PneumothoraxMR 8/17/09

J.Chen

Chest Pain

Differential Diagnosis Musculoskeletal Cardiac Gastrointestinal Respiratory Psychogenic Miscellaneous

Musculoskeletal

Chest Wall Strain

Costochondritis

Direct Chest truama

Cardiac

Gastrointestinal

Caustic Ingestion

Esophageal foreign body

Esophagitis

GERD

Respiratory

Asthma

Cough

Pleural Effusion

Pneumonia

Pneumothorax

Pneumomediastinum

Pulmonary Embolism

Psychogenic

Anxiety

Hyperventilation

Miscellaneous

Breast Mass

Shingles

Sickle Cell Crisis

Thoracic Tumor

Pneumothorax

Presence of air between the visceral and parietal pleura that leads to lung collapse

Pneumothorax

Traumatic

Iatrogenic

Spontaneous Primary Secondary

Traumatic Pneumothorax

Penetrating Trauma (eg Bullet, Knife) Air entering pleural space directly through chest wall

Blunt Trauma Rib Fracture Alveolar rupture from sudden compression

High Risk Occupations Diving Flying

Iatrogenic Pneumothorax

Transthoracic Needle Aspiration biopsy

Transbronchial Biopsy

Thracentesis

Central Venous Catheter Placement

Intercostal Nerve Block

Tracheostomy

CPR

Positive Pressure Ventillation

NG tube placement

Spontaneous Pneumothorax

Due to rupture of apical Blebs

PSP-Pt do not have clinically apparent lung disease

Subpleural bullae found in 76-100% of patients undergoing VATS

Risk Factors-PSP

Smoking

Tall, Thin stature

Marfan

Birt-Hogg Syndrome-AD, characterized by benign skin tumors, renal/colon cancer, Sp PTX

Pregnancy

Familial PTX

Conditions Associated with SSP

History

Usually occur while at rest

Acute onset of chest pain Severe Stabbing Radiates to ipsilateral shoulder Pleuritic

Sudden onset of SOB

Anxiety

Cough

Dyspnea

Physical Exam

Vital Signs: Tachypnea Tachycardia Hypotension Hypoxia Pulsus Paradoxus

General Appearance Diaphoretic Splinting Cyanotic

Physical Exam

Respiratory Decreased Breath Sounds Hyperresonance to percussion Decreased Tactile Fremitus “Scratch Sign”

Cardiovascular JVD Shift in PMI

Other Subcutaneous Emphysema Shifted Trachea Altered Mental Status

Laboratory Studies

ABG PO2 frequently decreased Increased A-a gradient PCO2:

Elevated with respiratory compromise Decreased from Hyperventilation

Imaging

CXR-confirmatory

CT Useful for finding small pneumothoraces Distinguish PTX from bleb or cyst Locating small blebs

US Increasing in use 95%sensitivity, 100%specificity

CT Scan

Managment

Small PTX (<3cm): Observation High Flow O2 No further management if CXR in 24 hr is

small/stable

Management

Large PTX Hospitalization Chest tube +/- suction until lung reexpands and air leak

resolves Chemical Pleuredesis

Talc Bleomycin, tetracycline, povidone iodine

Video Assisted Thorascopic Surgery (VATS) Removal of Blebs Surgical pleurodesis

Attach lung to intrathoracic chest wall Mechanical abrasion of the lung

Pleur-Evac

Recurrence rate based on intervention Overall between 16-52%