The Chest: Pneumothorax, Hemothorax, Effusions, & Empyema Bradley J. Phillips, M.D. Burn-Trauma-ICU Adults & Pediatrics

definition, classification, & management Pneumothorax definition, classification, & management

collection of air within the pleural space Pneumothorax (1) collection of air within the pleural space transforms the potential space into a real one may lead to various degrees of respiratory compromise 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

Pneumothorax (2) General Management First: evacuate the air Second: address the underlying source Third: promote pleural symphysis

Classification System Pneumothorax (3) Classification System Spontaneous Pneumothorax Primary Secondary Traumatic Pneumothorax Pulmonary source Tracheobronchial source Esophageal source

Pneumothorax (4) Primary Spontaneous Ptx a disease of younger individuals (15 - 35 yrs of age) males > females tall, slim body habitus cigarette smoking implicated usual cause: parenchymal blebs apex of the upper lobe superior segment of the lower lobe

Pneumothorax (5) Primary Spontaneous Ptx: “in most instances, the treatment of a first-occurrence consists of hospitalization, tube-thoracostomy to closed drainage, lung-re-expansion against the chest wall, and control of any persistent air-leak” [Graeber ‘98]

Pneumothorax (6) when do you operate on a primary spontaneous

Pneumothorax (7) Secondary Ptx: due to underlying pulmonary disease COPD / Asthma / Cystic Fibrosis Immunocompromised Infections Tb & Cocci PCP (becoming more common) Treatment: Closed Thoracostomy Water-seal Heimlich-Flutter Valve V.A.T.S.

Pneumothorax (8) Traumatic Ptx Parenchymal Injury vs. Tracheobronchial vs. Esophageal Blunt or Penetrating Iatrogenic central lines / thoracentesis / biopsy endotracheal tube placement (esp. dual-lumen tubes !) endoscopy / dilational techniques Barotrauma Ventilation / blast injury / Boerhave’s syndrome Operative

Pneumothorax (9) The Tension Ptx The Open Ptx: sucking-chest wound “path of least resistance” life-threatening emergency…how do you treat a tension ptx ?? The Open Ptx: sucking-chest wound intrinsic lung compliance creates complete collapse 3-sided dressing thoracostomy away from the traumatic wound

Pneumothorax (10) Treatment Options Observation: Inpatient vs. Outpatient Thoracostomy Drainage 3rd Interspace / 5th Interspace Negative Suction / Water-seal V.A.T.S. (becoming the “standard”) Muscle-sparing Thoracotomy Posterolateral & Anterolateral Thoracotomy

Pneumothorax (11) Questions ?

Questions…well, I have some - Pneumothorax (12) Questions…well, I have some - 1. What is the best diagnostic study ? 2. What is the role of “100 % Oxygen” & “Conservative-mgmt” ? 3. How would YOU treat a small Ptx (1 cm) in acute trauma ? 4. What is the predicted recurrence rate for a spontaneous Ptx ? 5. What is a “deep sulcus sign” ?

what are they ? where do they come from ? & how do you treat them ? Pleural Effusions what are they ? where do they come from ? & how do you treat them ?

Definition the accumulation of excess fluid within the pleural space in response to injury, inflammation, or both may represent a local response to disease or may just be a manifestation of a systemic illness

Pathogenesis of Effusions Rate of Fluid Rate of Fluid Accumulation Removal 1. Altered Pleural Membrane Permeability 2. Decreased Intravascular Oncotic Pressure 3. Increased Capillary Hydrostatic Pressure 4. Lymphatic Obstruction 5. Abnormal Sites of Entry

Clinical Manifestations Pain Cough Dyspnea Dullness to Percussion Diminished or Absent Vocal Resonance Diminished or Absent Tactile Vocal Fremitus Friction Rub

Clinical: A Few Points Large Effusions that prevent contact between the Visceral & Parietal Pleura during respiration are seldom associated with pleuritic chest pain. Tumors involving the parietal pleura generally produce constant dull pain (Remember Ben Daly, M.D.) Large effusions interfere with expansion of the lung and produce dyspnea, shortness of breath, and atelectasis

Radiologic Assessment (1) Chest X-Ray: PA & Lateral-Decub blunting of either costophrenic angle is indicative of the accumulation of between 250 - 500 ml of fluid Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening & fibrosis Sub-Pulmonic Effusion: accumulation of fluid between the lung & the diaphragm which gives the false impression of an elevated hemi-diaphragm

Radiologic Assessment (2) Ultrasound: Helpful in Confirming the Presence of a Small Pleural Effusion & Identifying Loculations C.T. : Extremely Sensitive !! also helps to view the underlying lung (which may be obscured by pleural disease) can distinguish between Lung Abscess & Empyema

