C31 Pneumothorax

Objectives: What is Pneumothorax? Pleural Anatomy and Function Signs and Symptoms Types of Pneumothorax Imaging Required Treatment Options

What is Pneumothorax? Definition: Air or gas in the pleural cavity results in a condition called pneumothorax, wherein air or gas pressure in the pleural cavity may cause the lung to collapse.1 The partial or complete collapse of the lung can result in immediate and severe shortness of breath and chest pain.1 Pneumothorax can be caused by trauma or pathological conditions that cause a spontaneous rupture of a weakened area of the lung.1

What is the Pleura? Pleura: Serous membrane covering the lung. Two layers: Inner Visceral- Covering over the lung itself. Outer Parietal- Covers the inner surface of the thoracic wall. Between the two layers is the pleural cavity where serous fluid is located.2 http://www.interactive-biology.com/3331/how-do-we-breathe-lungs-and-pleura/

Pleural function: The pleural fluid acts as a lubricant of the two pleura surfaces allowing the layers to slide smoothly over each other during respiration.2 The surface tension allows the lung surface to stay touching the thoracic wall creating a seal between the two surfaces.2 http://respiratorytherapycave.blogspot.com/2011/09/pleurisy-and-pleural-effusions.html

Signs and symptoms: Sudden chest pain Tachypnea- Abnormally rapid breathing. Tachycardia- Condition that makes your heart beat more than 100 times per minute. Unilateral decreased/Absent breath sounds Decreased oxygen saturation Low blood pressure3

Types of Pneumothorax: Primary/Secondary Spontaneous Tension Traumatic

Primary Vs. Secondary Primary: This type of collapsed lung may occur for no apparent reason, because it takes place without any underlying lung disease. Secondary: A collapsed lung may occur because of underlying lung diseases, such as chronic obstruction, pulmonary disease, cystic fibrosis, and other conditions.4

Primary Spontaneous Pneumothorax: Spontaneous: Not caused by an injury such as a rib fracture. https://www.thoracicgroup.com/conditions/spontaneous-pneumothorax/ Primary spontaneous pneumothoraces are likely due to the formation of small sacs of air or blebs in the lung tissue that rupture.3 This causes air to leak into the pleural space and cause pressure on the lungs with potential to collapse.3

Secondary Spontaneous Pneumothorax: Most patients will require admission to the hospital and require a chest tube for drainage.3 This form of pneumothorax may evolve into tension pneumothorax.3 https://www.medicinenet.com/pneumothorax/article.htm

Tension Pneumothorax: Tension: Increased pressure in the pleural space. This is frequently the result of a “check valve” mechanism that facilitates the ingress of gas in to the pleural space during inspiration, but blocks the egress of gas from the pleural space during expiration.5 https://jamanetwork.com/journals/jama/fullarticle/2653738

Tension Pneumothorax: Gas accumulates with the build-up of pressure within the pleural space and this could eventually cause respiratory failure.5 What to look for: Compression of lung Tracheal deviation Diminished lung markings Mediastinal shift Depression of hemithorax5 https://www.rpneumothorax_fig9_313791409esearchgate.net/figure/11-Chest-x-ray-PA-view-showing-tension-

Traumatic Pneumothorax: Trauma can result from penetration to the chest wall, or blunt trauma to the chest.6 Penetration: stab wound Blunt Trauma: broken rib They may be classified as: “Open” or “Closed” http://www.emsandbox.com/blunt-trauma-arrest-core-content/

Trauma Pneumothorax: Open: Ambient air or “outside air”, enters the pleural space during inspiration in the form of a sucking wound.5 Closed: A closed pneumothorax is when the chest wall remains intact.5 https://www.orthobullets.com/knee-and-sports/3122/pulmonary-conditions-in-athletes

Diagnostic Imaging: Chest Radiographs that can be done: Supine Upright Lateral Decubitus http://www.clker.com/clipart-x-ray-4.html

Supine Radiograph: http://www.wikiradiography.net/page/The+Supine+Pneumothorax Gas will accumulate in a subpulmonic location. Gas in this location outlines the anterior pleural reflection, the anterolateral border of the mediastinum and the costophrenic sulcus creating a “deep sulcus” sign.5  ED patients are usually supine and a small pneumothorax float anteriorly in the supine position, and if it is not big enough to wrap around the lateral edge of the lung, it may be missed.7 http://www.wikiradiography.net/page/The+Supine+Pneumothorax

Upright Radiograph: http://www.wikiradiography.net/page/The+Supine+Pneumothorax https://pmj.bmj.com/content/79/928/106 In an upright patient with pneumothorax, most of the gas accumulates in an apicolateral location.5 Bilateral pneumothorax: Arrows indicate the visceral pleural line on left and a small apical area of gas in the pleural space on right.8

