Pneomothorax & hemothorax by Farshid Mokhberi
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This document discusses pneumothorax and hemothorax. It defines pneumothorax as a collection of air in the pleural space, which can be spontaneous or traumatic. Tension pneumothorax is a life-threatening condition where air builds up pressure in the pleural space. Hemothorax is defined as a collection of blood in the pleural space. The document covers causes, pathogenesis, clinical presentations, and treatment approaches for pneumothorax and hemothorax.
Pneomothorax & hemothorax by Farshid Mokhberi
- 1. Pneumothorax & Hemothorax By Farshid Mokhberi Shahid Beheshti University of Medical Sciences
- 2. PulmonaryVentilation BOYLE’S LAW Gas pressure in closed container is inversely proportional to volume of container Pressure differences and Air flow From high to low gradient
- 3. Pressures Atmospheric pressure – 760 mm Hg Intrapleural pressure – 756 mm Hg Intrapulmonary pressure (Alveolar pressure) – varies, pressure inside lungs Transpulmonary Pressure – difference between the alveolar pressure and intrapleural pressure in the lung Ptp = Palv – Pip
- 5. Under Physiological Conditions Normally: Atmospheric P. > Alveolar P. > Intrapulmonary P. Transpulmonary pressure is always positive Intrapleural pressure is always negative and relatively large Alveolar pressure moves from slightly positive to slightly negative as a person breathes For a given lung volume the transpulmonary pressure is equal and opposite to the elastic recoil pressure of the lung.
- 6. Under Pathological Condition When transpulmonary pressure = Zero Remember: Ptp = Palv – Pip Alveolar pressure = Intrapleural pressure Examples: When the lungs are removed from the chest cavity Air enters the intrapleural space Pneumothorax Under both conditions the lungs collapse as a result of their inherent elastic recoil
- 7. Pneumothorax Definition: Collection of air with in the pleural space Due to rupture of a subpleural or intrapleural bleb Intrapleural pressure is the same as the atmospheric pressure Transforms the potential space into a real one With Progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario Impairs respiratory function Decreases venous return to the right side of the heart
- 8. Classification of Pneumothorax Spontaneous Pneumothorax Primary spontaneous pneumothorax Occurs without a precipitating event in a person who does not have known lung disease Secondary spontaneous pneumothorax Occurs due to an underlying lung disease Traumatic/Tension Pneumothorax Pulmonary source Tracheobronchial source Esophageal source
- 9. Epidemiology of Spontaneous Pneumothorax More common in men than women Spontaneous pneumothorax: commonly seen in tall, thin, young men 20 to 40 years of age Risk increases with smoking Approximately 25% recurrence rate within 2 years
- 10. Causes of Spontaneous Pneumothorax Primary Spontaneous Pneumothorax Idiopathic most common Scuba Diving Marfan Syndrome Homocystinuria Thoracic endometriosis Secondary Spontaneous Pneumothorax COPD (most common), Asthma & Cystic Fibrosis Immunocompromised Infections Pneumocystis jirovecii pneumonia On the rise due to AIDS TB & Cocci
- 11. Pathogenesis of Spontaneous Pneumothorax Rupture of the apical subpleural or intrapleural bleb produces a hole in the pleura. Pleural cavity pressure is the same as the atmospheric pressure. Spontaneous pneumothorax: loss of negative intrathoracic pressure Causes a portion of lung or the entire lung to collapse
- 12. Hypoxemia & Hypercapnia Hypoxemia is common collapsed and poorly ventilated portions of lung continue to receive significant perfusion V/Q mismatch Hypercapnia is unusual underlying lung function is relatively normal and adequate alveolar ventilation can be maintained by the contralateral lung
- 13. Clinical Findings in Spontaneous Pneumothorax Sudden onset of dyspnea with pleuritic type of chest pain (90%) Physical examination Tympanic percussion note Absent breath sounds Trachea deviated to the side of the collapse if there is total lung collapse
