Recognizing Pneumothorax

7/25/2019 Recognizing Pneumothorax

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RecognizingA Pneumothorax

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William erring, !"#" $ %&&%


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Remember

'here are two la(ers of pleura) parietal and visceral)the

pleural space between them *ormall( there is no air in the pleural space

'he visceral pleura is inseparable from the lung parench(ma

and moves with the lung


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+isceral

pleura

Parietal

pleura

Pleural space

$ rank *etter, !# *ovartis-


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'he +isceral Pleural White .ine

When air enters the pleural space, the parietal and visceral

pleura separate making the visceral pleura visible

'he thin white line of the visceral pleura is called thevisceral pleural white line

/ou must see the visceral pleural white lineto make

diagnosis of pneumothorax0


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A pneumothorax will bevisible as a thin white

line ) the visceral pleural

white line


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.ung !arkings

.ung markings ma( be absent distal to the visceral pleural

white line

1ut the( can be seen distal to the visceral pleural white line

even with a pneumothorax if lung is folded on itself

Absence of lung markings is not sufficient to make diagnosis

of pneumothorax0


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.arge bulla in the ..." *ote there is no

visceral pleural white line paralleling the chest wall

ARRS R2 $

Wh( 'he Pleural White .ine

Is Important


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3hest tube erroneousl( inserted into bulla

in .4. produces an intractable pneumothorax"

ARRS R2 $


Is Important


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'here are diseases other than a pneumothorax that

can cause an absence of lung markingsor example

1ullous disease

.arge c(sts in the lungPulmonar( embolism


Is Important


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Is Important

*one of those diseases is treated with a chest

tube

In fact, insertion of a chest tube into a bulla can

produce an intractable pneumothorax


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Skin fold or Pneumothorax

A fold of the patient5s skin ma( become trapped between

the patient and cassetteSkin folds are common

6speciall( in patient5s who have lost a great deal of

weight

'his skin fold can mimic a pneumothorax


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ow can we tell them apart7

Skin oldSkin old Pneumothorax


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'he ke( difference is that a skin fold is an edge

consisting of a densit( 8light9 and then a lucenc( 8dark9

Skin old

#ense

.ucent

'his is an edge


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Whereas the visceral pleural line is a

thin white line with a lucenc( 8darker9 on both sides of it

Pneumothorax

.ucent

#ense

.ucent

'his is a line


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ere the( are again side)b()side: the skin fold is an edge,

the pneumothorax is a line

Skin oldSkin old Pneumothorax


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Which is this7


'his is an

edge ;

skin fold


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Which is this7


'his is a line ;

pneumothorax


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'(pes of Pneumothoraces

'wo ma


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Simple Pneumothorax

In a simple pneumothorax, there is no shift of

the heart or mediastinal structures 8trachea9

Air in left hemithorax balances the air in the

right hemithorax


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Simple pneumothorax on the left side

*o shift of the heart or trachea

+isceral

pleural white

line

*o shift of

midlinestructures


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'ension Pneumothorax

Progressive loss of air into pleural space causing a

shift of the heart and mediastinal structures awa( from

side of pneumothorax

=pposite lung is compressed

Respirator( function severel( compromised


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'ension Pneumothorax

$ rank *etter, !# *ovartis-

Air enters Right hemithorax either from tear in lung or hole in chest

wall on inspiration> does not exit on expiration


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3omplete right)sided

pneumothorax

.ung is compressedagainst mediastinum

Shift of heart and

trachea to left


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Which is this7Simple or 'ension Pneumothorax

'ension pneumothorax)heart is shifted slightl(

to right b( large left)sided pneumothorax


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Shifts with a Pneumothorax

If simple, there is no shift of heart and?or trachea

If tension, there is a shift of heart and?or trachea

awa( from side of pneumothorax

'here is never a shift toward the side of a

pneumothorax


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3auses of a Pneumothorax

Spontaneous

Rupture of an apical sub)pleural bleb usuall( in a tall,

thin male

'rauma

'hrough chest wall, e"g" stab wound

Internal, e"g" rupture of a bronchus from a motor vehiclecollision


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3auses of a Pneumothorax

#iseases that decrease lung compliance

3hronic fibrotic diseases, e"g" eosinophilic granuloma

#iseases that stiffen the lung, e"g" h(aline membrane

disease

Rupture of an alveolus or bronchiole

6"g", asthma


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Important Points

/ou must see the visceral pleural white line to

diagnose a pneumothorax

A skin fold is an edge> the visceral pleural line

is a line

'here is a never a shift toward the side of apneumothorax


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Pneumothorax

'he visceral pleural white

line is seen and there are no

lung marking distal to it" 'hisis a simple pneumothorax

since there is no shift"


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*o Pneumothorax

'his is a skin fold" It is an edge,

not a line"


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ARRS R2 $

*o Pneumothorax

'his is a skin

fold" It is an

edge, not a

line"


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'here is a left)sided

tensionpneumothorax with

shift of the heart

and mediastinal

structures to theright"

Pneumothorax

Recognizing Pneumothorax

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