PNEUMOTHORAX
by1. Maharani Dewi Caropeboka, S.Ked
2. Widya Emiliana, S.Ked3. Giska Tri Putri, S.Ked4. Nora Ramkita, S.Ked
PreceptorDr. Dedi Zairus, Sp.P
Internal Medicine Clerkship ProgramDivision of Pulmonology
Dr. Hi. Abdul Moeloek General HospitalBandar Lampung
PNEUMOTHORAXTHEORY
Pneumothorax
- Pneumothorax is the presence of air within the pleural space
-Due to disruption of parietal, visceral or mediastinal pleura
-May also occur from spontaneous rupture of subpleural bleb
-A tension pneumothorax occurs when pleura forms a one-way flap valve
-Tension pneumothorax is a medical emergency.
Classification
1. Spontaneous pneumothorax Primary - no identifiable pathology Secondary - underlying pulmonary disorder 2. Catamenial 3. Traumatic Blunt or penetrating thoracic trauma 4. Iatrogenic Postoperative Mechanical ventilation Thoracocentesis Central venous cannulation
Diseases Associated with Pneumothorax Chronic obstructive lung disease Asthma HIV infection PCP Necrotizing pneumonia Bronchogenic carcinoma Sarcomas metastatic to the lungs Tuberculosis Cystic fibrosis Interstitial lung diseases associated with connective
tissue diseases Idiopathic pulmonary fibrosis Sarcoidosis Lymphangioleiomyomatosis Langerhans cell histiocytosis High-risk occupation (eg, diving,
flying)
Primary Spontaneous Pneumothorax
Primary spontaneous pneumothorax Usually occurs in young healthy adult men 85%
patients are less than 40 years old Male : female ratio is 6:1 Bilateral in 10% of cases Occurs as result of rupture of an acquired subpleural
bleb Blebs have no epithelial lining and arise from rupture of
the alveolar wall Apical blebs found in 85% of patients undergoing
thoracotomy Frequency of spontaneous pneumothorax increases after
each episode Most recurrences occur within 2 years of the initial episode..
Secondary Spontaneous pneumothorax Accounts for 10-20% of spontaneous
pneumothoraces can be due to: Chronic obstructive
pulmonary disease with bulla formation Interstitial lung disease
Primary and metastatic neoplasms
Risks factors for primary spontaneous pneumothorax (PSP)
Smoking Of patients with PSP, 91% reportedly are smokers or were smokers .
The risk of PSP is related to the intensity of smoking, with 102-times higher incidence rates in males who smoke heavily (ie, >22 cigarettes/d), compared to a 7-fold increase in males who smoke lightly (1-12 cigarettes/d
Tall, thin stature in a healthy person Marfan syndrome /EDS Pregnancy A 10-year retrospective series of 250 SP cases
found 5 pregnant women, suggesting that pregnancy is an unrecognized risk factor . The cases were all managed successfully with simple aspiration or vacuum-assisted thoracostomy (VATS), and no harm occurred to mother or fetus.
Traumatic pneumothorax Traumatic pneumothorax can result
from either blunt or penetrating trauma Tracheobronchial and esophageal
injuries can cause both mediastinal emphysema and pneumothorax
Iatrogenic pneumothorax is common to occur after :
- Pneumonectomy - Thoracocentesis - High-pressure mechanical ventilation - Subclavian venous cannulation
Catamenial pneumothorax
Catamenial pneumothorax refers to the development of pneumothorax at the time of menstruation. represents 3-6% of spontaneous pneumothorax in women. Typically, it occurs in women aged 30-40 years with a history of pelvic endometriosis (20-40%). It usually affects the right lung (90-95%) and occurs within 72 hours after the onset of menses.
