Aquillo, Angelica

Dela Cruz, Patricia Jane

Delos Santos, Joshua
Lopez, Eunice
Salazar, Levin
 Pneumothorax refers to air in the pleural space.
 Although air can enter the pleural space from
outside the body, as occurs in sucking chest
wounds, most cases of pneumothorax occur when
disruption of the visceral pleura allows air from the
lung to enter the pleural space.
 Pneumothorax is discussed according to etiologic
factor because traumatic pneumothorax is
managed differently from spontaneous
pneumothorax.
1. Primary spontaneous pneumothorax,
in which there is no underlying lung
disease.

 2. Secondary spontaneous
pneumothorax, in which lung disease is
present.
 Chest pain, which is typically sharp and
abrupt, occurs in nearly every patient
with pneumothorax.
 Palpation of the chest wall does not
worsen the pain, although respiratory
efforts may be difficult.
 Dyspnea occurs in approximately two-
thirds of patients when decreases in vital
capacity and PO2, probably secondary to
airway closure at low lung volumes, cause
ventilation/perfusion defects and
shunting.
 When spontaneous pneumothorax is
evacuated, hypoxemia may persist in
some patients.
 The following sections describe the
diseases that cause pneumothorax and
the important treatment differences
between them.
 Traumatic pneumothorax can be caused by either
blunt or penetrating wounds of the thorax.
 The common causes of penetrating wounds
include gunshots and knife punctures.
 In many cases, penetrating trauma to the chest
can be managed conservatively with a chest tube.
The clear indications for entering the chest
surgically are uncontrolled bleeding from
intercostal or pulmonary arteries and injury to
the heart or great vessels. In these situations, the
pneumothorax becomes secondary.
 The chest tube is multifunctional to
allow measurement of the rate of
bleeding, to allow the lung to be
pulled to the parietal pleural surface
to tamponade bleeding, and to allow
maximum ventilation.
 In blunt trauma to the chest,
pneumothorax can be the result of a
rib fracture that enters the lung
parenchyma and allows air to leak
into the pleural space.
 For this type of injury, a chest tube is placed,
and the rib fractures necessitate no specific
therapy.
 A more common injury is alveolar rupture,
which breaks through the pleural
membrane.
 Two special injuries that produce
pneumothorax are tracheal fracture and
esophageal rupture.
 Tracheal fracture results from
severe deceleration injury and
often occurs in concert with
fractures of the anterior aspect
of the first through third ribs.
 In this case, urgent
bronchoscopy is appropriate
because tracheal fracture must
be corrected surgically.
 Esophageal rupture produces an air-
fluid level in the pleural space.
 Pleural fluid amylase concentration is
elevated from a salivary source.
 Large-caliber chest tubes are placed for
trauma-related pneumothoraces to allow
exit of blood and blood clots, which can
be difficult to remove through small-bore
catheters.
 Air leaks from an injured lung can be
large.
When bleeding is a major
component of pleural injury, two
chest tubes are used: a
posterior chest tube to drain
blood that is gravity-dependent
and an anterior and apical
chest tube to drain air that
moves to the lung apex in the
absence of pleural disease.
 Iatrogenic pneumothorax is the most
common type of traumatic
pneumothorax. Common causes are
punctures of the lung from needle
aspiration lung biopsy, thoracentesis, and
central venous catheter placement.
 Unusual causes, such as feeding tube
placement into the pleural space, also
have been recorded.
 Because the pleural rupture is typically
small in the absence of parenchymal
lung disease, these lung punctures
usually resolve within 24 hours and
can be observed without chest tubes as
long as serial radiographs are
obtained.
 In radiographic series, spontaneous
pneumothorax occurs in 1% to 2% of all
infants soon after birth.
 The cause of pneumothorax is likely high
transpulmonary pressure during birth
coupled with transient bronchial
blockade caused by meconium, mucus, or
aspiration of blood; transpulmonary
pressure gradients of 100 cm H2O can be
produced.
 Recognizing pneumothorax is difficult
because breath
 sounds are transmitted widely through the
chest of the neonate.
 A shift of the heart sounds away from the
side of the pneumothorax may provide a
clue.
 Transillumination of the chest with a high-
intensity light is used in some centers.
 Almost all neonates with pneumothorax
need a chest tube.
Spontaneous pneumothorax
is defined as any
pneumothorax caused by
the escape of air into the
pleural space without an
obvious cause.
 Primary spontaneous pneumothorax occurs
without underlying lung disease.
 In a way, this term is a misnomer because CT
scans have shown the presence of small
subpleural blebs in more than 80% of patients.
 Primary spontaneous pneumothorax usually
occurs in patients in their late teenage years or
early 20s.
 Patients often are tall and slender, and the
lungs and pleural membrane may not have
grown at the same pace; the result is airspace
