PNEUMOTHORAX

Xie Can Mao

1st Affiliated Hospital of Sun Yat-sen Universty

1
 Introduction
The term pneumothorax was first coined by Itard,
a student of Laennec, in 1803
Laennec described the clinical picture of
pneumothorax in 1819
He described most pneumothoraces as occurring
in patients with pulmonary tuberculosis, although
he recognised that pneumothoraces also
occurred in otherwise healthy lungs, a condition
he described as pneumothorax simple

2
 Introduction
The modern description of primary
spontaneous pneumothorax occurring in
otherwise healthy people was provided by
Kjaergard in 1932

Primary pneumothorax remains a

significant global problem
The incidence is 18-28/100 000 per year
for men and 1.2-6/100 000 per year for
women 3
 Introduction
Secondary pneumothorax is associated with
underlying lung disease, whereas primary
pneumothorax is not

By definition, there is no apparent precipitating

event in either
Hospital admission rates for combined primary
and secondary pneumothorax are reported in
the UK at between 5.8/10 000 per year for
women and 16.7/10 000 per year for men
Mortality rates in the UK were 0.62/million for
men between 1991 and 1995
4
 Contents
What is pneumothorax
Pathogenesis and mechanisms
Pathophysiology
Clinical typing
Clinical manifestation
Diagnosis and differentiate diagnosis
Treatment

5
 What is pneumothorax
Pleural cavity is a latent closed space, in
which there is no air
The total gas pressure of capillaries is 706
mmHg, 54 mmHg less than atmosphere
Pneumothorax is defined as air in the
pleural space
That is, air between the lung and chest
wall, or in other term, air between the
visceral pleura and the parietal pleura
6
Pneumothorax

7
 Classification of pneumothorax
Divided into three types
Spontaneous
having an unknown cause or occurring as a
consequence of the nature course of a disease
process, such as COPD, tuberculosis
Traumatic
following any penetrating or non-penetrating chest
trauma, with or without bronchial rupture
Iatrogenic
occurring as the results of diagnostic or therapeutic
medical procedure. Intentional or a complication
8
Clinical typing of pneumothorax
Spontaneous pneumothoraces are
subclassified as:
Primary spontaneous pneumothorax (PSP)
Healthy people, most young people
Secondary spontaneous pneumothorax (SSP)
Underlying diseases
Chronic obstructive pulmonary disease
(COPD), pulmonary tuberculosis

9
Pathogenesis and mechanisms
In normal people, the
pressure in pleural space
is negative during the
entire respiratory cycle
Two opposite forces
result in negative
pressure in pleural space:
inherent outward pull of
the chest wall and
inherent elastic recoil of
the lung The negative pressure will
be disappeared if any
communication develops 10
Pathogenesis and mechanisms
When a communication
develops between an
alveolus or other
intrapulmonary air space
and pleural space
air will flow into the
pleural space until there
is no longer a pressure
difference or until the
communication is sealed

11
Pathogenesis and mechanisms
When a communication air will enter the pleural
develops through the space until the pressure
chest wall between the gradient is eliminated or
atmosphere and the the communication is
pleural space closed

12
 Pathophysiology
Pneumothorax:
Negative pressure eliminated
The lung recoil-small lung-volume decrease
V/Q decrease-shunt increase
Positive pressure
Compress blood vessels and heart
decreased cardiac output
Impaired venous return
Hypotension
Shock
Result in
A decrease in vital capacity
A decrease in PaO2

13
 Pathophysiology
Thoracoscopic studies
Blebs
Airfilled spaces between the lung parenchyma and
the visceral pleura
Shows a similar cystic space,
completely surrounded by pl