Inspiration Vs. Expiration https://radiopaedia.org/cases/pneumothorax-inspiratory-and-expiratory-x-rays-3?lang=us  Inspiratory and expiratory projections are one technique that can be used to make a pneumothorax more obvious. Expiration results in the lung reducing in volume, becoming more dense and making the pneumothorax easier to identify.9 The pneumothorax can more easily be seen on expiration due to the visceral pleural line being highlighted.

https://radiopaedia.org/images/7993509 Lateral Decubitus: Detection of a pneumothorax through radiographs is best seen in the lateral decubitus position.5 When viewing the image, the visceral line appears straight or convex toward the chest wall.5 Most of the pleural gas accumulates in the non-dependent lateral location. 5  https://radiopaedia.org/images/7993509

CT Imaging: CT scanning is the most accurate imaging modality for the detection of pneumothorax.5 https://www.istockphoto.com/illustrations/ct-scanner?sort=mostpopular&mediatype=illustration&phrase=ct%20scanner

CT Cross-Sectional In trauma, where it may not be possible to perform an upright film, chest radiographs may miss up to a third of pneumothoraces, while CT remains very sensitive.6 https://www.revolvy.com/page/Pneumothorax

CT Coronal View https://www.revolvy.com/page/Pneumothorax  Things such as small amounts of intrapleural gas, atypical collections of pleural gas, and loculated pneumothoraces can be seen using CT over radiographs.5 CT with the identification of underlying lung lesion: an apical bulla on the right side.

Treatments: Observation: If the pneumothorax is very small and there are no symptoms, the lung may re-inflate on its own. The patient should be observed closely for signs of respiratory or cardiac problems.4 Needle aspiration: A needle attached to a syringe is inserted into the chest cavity to remove air via suction.4 Percutaneous chest tube drainage: If the pneumothorax is large or if the patient has trouble breathing, a small plastic tube may be inserted into the pleural space to remove air. The collapsed lung will re-inflate as the pressure on the lung decreases.4

Lets Recap! Proceed to Quiz 

Which Type of Pneumothorax is this? Tension Primary Spontaneous Traumatic

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Type of Pneumothorax that involves Blunt Trauma? Tension Pneumothorax Open Traumatic Pneumothorax Closed Traumatic Pneumothorax Spontaneous Pneumothorax

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What is the best form of imaging for identifying a pneumothorax? X-ray MRI Nuclear Medicine CT

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Primary or secondary? Primary Secondary This type of collapsed lung may occur for no apparent reason, because it takes place without any underlying lung disease. Primary Secondary

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What is something to look for on a tension pneumothorax? Diminished lung markings Mediastinal shift Tracheal deviation All of the above

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Conclusion: Pneumothorax refers to gas in the pleural space. Depending on severity, there are three types of pneumothorax: Primary/Secondary Spontaneous, Tension, and Traumatic. X-ray and CT have different views to diagnose if a pneumothorax is present. The main feature of a Pneumothorax on a chest radiograph is a white visceral pleural line.

References Lampignano, J. P., & Kendrick, L. E. (n.d.). Bontrager's Textbook of Radiographic Positioning and Related Anatomy (9th ed.) Charalampidis, C. (2015, February 7). Physiology of the pleural space. Retrieved March 01, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4332077/  M. (2017, April 16). SPONTANEOUS VS. TENSION PNEUMOTHORAX. Retrieved March 01, 2019, from http://medicinespecifics.com/spontaneous-vs-tension-pneumothorax/ A. (2013, October 3). Collapsed Lung (Pneumothorax). Retrieved March 01, 2019, from https://my.clevelandclinic.org/health/diseases/15304-collapsed-lung-pneumothorax/management-and-treatment Stark, P. (2017, March 1). Imaging of pneumothorax. Retrieved February 13, 2019, from https://www.uptodate.com/contents/imaging-of-pneumothorax?search=imaging-of-pneumothorax &source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2 Pneumothorax. (n.d.). Retrieved March 01, 2019, from https://www.revolvy.com/page/Pneumothorax Chanana, L. (2016, November 14). Deep Sulcus Sign - Pneumothorax. Retrieved March 12, 2019, from http://emdidactic.blogspot.com/2016/11/deep-sulcus-sign-pneumothorax.html Peters, F., & Cathomas, G. (2003). Simultaneous bilateral spontaneous pneumothorax in a patient with recurrent, extraosseous multiple myeloma. Retrieved March 12, 2019, from https://pmj.bmj.com/content/79/928/106 H. K. (2005-2019). Pneumothorax: Inspiratory and expiratory x-rays. Retrieved March 12, 2019, from https://radiopaedia.org/cases/pneumothorax-inspiratory-and-expiratory-x-rays-3?lang=us