai. Oct;96(10):1290-7.
Following failed NA, small-bore (<14F) chest drain insertion is
1

CASE
REPORT

Patient
Identity
Name : Mr. G
Sex : Male
Age : 64 years old
Adress : Sukun Pondok Indah K-16, Malang
Education : Junior High School
Occupation : Retired
Body Weight

: 60 kg

Admitted to ER on January 17th, 2015

Primary Survey
A : Paten
B

: Unsymmetrical chest movement, RR 30x/mnt, retraction (-), SpO 2 88%

: BP 149/84 mmHg, PR 106x/mnt, warm acral

(Tax : 36,8C), CRT < 2 s

: Round and isochoric pupils, GCS 456

Triage : Red Zone

Two BLS vital sign measurements that are helpful in assessing
and monitoring the degree of respiratory distress are
respiratory rate and oxygen saturation. Tachypnea in adults is
generally defined as a respiratory rate greater than 25 breaths
per minute. Lastly, when pulse oximetry is used to monitor a
patient in respiratory distress and saturations are normal (94
98%), desaturation is a warning of decompensation.
McEvoy, Mike. 2013. How to Assess and Treat Acute Respiratory Distress
A rapid and thorough assessment is critical for patients with acute respiratory distress. Article

Primary
Survey
Initial Treatment
A

: -

: Semi-fowler position, O2 NRBM 10 lpm-Sat 90%

: IVFD NaCl 0,9% lifeline

: -

Anamnesa
Anamnesa
Chief complain: shortness of breath
Patient suffered from shortness of breath since one day before admission.
Patient feels shortness of breath while he did activity or rest, but it decreased
while he rest. Patient also complaint pain on left chest that get worse with
breathing. Patient went to doctor and got some medicine but the shortness of
breath was persist.
Patient has also been having little cough since 4 months ago, with no sputum
and blood. The cough worst since 3 days before admission. He also suffered
weakness since a month ago. Patient denied night sweating, fever or
decreased of body weight. Patient didnt go to the doctor for treat his cough.
Past medical history: There was no history of shortness of breath before and
TB. There was no history of 6 months drug consuming. No history of
hypertension and diabetes mellitus
Family history: There was no family with same complain. No history of diabetes
mellitus, hypertension, TB and malingnancy in his family.
Social history: Patient was a smoker since he was 20 years old, 5-10 sticks a
day. But he already stop smoking since one year ago. He lives at home with

Secondary Survey
General condition : looked
moderately ill

Body weight : 60 kg
Body Height : 165 cm
23,86
PR : 106x/minute
regular, strong

GCS: 456

BP: 149/84 mmHg

Head

Anemic conjunctiva (-/-) Icteric sclera (-/-)

Neck

JVP : R+0 cm H2O

Chest

Extremitie
s

Tax: 36,8C
SpO2: 88%

Lnn. enlargement (-)

Wall

Unsymmetrical chest movement (left<right)

Hear
t

Ictus invisible, palpable at ICS V MCL S

RHM ~ SL D
LHM ~ ictus
S1 and S2 single, murmur (-), gallop (-)

Stem Fremitus D>S S HS v v Rh

Lung
S HS v v
S HS v v
Abdomen

RR:
30x/minute

BMI :

- - - -

Wh - - - -

Flat, Bowel sound (+) normal, soefl, liver span 8 cm, traubes space
tympani, shifting dulness (-)
Warm; edema -/-/-

Laboratory Finding (January, 17th 2015)

Laboratory
Hb
Leucocyte
Erytrocyte
Thrombocyte
Hct
MCV
Leucocyte
MCH
Thrombocyte
MCHC
MCV
Differential count
MCH
SGOT
MCHC
SGPT
Differential
count
RBS
SGOT
Ureum
SGPT
Creatinine
RBS
Ureum
Creatinine