enlargement and a thin pleural membrane.
 Results of some studies suggest that
cigarette smoking is a risk factor in
more than 90% of cases of primary
spontaneous pneumothorax.
 The smoking history is typically short,
and smoking cessation is
recommended.
 Secondary spontaneous pneumothorax occurs in
patients with underlying lung disease.
 In most cases, the underlying lung disease is chronic
obstructive pulmonary disease (COPD) with some
component of emphysema.
 Pneumothorax also can occur with asthma and cystic
fibrosis, usually during an exacerbation of disease.
 Interstitial lung diseases in which lung volumes are
spared, such as sarcoidosis, organizing pneumonia,
pulmonary Langerhans cell histiocytosis, and
lymphangioleiomyomatosis, have a higher incidence
than diseases without any component of obstruction,
such as idiopathic pulmonary fibrosis.
 Depending on the extent of parenchymal lung
disease, pneumothorax can be devastating. A
Veterans Affairs cooperative study included
185 patients with secondary spontaneous
pneumothorax and monitored them for 5
years.
 Although only three patients died of
pneumothorax, the mortality rate was 43%.1
Severe underlying lung disease caused most
deaths.
 This finding suggested that most
pneumothoraces occur in patients with severe
lung dysfunction.
 The degree of dyspnea is
disproportionate to the size of
pneumothorax in this group of patients
because pulmonary reserve is already
diminished.
 Pneumothorax usually should be
evacuated and not observed in this
patient cohort.
 Catamenial pneumothorax occurs in
conjunction with menstruation and usually is
recurrent and right-sided.
 The reason for the right-sided predominance is
unclear. Many patients have endometriosis on
the pleural surface, although it may be
impossible to see because of hormonal
involution during menses.
 Once the diagnosis is considered,catamenial
pneumothorax is not difficult to manage
because most patients do not have a
recurrence when ovulation is suppressed.
 Tension pneumothorax occurs when air in the
pleural space exceeds atmospheric pressure.
 The radiographic appearance includes
mediastinal shift to the contralateral side,
diaphragmatic depression, and expansion of the
ribs.
 The lung does not collapse completely if it is
involved with a disease process such as acute
respiratory distress syndrome (ARDS).
 Not all patients with radiographic tension have
the physiologic changes commonly associated
with tension pneumothorax.
 However, almost all pneumothoraces that
occur during mechanical ventilation
enlarge if not drained.
 As pressure in the thorax increases and
mediastinal shift places torsion on the
inferior vena cava, venous return to the
right side of the heart decreases.
 Cardiac output decreases, and
hypotension with tachycardia results.
 Hypoxemia occurs as the lung continues
to compress because of intrapulmonary
shunting through the collapsed lung.
 The respiratory therapist (RT) can make
the diagnosis of tension pneumothorax.
 Treatment is emergency
decompression of the chest.
 This procedure usually is done with an
18-gauge intravenous (e.g., Jelco)
catheter inserted just over the second
rib on the anterior aspect of the chest in
the midclavicular line.
 Catheter placement should elicit a rush
of air through the catheter, and this sign
confirms the diagnosis.
 Blood pressure recovery should be
rapid, although resolution of
hypoxemia depends on complete lung
reexpansion and can be delayed.
 The soft intravenous catheter can be
left in place while a more conventional
chest tube is inserted.
RULE OF THUMB
 Tension pneumothorax is a clinical
diagnosis made at the bedside in more
than 50% of cases.
 The clinical signs are diminished breath
sounds, hyper resonance to percussion,
tachycardia, and hypotension.
 The size of a pneumothorax on a chest
radiograph can be estimated with the
knowledge that the volume of the lung
and thorax is proportional to
 the cube of their diameters
 In one case series of 74 patients with
tension pneumothorax, a clinical
diagnosis was made for 45 patients; the
associated mortality rate was 7%.
 In the other cases, the diagnosis was
delayed from the onset of clinical signs
by 30 minutes to 8 hours, resulting in a
31% mortality rate.
 RTS are in the perfect position to make a
timely diagnosis because ventilator
alarms give early warnings (e.g., high
pressure, lower compliance).
 The diagnosis of pneumothorax is established
with chest radiography.
 The diagnosis requires a high-quality film for
visualization of a visceral pleural line.
 In the ICU, 30% of cases of pneumothorax may be
missed in retrospect on a chest radiograph.
 Impediments to diagnosis include a low-quality
radiograph, supine position of the patient,
concomitant presence of mediastinal air, and
subpulmonic or mediastinal position of the
pneumothorax.
 Diagnosis is enhanced with additional
upright radiographs or decubitus views.
 The size of a pneumothorax is difficult to
assess with a chest radiograph because a
two-dimensional picture is being taken of a
three-dimensional thorax.
 Size can be confirmed with CT if needed.