Symptoms
Dyspnea Pleuritic chest pain
Nerve endings at pleural capsule Sense of impending doom Sudden onset
Tension pneumothorax Spontaneous pneumothorax
Physical Exam - Signs
Unstable patients vs. Stable patients Vital Signs
Asymmetric chest expansion Deviated trachea Diminished breath sounds
unilaterally Hyper-resonance unilaterally Decreased tactile fremitus
Diagnosis
Unstable patient Thoracentesis
Rapid release of air Vital signs stabilize
rapidly
Stable patient CXR
Monitor size by measuring distance from lateral lung margin to chest wall
Be sure that pneumothorax is not expanding
Imaging
Plain Radiographs Upright PA on
inspiration Detect other
pathologies: pneumonia, cardiac, etc.
Partially collapsed lung Tension Pneumothorax
Trachea and mediastinum deviate contralaterally
Ipsilateral depressed hemi-diaphragm
Chest CT Not routine Only to assess the need
for surgery (thoracotomy)
Management
1)Risk stratification 2)Interval of observation 3)Options to restore an air-free pleural
space
1. Risk Stratification
The decision to observe or to treat with an immediate intervention should be guided by a risk stratification that considers the patient's presentation and the likelihood of spontaneous resolution and recurrence
2. Interval of Observation Monitoring pneumothorax size during this time is important .
0-6 hours : The ACCP Delphi consensus statement recommends observation in an ED for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement of the lesion, in reliable patients
Emergency room observation with a repeat radiograph 6 hours later used to be common but may be used less often now .
24-96 hours : Additional follow up in 2 days is recommended, with preference given to a 24-48 hour follow-up radiograph in the outpatient setting.
Outpatient follow-up during the 96-h (4-d) window is essential to distinguish between a resolved pneumothorax and one that needs evacuation.
1 month: Full re-expansion can occur, on average, 3 weeks after the initial event .
Options to restore an air-free pleural spaceObservation without oxygen Simple observation is appropriate for
asymptomatic patients with a minimal pneumothorax (<15-20% by Light's criteria; 2-3 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement. Air is reabsorbed spontaneously by 1.25% of size pneumothorax per day.
Options to restore an air-free pleural space Supplemental oxygen : Oxygen administration at 3 L/min nasal canula or higher
flow treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone.
Simple aspiration, recent ED study supports needle aspiration as safe and effective as chest tube for PSP, conferring the additional benefits of shorter length of stay and fewer hospital admissions.
Chest tube for air removal: A tube inserted into the pleural space is connected to a device with one-way flow. Examples of such devices are Heimlich valves or water seal canisters , and tubes connected to wall suction devices. Thoracostomy with continuous (wall) suction.
Options to restore an air-free pleural spaceSurgery is often indicated for : recurrent pneumothorax, bilateral pneumothorax, prolonged air leak (longer than five
to seven days), or inability to fully expand the lung.
Options to restore an air-free pleural space Sclerotherapy with doxycline or talc should be
considered for poor surgical candidates, but this approach may complicate future surgical
intervention or lung transplant. A thoracic surgeon should be consulted on these
patients. If it is decided that the best treatment is surgical,
the recent development of thoracoscopic intervention offers certain benefits. The surgeon can thoracoscopically visualize the full pleura, staple or resect blebs, apply electrocautery, laser, resect pleura or instill sclerosant (usually talc).:
Indications for surgical assistance Persistent air leak for more than 7 days Recurrent ipsilateral pneumothorax Contralateral pneumothorax Bilateral pneumothorax First-time presentation in a patient with a high-risk
occupation (eg, diver, pilot) Patients with AIDS often need this intervention because
of extensive underlying necrosis. The risk of recurrent pneumothorax may also be
unacceptable for patients with plans for extended stays at remote sites.
Lymphangiomyomatosis , a condition causing a high risk of pneumothorax.
Video-assisted thoracoscopic surgery (VATS)
VATS is appropriate for recurrent primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). VATS with resection of large bullous lesions is associated with a recurrence rate of 2-14%. VATS is done under general anesthesia using a camera and 2 trocar ports.
CASE REPORT
The history taking and physical examination were done on 1st of July, 2013 in Pulmonary Ward (Melati) Dr. Hi. Abdul Moeloek General Hospital, Bandar Lampung.
