Post on 17-Jan-2018
description
PNEUMOTHORAX TUCOM Internal Medicine 4th year Dr. Hasan.I.Sultan
Pneumothorax Define as; Air accumulates in the pleural space
Classification of pneumothorax A-Spontaneous 1-Primary; Without
evidence of overt lung disease. Air escapes from the lung into the
pleural space through rupture of a small subpleural emphysematous
bulla or pleural bleb, or the pulmonary end of a pleural adhesion.
2-Secondary; Underlying lung disease, most commonly COPD and TB;
also seen in asthma, lung abscess, pulmonary infarcts, bronchogenic
carcinoma, all forms of fibrotic and cystic lung disease.
B-Traumatic; Iatrogenic (e.g. following thoracic surgery or biopsy)
Non-iatrogenic Clinical features; Commonest symptoms are
sudden-onset unilateral pleuritic chest pain or breathlessness
Small pneumothorax (50% of the volume of hemithorax) results in;
Decreased or absent breath sounds Resonant percussion Types of
spontaneous pneumothorax
1-Tension pneumothorax; It can act as a one-way valve allowing air
to enter the pleural space during inspiration but not to escape on
expiration. Intrapleural pressure may rise to well above
atmospheric levels causes mediastinal displacement towards the
opposite side and cardiovascular system compromise. Clinically,
rapidly progressive breathlessness, marked tachycardia,
hypotension, cyanosis and tracheal displacement away from the side
of the lesion 2-Closed pneumothorax; Communication between the lung
and pleural space seals off as the lung deflates and does not
reopen the mean pleural pressure remains negative spontaneous
reabsorption of air and re-expansion of the lung occur over a few
days or weeks, and infection is uncommon. 3-Open pneumothorax;
Communication fails to seal and air continues to transfer freely
between the lung and pleural space-- a bronchopleural fistula--
transmission of infection empyema. rupture of an emphysematous
bulla, tuberculous cavity or lung abscess into the pleural space.
Investigations Chest X-ray; CT of chest;
Shows the sharply defined edge of the deflated lung with complete
translucency (no lung markings) between this and the chest wall.
Chest X-rays also show the extent of any mediastinal displacement
and give information regarding the presence or absence of pleural
fluid and underlying pulmonary disease. CT of chest; Is useful in
distinguishing bullae from pleural air. Management Primary
pneumothorax where the lung edge is less than 2 cm from the chest
wall and the patient is not breathless normally resolves without
intervention. Percutaneous needle aspiration (PNA) of air is a
simple and well-tolerated alternative to intercostal tube drainage,
with a 60-80% chance of avoiding the need for a chest drain in
young patients presenting with a moderate or large spontaneous
primary pneumothorax. Intercostal tube drainage; indicate in above
patient who does not improved by PNA and in patients with
underlying chronic lung disease, however, even a small secondary
pneumothorax may cause respiratory failure. Need inpatient
observation. Inserted in the 4th, 5th or 6th intercostal space in
the mid-axillary line Supplemental oxygen as this accelerates the
rate at which air is reabsorbed by the pleura. Surgical
pleurodesis;
Second pneumothorax (even if ipsilateral). First episode of
secondary pneumothorax if low respiratory reserve makes recurrence
hazardous Occupational risk (e.g. flying or diving) should also
undergo definitive treatment after the first episode of a primary
spontaneous pneumothorax. Persistent air leak and the lung fails to
re-expand after appropriate pleural drainage. Thanks