PNEUMOTHORA

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PNEUMOTHORAX is the presence of air in the
pleural space.
can be
a) Spontaneous
b) Result of iatrogenic injury
c) Trauma to the lung or chest wall
 Classification
1. Spontaneous
# Primary
- No evidence of overt lung disease
- occurs in males aged 15-30
- air escapes from the lung into the pleural
space through rupture of a small emphysematous
bulla or pleural bleb
- smoking, tall stature & the presence of apical subpleural
blebs are additional risk factors
#Secondary
- underlying lung disease
- occurs mainly in males above 55 yrs
- most commonly COPD & TB
- also seen in asthma, lung abscess, pul infarcts,
bronchogenic carcinoma, all forms of fibrotic &
cystic lung disease
2. Traumatic

- iatrogenic ( foll thoracic surgeryor biopsy)

- chest wall injury

TYPES

1. Closed spontaneous pneumothorax

2. Open spontaneous pneumothorax

3. Tension pneumothorax
 Closed type
 Communication b/n airway and the pleural space
seals off as the lung deflates

 Mean pleural pressure remains negative

 Spontaneous reabsorption of air & re-expansion of

lung occur over a few days or weeks

 Infection uncommon
Open type
 Communication b/n pleura & bronchus doesn’t
seals off (Bronchopleural fistula)

 Intra pleural pressure = atm. Pressure

 Collapsed lung, no re expansion

 Transmission of infection from the airways into

the pleural space through fistula common
(empyema)
 Tension type
 Communication b/n the airway & the pleural
space acts as a one-way valve

 Allowing air to enter the pleural space during

inspiration but not to escape on expiration

 Large amt of air accumulates progressively in the

pleural space

 Intrapleural pressure increases above atm

 Pressure causes mediastinal shift towards the
opposite side

 with compression of the opposite lung

 & impairment of systemic venous return

 Causing cardiovascular compromise

 Occasionally tension pneumothorax may
occur without mediastinal shift, if malignant
ds or scarring has splinted the mediastinum
Clinical features

 Sudden onset of unliateral pleuritic chest pain

 Breathlessness

[In pts with a small pneumothorax, physical

examination may be normal ]
General examination

 Cyanosis

 Rapid thready pulse

 Signsof peripheral circulatory failure in

severe cases
 Inspection & palpation
 Dyspnoea
 Accessory muscles of respiration

 Shift of trachea

 Shift of mediastinum to opposite side

 Fullness of chest on the affected side

 Diminished chest movements

 Marked diminished vocal fremitus on
affected side
 Reduction in total chest expansion

 Increase in size of affected hemithorax

 Diminished expansion of the affected

hemithorax
Percussion
 Hyper-resonant on affected
pneumothorax.

 Right sided pneumothorax-liver dullness is

obliterated and cardiac dullness is shifted
to the opposite side
 Auscultation

 Diminished to absent breath sounds

 Absence of adventitious sounds

 Diminished vocal resonance

 Bronchopleural fistula-amphoric broncial

breathing.
 Investigations
Chest x ray
Shows : increased radiolucency, with absence of
bronchovascular markings
 extend of mediastinal shift.
 pleural fluid ,if present .
 underlying pulmonary disease .
 (costophrenic angles are clear)
[care must be taken to differentiate b/n a large pre-existing bulla &
a pneumothorax to avoid misdirected attempts at aspiration]
CT

Helps to differentiate between large pre

existing emphysematous bullae and
pneumothorax .
TREATMENT
Primary pneumothorax

 If the lung edge is < 2cm from the chest wall

and patient is not breathless
↓
Resolves normally with out intervention
 If the patient is having severe symptoms
↓
Percutaneous needle aspiration
↓
If it fails , intercostal tube drainage is done
PERCUTANEOUS NEEDLE ASPIRATION OF AIR
Intercostal
drainage
 Secondary pneumothorax

Even a small secondary pneumothorax may

cause respiratory failure, so all such patients require
↓
Intercostal tube drainage

[Intercostal drains are inserted in the 4th ,5th or 6th

intercostal space in the midaxillary line ,connected
to an under waterseal]
 Clamping of the drain is potentially dangerous

 Should be removed 24hrs after the lung has fully

reinflated and bubbling stopped .

 Continued bubbling after 5 -7 days is an indication

for surgery .

 All patients should receive supplemental oxygen

 If intercostal tube drainage fails
↓
Thoracoscopy (VATS ) or thoracotomy with
stapling of blebs and pleural abrasion is indicated
 If surgery is contraindicated, pleurodesis
should be done .
↓
Intrapleural injection of sclerosing agent
 Tension pneumothorax
 It is a medical emergency.

 A large bore needle is inserted into pleural

space through 2nd intercostal space.

 Needle should be left in place until a

thoracostomy tube can be inserted.
 Traumatic pneumothorax

 Supplemental oxygen or aspiration done.

 Tube thoracostomy , if not improves.

 If hemo pneumothorax is present, 1 chest

tube should be placed in the superior part to
evacuate air, other should be placed in the
inferior part to remove blood.
 Recurrent spontaneous
pneumothorax

 Surgical pleurodesis is recommended in all

patients following a 2nd pneumothorax(even
if ipsilateral)
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