Pleural Fluid Analysis Thoracentesis = Pneumothorax

Pleural Fluid Analysis Thoracentesis: Transudate vs. Exudate 1. Gross Appearance 2. Cell Count & Differential 3. Gm Stain, C & S 4. Cytology 5. LDH 6. Protein 7. Glucose, Amylase

straw-colored, clear, odorless fluid with a Transudate straw-colored, clear, odorless fluid with a WBC less than 1000 / ul Pleural Membranes are Intact Secondary to Altered Starling Forces Low in Protein & other Large Molecules CHF, Cirrhosis, Nephrotic Syndrome Hypoalbuminemia, Constrictive Pericarditis, SVC Obstruction, PE

Exudate Characterized by Increased Protein & LDH [Pleural Fluid vs. Serum Levels] Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic Drainage Parapneumonic, Infections, Malignancy, Vasculitic Disease, GI Disease, TB, PE

Criteria for “Exudative Effusion” criteria value 1. Pleural Protein : Serum Protein > 0.5 2. Pleural LDH : Serum LDH > 0.6 3. Pleural LDH > 200 only need 1 critical value to establish the diagnosis of exudate

a bloody pleural effusion occurring in a patient without a history of trauma or pulmonary infarction is Indicative of Neoplasm in 90 % of cases! Because a RBC count as low as 5000 - 10,000 /ul, can cause a pleural effusion to turn red, the finding of blood-tinged fluid per se has little diagnostic value (usually from needle trauma) A True Hemothorax is when the Pleural Fluid Hct exceeds 50 % of the Peripheral Blood Hct !

Treatment Transudative Effusion: focus on the systemic cause Exudative Effusion: dependent on the exact sub-type Consider Chest Thoracostomy Gross Pus / Empyema pH < 7.2 Hemothorax Complicated Parapneumonic Processes Malignant Effusions…but remember the role of pleurodesis!

appropriate treatment may produce dramatic symptomatic relief ! although pleural disease itself is rarely fatal, it may be a significant cause of patient morbidity appropriate treatment may produce dramatic symptomatic relief !

Pleural Effusions Questions ?

“ the collection of blood between the visceral and parietal pleura…” Hemothorax “ the collection of blood between the visceral and parietal pleura…”

Hemothorax (1) Causes of a Spontaneous Hemothorax Pulmonary: bullous emphysema, PE, infarction, Tb, AVM’s Pleural: torn adhesions, endometriosis Neoplastic: primary, metastatic (melanoma) Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation Thoracic Pathology: ruptured aorta, dissection Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum

The Pathophysiologic Process Hemothorax (2) The Pathophysiologic Process 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

The Pathophysiologic Process Hemothorax (3) The Pathophysiologic Process over time, the clot is partially-absorbed, leaving behind loculated fluid and fibrinous septations macro-fibrin deposition begins to provide a structural framework this “peel” slowly contracts to entrap the underlying lung

Hemothorax (5) Goal of Treatment to remove the pleural blood and allow for complete lung re-expansion

Hemothorax (4) General Management Options thoracentesis: bedside / ultrasound-guided / C.T.-guided thoracostomy drainage: the mainstay thorascopic surgery: less than 2 wks. & use a 30-degree scope thoracotomy: massive hemothorax / instability / chronic hemothorax local fibrinolytic therapy: urokinase (1000 IU/ml) in 150cc solution

Hemothorax (6) Often, there is an accompanying pneumothorax Dual Chest Tube Management Superior-Apical: Ptx Diaphragmatic-posterior: Htx Consider targeted-drainage into a loculated collection All tubes to negative suction with protective water-seal Prophylactic antibiotics may be indicated while the tubes are in (controversial!!) Chest tubes removed: 100 -150 cc’s / day

Hemothorax (6) Undrained hemothorax increases the risk of empyema & fibrothorax Large collections should be drained slowly to minimize the development of re-expansion-pulmonary-edema [“R.E.E.P.”] (stop after 2 liters…wait 6-8 hrs, then drain out another 1-2 liters, etc) Computed tomography is the diagnostic of choice

Hemothorax Questions ?

Questions…well, I have some – Hemothorax Questions…well, I have some – When do YOU operate on a “Traumatic Hemothorax” ? What options exist in trying to drain a hemothorax (chest tube placement) ? What are the reported complications of chest tube placement ?

What is an Empyema ?

An Accumulation of Pus in the Pleural Cavity Empyema Thoracis An Accumulation of Pus in the Pleural Cavity 1-2 % incidence in the pediatric population Up to 18 % in immunocompromised adults General Management Appropriate Antibiotic Coverage Thoracostomy Drainage Streptokinase / Urokinase Surgical Intervention - Decortication

The Stages of Empyema Stage I - “Exudative” sterile pleural fluid develops secondary to inflammation without fusion of the pleura Stage II - “Fibrinopurulent” a fibrinous peel develops on both pleural surfaces limiting lung expansion Stage III - “Organizing” in-growth of capillaries & fibroblasts into the fibrinous peel

Empyema: A Pediatric Review

Empyema... Questions ? “don’t let it happen !!!”

The Chest: Pneumothorax, Hemothorax, Effusions, & Empyema Any Questions…?