Identification of Patient Name : Mr. Nuryanto Age : 40 Gender : male Address : Jl. Jati Tanjung Raya, Bandar
Lampung Profesion : Merchant Education : Elementary school Marriage status : Married Religion : Moslem Admission date : June 30th 2013
HISTORY Anamnesis : Autoanamnesa Chief Complaint : Shortness of breath Secondary Complaint : Cough, chest pain History of Present Illness :
The patient came to the hospital with shortness of breathe for 3 months. The shortness of breathe occured gradually then suddenly developed rapidly into severe breathlessness and get worse for the past 5 days, so that the shortness of breathe felt in rest position. He didn’t notice any wheezing or weird breath sounds. He was doing his job (merchant) when he felt the rapidly progreessing shortness of breathe. He also already had a wet cough with colorless phlegm for the last 6 months. The phlegm never mixed with blood nor changed in color. The cough occured gradually and not affected by time (no difference in the morning or night ) or cold air. There was slight fever, and felt mostly in the evening for the last 6 months and then he was sweaty at night. The fever never gets high, and not accompanied with symptoms of common cold like rainy nose or fatigue. He also felt lost in appetite, and he lost weight drastically since the last 1 year. He didn’t have difficulty swallowing or have choke episode. After having severe breathlessness, he was brought to Bintang Amin Hospital, and he was told that there was air trapped in his left lung. Four days ago, the doctor put a tube into his chest to rescue the air that trapped and he felt a little relieve. His phlegm had been evaluated and positive for acid bacilli. He has been diagnosed as diabetes for a year and receive oral medicine from public health centre.
History of Past IllnessHis past illness is unremarkable. He never had asthma or severe breathlessness before. He also never took any 6 months regiments / antituberculosis drug.
History of Family IllnessThere was no family member who diagnosed as tuberculosis, or having wet cough more than 2 weeks.
Lifestyle and ActivityThe patient was an active smoker for more than 10 years, a pack a day. The patient is a merchant, and still able to do his work before the worsening of his breathlessness.
Physical Examination
General appearance : Looks ill Consciousness : Compos mentis,
E4V5M6 Height : 158 cm Weight : 40 kg BMI : 16.06 kg/m2
Blood Pressure : 100/70 mmHg Pulse : 84 bpm , regular Temperature : 36.80 C Respiration Rate : 24x/minute
Head : Normocephali, atraumatic, normal hair distribution, hair not easily revoked
Eye : isochor pupils, anemic conjuctiva +/+, icteric sclera -/- visual field intact,
Nose : Symmetrical, septum deviation (-), discharge (-), concha oedem (-)
Mouth : caries , stomatitis (-) Throat : tonsil T1-T1 calm, hyperemis
pharing (-) Neck : thyroid gland normal size,
lymph nodes not palable, deviation of trachea (-)
Thorax Lung Inspection : symmetrical shape,
asymetrical chest movement, decreased left hemithorax movement, accessory muscle use (-), WSD placed in axillary anterior line 5th intercostal space
Palpation : Subcutaneous crepitation (+), absent vocal fremitus on the left hemithorax, no tenderness.