pleura

14
 Pathophysiology
Bullae
Air filled spaces within the lung parenchyma
itself Surrounded by fibrous tissue

Lung parenchyma

15
 Blebs
Maleaged 22
Admission
forexplode dyspnea,
left chest pain for 2
weeks . Historic left
pneumotorax.

0.53cm

Bullae

17
 Pathophysiology
Blebs and bullae are also known as
emphysema-like changes (ELCs)
The probable cause of pneumothorax is
rupture of an apical bleb or bulla
Because the compliance of blebs or bullae
in the apices is lower compared with that
of similar lesions situated in the lower
parts of the lungs
18
 Pathophysiology
It is often hard to assess whether bullae
are the site of leakage, and where the site
of rupture of the visceral pleura is
Smoking causes a 9-fold increase in the
relative risk of a pneumothorax in females
A 22-fold increase in male smokers
With a dose-response relationship
between the number of cigarettes smoked
per day and occurrence of PSP
19
 Clinical typing of pneumothorax

closed communicated tension

Rupture small large valve-like

sealed open in not out
Pressure P or N atmosphere high
After
Aspiration N atmosphere high again

20
 Clinical manifestation
Symptom
Depend on whether underlying pulmonary disease or
not
Depend on the speed of pneumothorax occurred
Depend on size of pneumothorax
Depend on the level of intrapleual pressure
The patient with underlying pulmonary disease
will undergo severe dyspnea
The healthy person will have minimal symptoms
although having large volume of pneomothorax
21
 Clinical manifestation
Happened most patients at rest and some
during heavy exercise
Chest pain-prickling-like, cutting-like
Having an acute onset
Air stimulates pleura
Dyspnea
Collapsed lung and vital capacity decrease
Dry cough
Air stimulates pleura
22
23
 Clinical manifestation
Tension pneumothorax
risk factors
Receiving positive-pressure mechanical
ventilation
During cardiopulmonary resuscitation
Undergoing hyperbaric oxygen therapy
Evolving during the course of spontaneous
pneumothorax

24
Tension pneumothorax

25
 Clinical manifestation
Tension pneumothorax
Distressed with rapid labored respiration
Cyanosis
Marked tachycardia
Profuse diaphoresis
Patient who suddenly deteriorate clinically,
be suspected if the patient with
Mechanical ventilation
Cardiopulmonary resuscitation
26
 Clinical manifestation
Physical examination
Depend on size of pneumothorax
Depend on whether pleural effusions or not
The vital signs usually normal
The side with pneumothorax is larger than the
contralateral side
Chest moves less during the respiratory cycle

27
 Clinical manifestation
Physical examination
Tactile fremitus is absent
The percussion note is hypersonant
The breath sounds are reduced or absent on
the affected side
The lower edge of the liver may be shifted
inferiorly with a right-side pneumothorax
The trachea may be shifted toward the
contralateral side if the pneumothorax is large
28
 Clinical stability
Stable patients Unstable patients
RR: <24/min
HR: 60-120/min
BP: normal
SO2: >90% (room air) Not fulfilling the
Patient can speak in definition of stable
whole sentences
between breaths
All above present
29
Evaluate the severity and make decision for treatment
Imaging- Plane chest X-ray film
Establishing the
diagnosis
The characteristics of
pneumothorax
Pleural line
No lung markings in
pneumothorax
The outer margin of
visceral pleura separated
from the parietal pleura
by a lucent gas space
devoid of pulmonary
vessels 30
 Plane chest X-ray film
In erect patients, pleural
gas collects over the
apex, and the space
between the lung and
chest wall is most notable
there
In the supine position,
gas migrates along the
broad ventral surface of
lung, making detection on
a frontal radiograph
difficult
31
 Plane chest X-ray film
It is very important to
differentiate the pleural
line of a pneumothorax
from that of a skinfold,
clothing, tubing, or chest
wall artifact
Careful inspection of the
film may show that the
artifact extends beyond
the thorax, or that lung
markings are visible
beyond the apparent
pleural line 32
 Plane chest X-ray film
In the absence of
underlying lung disease,
the pleural line of a
pneumothorax usually
parallels the shape of
chest wall
Artifactual densities
generally do not parallel
the course of the chest
wall over their entire
length

33
 Plane chest X-ray film
Quantification of the size
The size of a pneumothorax, in terms of
volume, is difficult to assess accurately
from a chest radiograph
The simple method to estimate the size
Small, a visible rim of < 2 cm between the
lung margin and the chest wall
Large, a visible rim of 2 cm between the lung
margin and chest wall