Result

Normal Value

Unit

17,30

11,4-15,1

g/dL

11.450
5,92

4.700-11.300
4,0-5,5

10/L
/L

349.000
51,1

142.000-420.000
40-47

/L
%

11.450
86,30

4.700-11.300
80-93

/L
fL

349.000
29,20

142.000-420.000
27-31

/L
Pg

33,90
86,30

32-36
80-93

g/dL
fL

0,0/0,3/82,9/11,7/5,1
29,20

0-4/0-1/51-67/25-33/2-5
27-31

Pg
%

33,90
22

32-36
0-32

g/dL
U/L

0,0/0,3/82,9/11,7/5,1
21

0-4/0-1/51-67/25-33/2-5
0-32

U/L
%

127
22

<200
0-32

mg/dL
U/L

20,20
21

16,6-48,5
0-32

mg/dL
U/L

1,11
127

<200
<1,2

mg/dL

20,20

16,6-48,5

mg/dL

1,11

<1,2

mg/dL

ELECTROLYTE SERUM
Na

137

136-145

mmol/L

3,63

3,5-5,0

mmol/L

Cl

111

98-106

mmol/L

BLOOD GAS ANALYSIS (with NRBM 10 lpm)

pH

7,37

7,35-7,45

pCO2

30,4

35-45

mmHg

192,9

80-100*

mmHg

HCO3

17,8

21-45

mmol/L

BE

-7,7

(-3) ( +3)

mmol/L

O2
saturation

99,6

>95

pO2

ChestX-Ray
X-ray
Chest

PA position, enough KV, enough

inspiration
Soft tissue and bone normal
Left and right phrenicocostalis
angle sharp
Left hemidiaphragm flatten,
right hemidiaphragm normal
Trachea in the middle
Hillus normal
Cor: normal size, normal aorta
Pulmo: normal vascular
pattern, fibroinfiltrates upper
middle and lower lobe lung
dextra, clear space hemithorax
sinistra with lung collapse
Conclusion:
- Left pneumothorax
-TB active far advance lesion

ECG

ECG

Conclusion: sinus rhythm 98 bpm

Working Diagnosis
SOB dt Spontaneous Secondary
pneumothorax
Lung TB
Pneumonia

Management
Semi-fowler position
O2 NRBM 10 lpm
IVFD NS 0,9% lifeline
Chest tube insertion

Disposition

Pulmonary
Department

Management
Semi-fowler position
O2 NRBM 10 lpm
IVFD NS 0,9% lifeline
Chest tube insertion

Discussion

Etiology
Secondary pneumothorax develops in patients with known
clinical and/or radiographic lung disease (Al-Qudah, 2006).
Causes of secondary SP were pulmonary tuberculosis (19/34,
55.9%), chronic obstructive pulmonary disease (14/34, 41.2%),
and pneumonia (8/34, 23.5%) (Saiphoklang, 2013).

Symptoms of
Pneumothorax

Symptoms of Lung
TB

The common presenting

symptoms were dyspnea
(73%), chest pain or discomfort
(68%), pleuritic pain (46%),
cough (20%), and fever (13%)
(Saiphoklang, 2013)

Primary TB infection may be

asymptomatic, cause fever and
pleuritic pain. Cough,
arthralgia and occur rarely.
Older individual more likely to
present with non specific
finding of dyspnea and fatigue
(Hoffmann dan Churcyard,
2009)

Saiphoklang N1, Kanitsap A2. 2013. Prevalence, clinical manifestations and mortality
rate in patients with spontaneous pneumothorax in Thammasat University Hospital.
J Med Assoc Thai. Oct;96(10):1290-7.