Percussion : hypersonor on left hemithorax Auscultation : absent breathe sounds of the
left hemithorax, vesicular breath sound on the right hemithorax. Wheezing (-), Crackles (-)
HeartInspection : ictus cordis not visiblePalpation : ictus cordis not palpablePercussion : heart boundary difficult to assessAuscultation : S1/S2 heart sounds, regular ,
murmur (-), gallop(-)
AbdomenInspection : abdomen flat, no tension, no dilated
veinsPalpation : no percussion pain, no defense
muscular, no enlarged liverPercussion : timpanic, shifting dullness (-)Auscultation : bowel movement (+), normal
Extemity : warm , oedem (-), cyanosis (-)
Laboratory ang Imaging
Hb 11.2 g/dl Leucocyte 10.000/ml Diff count 0/1/1/83/11/4 ESR 40 mm/jam Thrombocyte 423.000 SGOT 90 U/L SGPT 52 U/L Ureum 25 mg/dl Creatinine 0.5 mg/dl Postero-anterior chest X ray ( June 30th 2013)
Irregular luscent area in the soft tissue Bones and joints (clavicula, scapula, costae, vertebrae) are intact Deviation of trachea to the right side Clear pleural line Avascular and hyperluscent area in left lung field Deviation of mediastinal structure to the right Blunting of left costophrenic angle (air fluid level form)
Conclusion : Left hydropneumothorax
RESUME
40 year old male was admitted to the hospital because of worsening of shortness of breathe for the past week. Four days ago, he had a tube inserted into the left side of his chest to rescue the air that trapped in his lungs. After the procedure, he felt a little relieve. He had felt mild shortness of breathe for about 3 months before it got worse suddenly. He also have wet cough with colourless phlegm for 6 months.. A mild fever, night sweat, and rapid decrease of body weight (+).The phlegm had been tested last week, and positive for acid fast bacilli. He was diagnosed diabetes for a year and taking 1 tablet for the diabetes.
Physical examination revealed the patient looks ill but not in acute distress, compos mentis, afebris, BP 110/70 mmHg, Pulse 84 bpm reguler, respiration rate 24 x/minute, IMT 16.06. Anemic conjunctiva +/+. Chest examination revealed WSD tube inserted into fifth intercostal space, left axillary line. A subcutaneous crepitation observed. Decreased left side thoracic expansion and absent breath sound on the left side.
Laboratory findings revealed mild anemia (Hb 11,9 g/dl), total leucoocyte count of 10.000 , and increased ESR (45 mm in the end of 1st hour) .
The posteroanterior chest x ray revealed a left pneumothorax with subcutaneous emphysema.
DiagnosisPulmonary tuberculosis with positive acid fast bacilli + hydropneumothorax + type II diabetes normoweight
Treatment
O2 2 Litres/minute Massage IVFD RL gtt X/minute Dexamethasone 5 mg/ 8h (IV) OBH 3x1C Rifampicin 1x450 mg Isoniazid 1x300 mg Ethambutol 1x750 mg Pyrazinamide 1x 750 mg Ceftriaxone 1 gram/12 hours Ranitidine 40 mg/12 hours
Prognosis
Quo ad vitam : dubia ad bonam Quo ad functionam: dubia ad bonam Quo ad sanationam : dubia ad
bonam
DISCUSSION
What are the problems of the patient ?
The problem of the patient that we found including :
Hydropneumothorax ec pulmonary tuberculosis
Subcutaneous emphysema Type II diabetes melitus
The patient was admitted to the hospital because of worsening of shortness of breathe for the past few days. He already felt mild shortness of breathe for 3 months, until it suddenly got worse and made him dyspneic even in resting state. There was some possible cause of sudden onset severe breathlessness. But with deeper history taking, it might be possible to distunguish the likely cause of severe breathlessness. This patient’s symptomp including productive cough for 6 months along with night sweat, prolonged mild fever, and decreased body weight make pulmonary tuberculosis is likely. Besides, the absence of weird breath sounds (like wheezing) and no history of asthma attack make asthma is unlikely. The absence of high fever makes pneumonia is unlikely too. The patient was a moderate smoker ( Brinkman index 200-600), then the very severe of COPD exacerbation or pulmonary carcinomas should be kept in mind.. Another cause that come from outside the respiratory organs (i.e. cardiovascular, neurological, metabolism) must be evaluated.
Then, it could be confirmed by physical examination. The absence of breath sound in one side of the chest along with decreased expansion movement , decreased vocal fremitus, and hyperresonance percussion could lead to the pneumothorax diagnosis. Beside, there was absence heart dullness that supposed to be found in chest percussion on the left side of the chest. That might be because of shift of mediastinal structure due to enforcement of the trapped air. The trachea could’ve been deviated too.
If the patient is stable, we could use chest x ray to confirm. But in emergency setting, confirming chest x ray is not mandated.
