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PNEUMOTHORAX
TUCOM
Internal Medicine
4th year
Dr. Hasan.I.Sultan
Pneumothorax
Define as; Air accumulates in the pleural space
Classification of pneumothorax
A-Spontaneous
1-Primary; Without evidence of overt lung disease. Air
escapes from the lung into the pleural space through
rupture of a small subpleural emphysematous bulla or
pleural bleb, or the pulmonary end of a pleural adhesion.
2-Secondary; Underlying lung disease, most commonly
COPD and TB; also seen in asthma, lung abscess,
pulmonary infarcts, bronchogenic carcinoma, all forms of
fibrotic and cystic lung disease.
B-Traumatic;
• Iatrogenic (e.g. following thoracic surgery or biopsy)
• Non-iatrogenic
Clinical features;
Commonest symptoms are sudden-onset unilateral
pleuritic chest pain or breathlessness
Small pneumothorax (<2 cm visible rim of air on
chest x ray between lung margin and chest wall
and occupying <50% of the volume of hemithorax)
o The physical examination may be normal.
A larger pneumothorax (>2 cm visible rim of air on
chest x ray between lung margin and chest wall
and occupying >50% of the volume of hemithorax)
results in;
o Decreased or absent breath sounds
o Resonant percussion
Types of spontaneous pneumothorax
1-Tension pneumothorax; It
can act as a one-way valve
allowing air to enter the pleural
space during inspiration but not
to escape on expiration.
Intrapleural pressure may rise to
well above atmospheric levels
causes mediastinal displacement
towards the opposite side and
cardiovascular system
compromise. Clinically, rapidly
progressive breathlessness,
marked tachycardia,
hypotension, cyanosis and
tracheal displacement away from
the side of the lesion
2-Closed pneumothorax;
Communication between
the lung and pleural space
seals off as the lung
deflates and does not
reopen the mean pleural
pressure remains negative
spontaneous reabsorption
of air and re-expansion of
the lung occur over a few
days or weeks, and
infection is uncommon.
3-Open pneumothorax;
Communication fails to
seal and air continues to
transfer freely between
the lung and pleural space- a bronchopleural fistula-transmission of infection –
empyema. rupture of an
emphysematous bulla,
tuberculous cavity or lung
abscess into the pleural
space.
Investigations
Chest X-ray;
Shows the sharply defined edge of the deflated lung
with complete translucency (no lung markings)
between this and the chest wall. Chest X-rays also
show the extent of any mediastinal displacement
and give information regarding the presence or
absence of pleural fluid and underlying pulmonary
disease.
CT of chest;
Is useful in distinguishing bullae from pleural air.
Management
Primary pneumothorax where the lung edge is less
than 2 cm from the chest wall and the patient is
not breathless normally resolves without
intervention.
Percutaneous needle aspiration (PNA) of air is a
simple and well-tolerated alternative to intercostal
tube drainage, with a 60-80% chance of avoiding
the need for a chest drain in young patients
presenting with a moderate or large spontaneous
primary pneumothorax.
Intercostal tube drainage; indicate in above patient
who does not improved by PNA and in patients
with underlying chronic lung disease, however,
even a small secondary pneumothorax may cause
respiratory failure.
Need inpatient observation.
Inserted in the 4th, 5th or 6th intercostal space in
the mid-axillary line
Supplemental oxygen as this accelerates the rate at
which air is reabsorbed by the pleura.
Surgical pleurodesis;
• Second pneumothorax (even if ipsilateral).
• First episode of secondary pneumothorax if low
respiratory reserve makes recurrence hazardous
• Occupational risk (e.g. flying or diving) should also
undergo definitive treatment after the first
episode of a primary spontaneous pneumothorax.
• Persistent air leak and the lung fails to re-expand
after appropriate pleural drainage.