34
Estimation of pneumothorax volume

Light equation
pneumothorax1
L3/HT3 100
Kircher equation
Hemithorax (HT)
pneumothorax
Thorax arealung area
Thorax area 100

Collins equation
Lung (L)
4.2+[4.7(A+B+C)]

35
Estimation of pneumothorax volume

BTS guideline(1993)
Small
Moderate
large
BTS guideline(2003)
Lung margin to chest
wall
small<2cm
large2cm
ACCP guideline
Lung apex to chest top
Small <3cm
large3cm 36
 Plane chest X-ray film
Since the volume of a pneumothorax
approximates to the ratio of the cube of the lung
diameter to the hemithorax diameter
A pneumothorax of 1 cm on the PA chest
radiograph occupies about 27% of the
hemithorax volume
Lung is 9 cm, hemithorax is 10 cm in diameter
Equation
Volume of pneumothorax = (HT3 L3) HT3
= (103 93) 103
= (1000 729) 1000
= 0.27
37
 Plane chest X-ray film
A pneumothorax of 2 cm on the PA chest
radiograph occupies about 49% of the
hemithorax volume
Lung is 8 cm, hemithorax is 10 cm in diameter
Equation
Volume of pneumothorax = (HT3 L3) HT3
= (103 83) 103
= (1000 512) 1000
= 0.49
38
 CT scanning
CT scanning is the most robust approach
if accurate size estimates are required
It is only recommended to difficult cases
such as patients in whom the lungs are
obscured by overlying surgical
emphysema
To differentiate a pneumothorax from
suspected bulla in complex cystic lung
disease
39
CT scanning
bullae

pneumothorax

40
 CT scanning

bullae

p pneumothorax
n
e
u
m
o
t 41

h
 CT scanning

pneumothorax

42
 CT scanning
Small pneumothorax

Subcutaneous emphysema
43
 Differentiation
Asthma and obstructive emphysema
Repeated wheezing episode
Dyspnea gradually progress
In the course of disease, if patients
Onset of severe dyspnea, cold sweat, dysphoria
No response to bronchial dilators, antibiotics

Consider pneumothorax
Chest X-ray radiograph to conform the
diagnosis
44
 Treatment
Goals
To promote lung expansion
To eliminate the pathogenesis
To decrease pneumothorax recurrence
Treatment options according to
Classification of pneumothorax
Pathogenesis
Pneumothorax frequency
The extension of lung collapse
Severity of disease
Complication and concomitant underlying diseases

45
 Observation - PSP
Observation along is advised for small, closed
mildly symptomatic spontaneous
pneumothoraces
Patients with small PSP and minimal symptoms
do not require hospital admission
However, it should be stressed before discharge
that they should be return directly to hospital in
the event of developing breathlessness
Most patients in this group who fail this
treatment have secondary pneumothoraces

46
 Observation - SSP
Observation along is only recommend in
patients with small SSP of less than 1 cm
depth or isolated apical pneumothoraces
in asymptomatic patients
Hospitalisation is recommended in these
cases
All other cases will require active
intervention ( aspiration or chest drain
insertion)
47
 Observation - PSP or SSP
Marked breathlessness in a patient with a
small (<2 cm) PSP may herald tension
pneumothorax
Observation along is inappropriate and
active intervation is required
If a patient is hospitalised for observation,
supplemental high flow (10 l/min) oxygen
should be given where feasible
48
 Observation - PSP or SSP
Inhalation of high concentration of oxygen
may reduce the total pressure of gases in
pleural capillaries by reducing the partial
pressure of nitrogen
This should increase the pressure gradient
between the pleural capillaries and the
pleural cavity
Thereby increasing absorption of air from
the pleural cavity
49
 Observation - PSP or SSP
The rate of resolution/reabsorption of
spontaneous pneumothoraces is 1.25
1.8% of volume of hemithorax every 24
hours
The addition of high flow oxygen therapy
has been shown to result in a 4-fold
increase in the rate of peumothorax
reabsorption during the periods of oxygen
supplementation

