PNEUMOTHORAX
Dr G.B.L Samarasekera
Consultant Respiratory physician
DGH -Gampaha
Case History
• A 65 years old man presented with worsening shortness of breath for 3
days duration.
• PMH – COPD for 5 years ( recent PFT FEV1/FVC 50%, FEV1 0.89( 35%) FVC
1.44 (75%) )
• Smoking history – 25 pack years
• On examination – Spo2 -82% and Global reduction of breath sounds with
bilateral rhonchi
• ABG- decompensated type II respiratory failure
• Patient was started on NIV ( Bi PAP) , failing maximal medical management.
• Few hour later patient suddenly deteriorated
What is the next step of management
• 1. arterial blood gas
• 2. chest x-ray
• 3. full blood count and CRP
• 4. pulmonary function test
• 5. 100% oxygen
Answer
• Chest X-ray
Pneumothorax
Primary Spontaneous Pneumothorax
• Underlying lung is normal
• Occurs in young healthy individuals
• it is caused by rupture of pleural blebs
Predisposing factors
• Smoking
• Tall thin male
Recurrence
• 50% on the same side
• 10% in opposite side
Secondary spontaneous pneumothorax
Is associated with underlying lung diseases
• COPD (Emphysematous bullae)
• Severe asthma
• Cystic lung diseases
• infections (pneumocystis , tuberculosis , abscess forming organisms)
• Interstitial lung diseases (histiocytosis X, sarcoid)
• Connective tissues disorders (Ehlers-Danlos, Marfans and
Rheumatoid)
• Tumours
Traumatic Pneumothorax
Accidental trauma
• Blunt trauma: with fracture ribs
• Penetrating trauma: stab wound or gun shot injury
Iatrogenic trauma
• Positive pressure ventilation
• Interventional procedures:
Tension Pneumothorax
• Occurs when air enters but cannot leave the pleural space ,causing
progressive build up of pressure, compromise of the mediastinal
structures leading to impairment of venous return and risk of death.
Epidemiology
• Over half of pneumothorax are traumatic in origin ( trauma or
iatrogenic)
• There is bimodal age distribution ( primary 15-34years) and
secondary (over 55 years)
• Pneumothorax is commoner in men.
• Genetic conditions
Ehlers – Danlos syndrome, cystic fibrosis, homocystinuria and alpha 1 antitrypsin deficiency
Clinical Features
• Primary pneumothorax may be asymptomatic
• Usually complains of sharp pleuratic chest pain with or without
dyspnoea
• Dyspnoea invariably presents with secondary pneumothorax and
may be severe and associated with respiratory failure even with small
pneumothorax
Signs
• Hyper- resonance
• Reduced chest expansion
• Reduced vocal fremitus
• Reduced /absent breath sounds
• Tension pneumothorax associated with tachycardia, hypotension ,
mediastinal shift and respiratory failure
ICD insertion
• Patients with PSP or SSP and significant breathlessness associated with
any size of pneumothorax should undergo active intervention.
• Chest drains are usually required for patients with tension or bilateral
pneumothorax who should be admitted to hospital.
• Observation is the treatment of choice for small PSP without significant
breathlessness.
• Patients with a small PSP without breathlessness should be considered
for discharge with early outpatient review. These patients should also
receive clear written advice to return in the event of worsening
breathlessness.
• Needle aspiration or chest drain?
• Needle (14–16 G) aspiration (NA) is as effective as large-bore (>20 F)
chest drains and may be associated with reduced hospitalisation
and length of stay.
• NA should not be repeated unless there were technical difficulties.
• Following failed NA, small-bore (<14 F) chest drain insertion is
recommended. (A)
• Large-bore chest drains are not needed for pneumothorax. (D)
Management of SSP
• All patients with SSP should be admitted to hospital for at least 24 h
and receive supplemental oxygen in compliance with the BTS
guidelines on the use of oxygen.
• Most patients will require the insertion of a small-bore chest drain. (
• All patients will require early referral to a chest physician. (D)
• Those with a persistent air leak should be discussed with a thoracic
surgeon at 48 h.
Discharge and follow up
• Patients should be advised to return to hospital if increasing
breathlessness develops.
• All patients should be followed up by respiratory physicians until full
resolution.
• Air travel should be avoided until full resolution.
• Diving should be permanently avoided unless the patient has
undergone bilateral surgical pleurectomy and has normal lung
function and chest CT scan postoperatively.
• Please advice to STOP SMOKING
Preventing recurrence of a Pneumothorax
Primary
• Discourage smoking
• VATS
In most cases VATS pleurodesis should recommended following a
second episode of pneumothorax ( first recurrence) and first contra
lateral pneumothorax.
Preventing recurrence of a pneumothorax
THANK YOU