Physical Examinations of Pneumothorax

Vital signs
RR, SpO2

Respiratory
Reduced chest wall
movement
Resonance to percussion
Reduced or absent tactile
fremitus
Absent or reduced breath
sounds on the affected
side (Kirmani and Page,
2014)

Vital signs
RR=30x/minute, SpO2
88%

Respiratory

Unsymmetrical chest
wall movement chest
Unsymmetrical
(left<right)
wall
movement
Stem fremitus D>S
(left<right)
Hypersonor on left
Stem
fremitusbreath
D>S
sideReduced
sound on left
side
Hypersonor
on
left side

Reduced breath sound

on left side

Laboratory Finding
Laboratory

Result

Normal Value

Unit

17,30

11,4-15,1

g/dL

Erytrocyte

5,92

4,0-5,5

10/L

Hct

51,1

40-47

11.450

4.700-11.300

/L

Hb

Leucocyte

Differential
0,0/0,3/82,9/11,7/5,1 0-4/0-1/51-67/25-33/2-5
%
count
In patients with hypoxemia, the existence of multiple compensatory systems
(increased cardiac output, increased levels of hemoglobin, increased
arteriovenous oxygen difference) allows in most cases adequate oxygen
delivery to the tissues, despite serious arterial desaturation (Markou et.al,
2004).
Neutrophils are the first line of innate immune defense against infectious
diseases. They also have always been considered tissue-destructive cells
responsible for inflammatory tissue damage occurring during acute infections
(Kumar, 2010)
Mild monocytosis can be seen in chronic infections such as diabetic ulcers,

TB IRIS
Immune Reconstitution Inflammatory Syndrome
(IRIS) refers to :
a phenomenon experienced by people living with
HIV who have recently initiated antiretroviral
therapy.
a paradoxical inflammatory reaction against a
foreign antigen (alive or dead) in patients who
have started antiretroviral therapy and who have
undergone a reconstitution of their immune
responses against this antigen. (Colebunders,
2010)

Pathophysiology
Pathophysiology
The partial reconstitution of the immune system
following initiation of antiretroviral therapy in these
patients can result in an exaggerated inflammatory
response against any concurrent opportunistic
infection. Sometimes the opportunistic infection
pathogen against which the inflammatory response is
directed remains clinically 'silent' prior to initiation of
antiretroviral therapy, such that antiretroviral therapy
'unmasks' a previously undiagnosed disease.

Tuberculosis - Immune Reconstitution Inflammatory

Syndrome (TB-IRIS) refers specifically to IRIS that occurs
in the context of a patient with active Mycobacterium
tuberculosisinfection, and is a relatively common
complication for HIV-infected persons who initiate
antiretroviral therapy in resource-limited settings,
particularly in regions that have a high TB prevalence.

Pathogenesis
Pathogenesis
Increased lymphoproliferative response to
mycobacterium antigens in vitro
Restoration of cutaneous response to Tuberculin
Increased [Il-6], activation markers (CD38)
Associated with TNFA-308*1, IL6-174*G
(Colebunders, 2010)

Risk Factors for TB/IRIS

Starting ARVs within 6 weeks of TB treatment
Disseminated, extra-pulmonary disease
Low base line CD4 count (have a CD4 count <
100 cells/mm3)
have a prompt rise in CD4 count in the initial 3
months of HAART
Fall in viral load
High bacillary burden (?)

Recommendations to prevent TB IRIS

Exclude TB before starting antiretroviral
therapy
Treat first the TB and start antiretroviral
treatment only once the patient has
clinically improved, is tolerating very well
his TB treatment
Increase awareness about TB IRIS

BLOOD GAS ANALYSIS (with NRBM 10 lpm)

pH

7,37

7,35-7,45

PaCO2

30,4

35-45

mmHg

PaO2

192,9

80-100*

mmHg

HCO3

17,8

21-45

mmol/L

BE

-7,7

(-3) ( +3)

mmol/L

O2 saturation

99,6

>95

Arterial blood gas measurements are frequently abnormal in patients

with pneumothorax, with the arterial oxygen tension (PaO2) being <10.9
kPa in 75% of patients, but are not required if the oxygen saturations
are adequate (>92%) on breathing room air. The hypoxaemia is greater
in cases of SSP, the PaO2 being <7.5 kPa, together with a degree of
carbon dioxide retention in 16% of cases in a large series (MacDuff et.al,
2010).
MacDuff, A. et. al.2010. Management of Spontaneus Pneumothorax : British Thoracic Society pleural disease guideline 2010