50
 Simple aspiration
Simple aspiration is recommended as first line
treatment for all PSP requiring intervention
Simple aspiration is less likely to succeed in
secondary pneumothoraces and in this situation,
is only recommended as an initial treatment in
small (<2 cm) pneumothoraces in minimally
breathless patients under the age of 50 years
Patients with secondary pneumothoraces
treated successfully with simple aspiration
should be admitted to hospital and observed for
at least 24 hours before discharge
51
 Repeated and catheter aspiration
Repeated aspiration is reasonable for
primary pneumothorax when the first
aspiration has been unsuccessful
A volume of < 2.5 L has been aspirated on
the first attempt

The aspiration can be used by needle or

catheter
52
 Catheter aspiration
Catheter aspiration
of pneumothorax
can be used where
the equipment and
experience is
available

53
 Intercostal tube drainage
Making a small incision
Using a forceps to extend the hole
Inserting a catheter into pleural cavity

Fix the catheter and cover with gauze

54
Intercostal tube drainage

55
 Intercostal tube drainage
INDICATIONS
Unstable pneumothorax
Severe dyspnea
Large lung collapse
Open or tension pneumothoraces
Frequent recurrent pneumothoraces
Simple aspiration or catheter aspiration
drainage is unsuccessful in controlling
symptoms
56
 Intercostal tube drainage
Position of intercostal tube
The chest tube should be positioned in the
uppermost part of the pleural space,
where residual air accumulates
This procedure permits the air in the
pleural space to be evacuated rapidly

57
 Intercostal tube drainage
The site of chest
tube insertion is in
the midclavicular
line of second and
third intercostal
or anterior axillary
line of fifth and
sixth intercostal

58
 Guidewire tube thoracostomy
Making a small
skin incision
slightly larger than
the diameter of the
chest tube

59
 Guidewire tube thoracostomy
Introduction of 18-
gauge needle into
the pleural space

60
 Guidewire tube thoracostomy
Insertion of wire
with J end into
the pleural space

61
 Guidewire tube thoracostomy
With guidewire in
space, the tract is
enlarged by
advancing
progressively
larger dilators over
the wire guide

62
 Guidewire tube thoracostomy
Introduction the
chest tube
inserter/chest tube
assembly over the
guidewire

63
 Guidewire tube thoracostomy
The guidewire and
chest tube inserter
have been
removed, leaving
the chest tube
positioned with the
pleural space

64
 Trocar tube thoracostomy
Insertion of trocar into the pleural space
Note the position of the hands, the position
of the trocar relative to the ribs

65
 Trocar tube thoracostomy

Insertion of the chest tube through the

trocar

66
 Operative tube thoracostomy
The physicians
index finger is used
to enlarge the
opening and to
explore the pleural
space

Is it brutal?
No! 67
 Operative tube thoracostomy
Placement of chest
tube intrapleurally
using large
hemostat

68
Drainage system

69
 One bottle system
Consists of one bottle that serves as both a
collection container and a water seal
The chest tube is connected to a rigid straw
inserted through a stopper into a sterile bottle
Enough sterile saline solution is instilled into the
bottle so that the tip of the rigid straw is about 2
cm below the surface of the saline solution
The bottles stopper must have a vent to prevent
pressure from building up when air or fluid
coming from the pleural space enters the bottle

70
One bottle system

71
 One bottle system
This system works as follow
When the pleural pressure is positive, the
pressure in the rigid straw becomes positive
If the pressure inside the rigid straw is greater
than the depth to which the straw is inserted
into the saline solution, air will enter the bottle
Air will be vented to the atmosphere
If the pleural pressure is negative, saline will
be drawn from the bottle into the rigid straw
and no extra air will enter the system
72
 Three bottle system
Three bottle system consists of
Collection bottle for collecting pleural fluid
Water seal bottle for regulating pressure
Suction control bottle connect to the negative
pressure pump, for suction of the air of pleural space,
pres level: -10 - -20 cm H2O

73
 Three bottle system
When suction is applied to the suction-control
bottle, air enter this bottle through its rigid straw
if the pressure in the bottle is more negative than
the depth to which the straw is submerged