Pneumothorax itself is one of the complication of pulmonary tuberculosis. Seaton et al recorded that 1.4% of people with pulmonary tuberculosis can have pneumothorax, and with the cavity can increase the risk up to 90%. Pneumothorax that caused by TB can be classified as secondary spontaneous pneumothorax.
We also found subcutaneous crepitation, that might be due to subcutaneous emphysema. Subcutaneus emphysema is the accumulation of air in the soft tissue. Most cases of subcutaneous emphysema are benign. The patient also diagnosed as diabetes for a year and have taken oral medicine to control the blood glucose. Further evaluation of patient’s blood glucose profile (fasting blood glucose, glucose tolerance test) should be performed.
Is the management of the patient ? O2 2 Litres/minute IVFD RL gtt X/minute OBH 3x1C Rifampicin 1x450 mg Isoniazid 1x300 mg Ethambutol 1x750 mg Pyrazinamide 1x 750 mg Ceftriaxone 1 gram/12 hours WSD
Oxygen administration at 3 L/min nasal canula or higher flow treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone. There is no need for the patient to receive intravenous fluid deliveries.
The antituberculosis regimen given is 1st category, dosage for weight between 40 to 60 kgs. The patient given 1st category because he has never taken any antituberculosis regiment (new case) and his sputum evaluation show positive result for acid fast bacilli. He weighs 40 kg. So in this patient, whom given 450 mg of rifampicin; 300 mg of isoniazid; 750 mg of pyrazinamide; and 750 mg of ethambutol, the antituberculosis drug is adequate. The antituberculosis given to the patients for 2 months. This called “intensive phase”. This patients laboratory result showed 2-fold increase of SGOT/SGPT. This patient still can receive the antituberculosis therapy but with strict supervision.
The ceftriaxone used as the empiric therapy because of invasive procedure done and possibility concordance of bacterial infection that causing hydropneumothorax. The dosage of ceftriaxone is 50-100 mg/kg/day, divided into 2 doses. This patient weighs 40 kg so the dosage was 2 grams, divided into 2 dose.
WSD in pneumothorax is indicated if pneumothorax >25%. In this patient, the pneumothorax is more than 25%. There are currently two methods described in adults:
If lateral edge of lung is > 2cms. from thoracic cage at the level of the hilum, then this implies pneumothorax is at least 50%, and hence large in size.or
Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed).
To express the pneumothorax size as a percentage, multiply the fractional size by 100.
Regarding the patient’s condition of having type II diabetes melitus, the diet of the patient should’ve been changed to the DM diet, for kcal. If the patient given sulfonyl urea, the dosage should be given more because of its interaction with the antituberculosis drugs. Rifampicin could decrease effectivity of sulfonyl urea. The use of ethambutol can increase the risk of visual impairment caused by diabetic retinopathy.
REFERENCES Sahn, SA, Heffner, JE. Spontaneous
Pneumothorax NEJM, 2000; 342:868 Light, Richard W. 2007. Pleural Diseases.
Lippincolt William & Wilkins : Philadelphia. Accessed from http://books.google.co.id/books?id=vHEpRHQXaKU C&pg=PA309&lpg= PA309&dq=calculate+percentage+pneumothorax&source=bl&ots=iS-N6UtpPG&sig=rXuS9ComWd4Y8CaX4HXNeplzSts&hl=id&sa=X&ei=OJ7dUdmdGMiHrgeU3ICgBg&ved=0CFQQ6AEwBQ#v=onepage&q=calculate%20percentage%20pneumothorax&f=false July 8th 2013.
Anonym. 2013. Primary Spontaneous Pneumothorax. Accessed from http://www.rch.org.au /clinicalguide/guideline_index/Primary_Spontaneous_Pneumothorax/ July 8th 2013.
Daley, Brian James MD,FACS,FCCP,CNSC et al. 2013. Pneumothorax. Accessed from http://emedicine.medscape.com/article/424547-overview July 8th 2013.
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