- 14. Upright chest x-ray White visceral pleural line Absence of vessel markings peripheral to line
- 15. Treatment of Spontaneous Pneumothorax Observation alone if asymptomatic and pneumothorax < 15% One hundred percent oxygen administration Reduces partial pressure of nitrogen increases rate of pneumothorax absorption Chest tube insertion or thoracoscopy may be required. V.A.T.S. (Video AssistedThoracoscopic Surgery) is becoming the standard
- 17. Tension Pneumothorax Definition: A tension pneumothorax is generally considered to be present when a pneumothorax leads to significant impairment of respiration and/or blood circulation
- 18. Causes ofTension Pneumothorax Penetrating trauma to the lungs (e.g., knife wound) valve type of pleural tear Rupture of tension pneumatocysts
- 19. Pathogenesis ofTension Pneumothorax Flap-like pleural tear (check valve) allows air into the pleural cavity but prevents its exit. Similar in concept to filling a tire up with air Increased pleural cavity pressure Increase in pleural cavity pressure with each breath Produces compression atelectasis a condition in which a region of the lung cannot be ventilated as a result of intrathoracic pressures that compress the alveoli in that region
- 20. Clinical Findings ofTension Pneumothorax Sudden onset of severe dyspnea and pleuritic chest pain Physical examination Tympanic percussion note and absent breath sounds Trachea and mediastinal structures deviate to contralateral side if large tension pneumothorax Compromised venous return to the heart, if the pneumothorax is located on the left side Due to obstruction of the venous return
- 23. Treatment ofTension Pneumothorax Relieve pressure first. Insert a needle into the second intercostal space on the midclavicular line. Insert a chest tube.
- 24. Hemothorax Definition: The collection of blood between the visceral and parietal pleura In the pleural space
- 25. Causes of Hemothorax Pulmonary: Bullous Emphysema, PE, Infection,TB,AVM’s Pleural:Torn adhesions, Endometriosis Neoplastic: Primary, Metastatic (Melanoma) Blood Pathology:Thrombocytopenia, Hemophilia, Anticoagulation medications (Heparin,Warfarin) Thoracic Pathology: Ruptured aorta
- 26. Pathogenesis of Hemothorax The accumulation of pleural blood forms a stable clot Overall ventilation & Oxygenation becomes impaired Mechanical compression of the lung parenchyma Mediastinal shift Flattening of the hemidiaphragm
- 27. Clinical Findings of Hemothorax Dyspnea Tachypnea Cyanosis Due to loss of blood Hypotension Due to loss of blood Tachycardia Normal Response to hypotenstion Tracheal deviation to unaffected side Decrease or absent of breath sounds on the affected side
- 29. Treatment of Hemothorax Goal of treatment: To remove the pleural blood and allow for complete lung re-expansion Thoracocentesis orThoracostomy Remove blood
- 31. ThankYou
- 32. References: Light, RW. Primary Spontaneous Pneumothorax. In: UpToDate, Basow, DS (Ed: 19.3), UpToDate, Waltham, MA, 2013. Light, RW. Secondary Spontaneous Pneumothorax. In: UpToDate, Basow, DS (Ed: 19.3), UpToDate, Waltham, MA, 2013. MacDuffA, Arnold A, Harvey J, BTS Pleural Disease Guideline Group (December 2010). "Management of spontaneous pneumothorax: BritishThoracic Society pleural disease guideline 2010". Thorax 65 (8): ii18–ii31 Leigh-Smith S, HarrisT (January 2005). "Tension pneumothorax—time for a re-think?". Emergency MedicineJournal 22 (1): 8–16. doi:10.1136/emj.2003.010421 Misthos, P; Kakaris S, Sepsas E et al. (May 2004). "A prospective analysis of occult pneumothorax, delayed pneumothorax and delayed hemothorax after minor blunt thoracic trauma". European Journal of Cardio-thoracic Surgery 25 (5): 859–864. doi:10.1016/j.ejcts.2004.01.044 Rapid Review Pathology Revised Reprint:With STUDENTCONSULTOnlineAccess, 3e by Edward F. Goljan MD (Apr 29, 2011)