74
 Observation of drainage
No bubble released
The lung reexpansion
The chest tube is obstructed by secretion or blood
clot
The chest tube shift to chest wall, the hole of the
chest tube is located in the chest wall
If the lung reexpansion, removing the chest tube
24 hours after reexpansion
Otherwise, the chest tube will be inserted again
or regulated the position
75
 Complications of intercostal tube
drainage
Penetration of major organs
Lung, stomach, spleen, liver, heart and great
vessels
It occurs more commonly when a sharp metal
trocar is inappropriately applied
Pleural infection
Empyema, the rate of 1%
Surgical emphysema
Subcutaneous emphysema
76
 Chemical pleurodesis
Goals
To prevent pneumothorax recurrence
To produce inflammation of pleura and
adhesions
Indications
Persist air leak and repeated pneumothorax
Bilateral pneumothoraces
Complicated with bullae
Lung dysfunction, not tolerate to operation

77
 Chemical pleurodesis
Sclerosing agents
Tetracycline
Minocycline
Doxycline
Talc
Erythromycin
The instillation of sclerosing agents into the
pleural space should lead to an aseptic
inflammation with dense adhesions, leading
ultimately to pleural symphysis
78
 Chemical pleurodesis
Methods
Via chest tube or by surgical mean
Administration of intrapleural local anaesthesia, 200
400 mg lidocaine intrapleurally injection
Agents diluted by 60 100 ml saline
Injected to pleural space
Clamp the tube 1 2 hours
Drainage again
Observed by chest X-ray film, if air of pleural space is
absorption, remove the chest tube
If pneumothorax still exist, repeated pleurodesis
79
 Chemical pleurodesis
Side effct
Chest pain
Fever
Dyspnea
Acute respiratory distress syndrome
Acute respiratory failure

80
 Surgical treatment
Indication
No response to medical treatment
Persist air leak
Hemopneumothorax
Bilateral pneumothoraces
Recurrent pneumothorax
Tension pneumothorax failed to dainage
Thicken pleura makes lung unable to
reexpansion
Multiple blebs or bullae
81
Complications of pneumothorax
Pyopneumothorax
Caused by aspiration or intercostal chest tube
insertion (iatrogenic)
Also results from necrotic pneumonia, lung
abscess, or caseous pneumonia
Chest X-ray shows hydropneumothorax
The pleural effusion is purulent
Antibiotics and intercostal drainage
Surgical mean
82
 Complications
Hemopneumotorax
Bleeding in pleural space
Common cause is rupture of vessels in
adhesions
When lung reexpansion, bleeding will stop

When bleeding persists, surgical ligation

will be needed
Infusion

83
Complications

84
Complications

85
 Complications
Mediastinal and subcutaneous
emphysema
Alveoli rupture, the air enter into pulmonary
interstitial, and then goes into mediastinal and
subcutaneous tissues
After aspiration or intercostal chest tube
insertion, the air enters the subcutaneous by
the needle hole or incision surgical
emphysema
Physical exam crepitus is present 86
 Complications

Pneumocardium
Pneumoperitoneum
Pneumomediastinum Surgical emphysema 87
 Complications

Subcutaneous
emphysema
88
 complications
Treatment
Automatic absorption when pneumothorax is
gone
Inhalation of high concentration of oxygen
Making a small incision in suprasternal pit for
draining the air from mediastinal and
subcutaneous tissues

89
 Case study
Female, 20
Chest pain 3 hours,
and suddenly
dyspnea
Cyanosis
Marked tachycardia
Profuse diaphoresis

90
 Questions
The diagnosis is The type of
A. PSP pneumothorax is
B. SSP A. closed
C. pulmonary B. open
embolism C. tension
D. Asthma episode D. hemothorax

91
 Questions
Which choice is Which treatment is
right the first step
A. Stable A. oxygen inhalation
B. unstable B. bronchial dilators
C. aspiration
D. chest tube
drainage

92
 Case study
Male, 70
Dyspnea 24 hours
No chest pain
COPD history 20 ys
Cyanosis
Marked tachycardia

93
 Questions
The diagnosis is Which treatment
A. AECOPD prefer
B. asthma episode A. oxygen therapy
C. PSP B. aspiration
D. SSP C. chest tube
D. surgical procedure

94
95