Hemopneumothorax
Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDs), FCCP
Consultant Cardiothoracic Surgeon
Asst. Professor of Surgery
Division of Cardiothoracic Surgery
King Abdulaziz University
Definition
• A pneumothorax is a collection of free air in the
chest outside the lung that causes the lung to
collapse.
incidence
• Spontaneous pneumothorax affects about 9,000
persons each year in the U.S. who have no history of
lung disease. This type of pneumothorax is most
common in men between the ages of 20 and 40,
particularly in tall, thin men. Smoking has been
shown to increase the risk for spontaneous
pneumothorax
Etiology
• Spontaneous pneumothorax is caused by a rupture
of a cyst or a small sac (bleb) on the surface of the
lung (apical segment of upper lobe and or superior
segment of lower lobe)
• May also occur following an injury to the chest wall
such as a fractured rib, any penetrating injury (gun
shot or stabbing),
Etiology
• A pneumothorax can also develop as a result of
underlying lung diseases, including cystic fibrosis,
chronic obstructive pulmonary disease (COPD), lung
cancer, and infections of the lungs (pnemocysts
carinii).
Types of pneumothorax
• A spontaneous pneumothorax, also referred to as a
primary pneumothorax, occurs in the absence of a
traumatic injury to the chest or a known lung disease
• A secondary (also termed complicated)
pneumothorax occurs as a result of an underlying
condition
Tension Pneumothorax
• Tension pneumothorax: The accumulation of air
under pressure in the pleural space.
• The air enters the pleural cavity and is trapped there
during expiration so the air pressure within the
thorax mounts higher than atmospheric pressure,
compresses the lung, may displace the mediastinum
and its structures (including the lung) toward the
opposite side, and cause cardiopulmonary
impairment (decrease cardiac output)
Clinical Presentation
• Sudden onset chest pain sharp in nature .
• Shortness of breath
• Tachypnea
• Tachycardia
• Cyanosis
• Decrease or abscent breath sounds
Diagnosis
• Clinical presentation
• Chest X-ray
Radiographic Picture
Radiographic Picture
Treatment
• A small pneumothorax without underlying lung
disease may resolve on its own.
• A large pneumothorax and a pneumothorax
associated with underlying lung disease often require
placement of a chest tube to evacuate the air
Thoracostomy Tube
Hemothorax
• Hemothorax refers to a collection of blood within the
pleural cavity.
Etiology
• Traumatic
– Blunt trauma
– Penetrating trauma (including iatrogenic)
• Nontraumatic or spontaneous
– Neoplasia (primary or metastatic)
– Blood dyscrasias, including complications of
anticoagulation
– Pulmonary embolism with infarction
– Torn pleural adhesions in association with
spontaneous pneumothorax
Clinical Presentation
• Hemodynamic changes vary depending on the
amount of bleeding and the rapidity of blood loss
• Shock (blood loss > 750cc)
• A large enough collection causes the patient to
complain of dyspnea
Workup
• Chest radiography
– The upright chest radiograph is the ideal primary
diagnostic study in the evaluation of hemothorax
- Hemothorax is noted as a meniscus of fluid
blunting the costophrenic angle
• CT scan
– CT scan is a highly accurate diagnostic study for
pleural fluid or blood
Radiographic Picture
Treatment
• If a hemothorax is equal to or greater than the
amount required to obscure the costophrenic sulcus
or is found in association with a pneumothorax
based on chest radiograph findings, it should be
drained by tube thoracostomy
Treatment
• Surgical exploration in cases of traumatic hemothorax
should be performed in the following circumstances:
• Greater than 1000 mL of blood is evacuated immediately
after tube thoracostomy. This is considered a massive
hemothorax.
• Bleeding from the chest continues, defined as 150-200
mL/h for 2-4 hours.
• Persistent blood transfusion is required to maintain
hemodynamic stability