Adjunct
Examination
(Chest X-ray)
Adjunct
Examination

Size of Pneumothorax

After Chest Tube Insertion

Subjective

: Shortness of breath

Objective : Looked mildly ill

GCS 456
BP 120/80 mmHg
PR 80x/mnt
RR 20x/mnt
SpO2 98% (nasal canule 2 lpm)
Lung : Symmetrical chest movement
Stem Fremitus D=S
S S v v Rh

- -

Wh - -

SS vv

- -

- -

SS vv

- -

- -

BLOOD GAS ANALYSIS (nasal canule 2 lpm)

pH

7,33

7,35-7,45

pCO2

39,4

35-45

mmHg

98

80-100

mmHg

HCO3

20,9

21-45

mmol/L

BE

-5,2

(-3) ( +3)

mmol/L

O2
saturation

96,9

>95

pO2

Lessons Learnt

When we got patient with shortness of breath, we should do appropriate first

aid treatment and diagnose the underlying causes of it from good history
taking, physical examination, and adjunction examination interpretation.
There are 3 major underlying diseases (TB, COPD, and Pneumonia) that can
cause Spontaneous Secondary Pneumothorax. So we should keep in our
mind the possibility of SSP occur when we treat patient with these diseases.
Pneumothorax is one of Pulmonary Emergency that need fast and precise
treatment based on the underlying causes, size of pneumothorax, and
clinical manifestation.

http://
www.jems.com/article/patient-care/how-assess-and-treat-acute-respiratory-d
The pathogenesis of pneumonia in each etiologic agent may be different; in
general, patients with typical bacterial pneumonia manifest more toxic clinical
symptoms with leukocytosis, neutrophilia with band form neutrophils, and
bacteremia. In initial pneumonia lesions, mainly activated neutrophils and
mononuclear phagocytes are predominantly observed, and mediators such as
proteolytic enzymes, oxygen radicals, and cytokines from these cells may be
associated with host lung injury.
Mycoplasma pneumoniaepneumonia, bacterial pneumonia and viral
pneumonia

Kyung-Yil LeeI; You-Sook YounII; Jae-Wook LeeII; Jin-Han KangI

I
MD. PhD. Departments of Pediatrics, College of Medicine, The Catholic
University of Korea, Seoul, Republic of Korea
II
MD. Departments of Pediatrics, College of Medicine, The Catholic University of
Korea, Seoul, Republic of Korea
Jornal de Pediatria
PrintversionISSN0021-7557

Most instances of neutrophilia are secondary to a pathologic process outside the

marrow. It can occur in infectious diseases, especially acute bacterial infections;
neoplasia, either affecting the myeloid system (chronic myelogenous leukemia
and other myeloproliferative disorders) or secondary to a solid tumor
(paraneoplastic syndrome); inflammation secondary to tissue necrosis, metabolic
and collagen diseases, hypersensitivity reactions; hemorrhage; hemolysis; and
stress.
Monocytosiscan follow chronic infectious disorders (tuberculosis, brucellosis),
rheumatic diseases (lupus, rheumatoid arthritis), chronic inflammatory bowel
disease, and some malignant processes (Hodgkin's and non-Hodgkin's
lymphoma). Monocytes play an important role in other chronic granulomatous
diseases: sarcoidosis, histiocytosis X, and storage diseases (Gaucher's disease,
NiemannPick disease).
Lymphocytopeniacan be seen mainly in association with several congenital
diseases of the immune system or following treatment with corticosteroids,
antineoplastic agents, or radiation.

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.

Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.