1. PBL 14 London Chest Hospital 8 th April 2009 Mike Cunningham Anaesthetic Reg

2. Initial appearance Have you got second, Doc … ?

3. Diagnosis Initial appearance ● Tall, 30 yr ♂in obvious pain ● SOB ● Unable to talk in sentences ● A – Patent ● B – RR 40 ● R chest – reduced movement ● Resonance R > L ● BS reduced on R ● SpO 2 92% ● C – Pale ● HR 100 reg ● NIBP 100/60 ● CR 3s ● GCS 15

4. Differentials Diagnosis ?

5. Pneumothorax Chest pain differential ● Pneumothorax ● PE ● Pleurisy ● Myocardial ischaemia – Coronary atheroma, thrombus or vasospasm – Aortic valve disease or aortitis – Severe anaemia – Paroysmal tachycardia ● Pericarditis ● Dissecting aneurysm ● Pulmonary hypertension ● Oesophageal pain ● Reflux / Spasm / Carcinoma ● GU / DU / Gallbladder ● C/T-spine referred pain ● Mediastinitis ● Chest wall ● Rib fractures ● Metastatic deposits ● Fibrositis or myalgia ● Herpes zoster ● Costochondritis ● Da Costa's syndrome

6. Epidemiology / Aetiology Pneumothorax ● Gas in the pleural space ● Defect in parietal, visceral or mediastinal pleura. ● Types: ● Spontaneous – Primary / Secondary ● Iatrogenic / Traumatic ● Simple / Tension

7. Signs & symptoms: simple Epidemiology / Aetiology [Henry 2003] ● Incidence ● Males 18 - 28 / 100 000 ● Females 1.2 – 6 / 100 000 ● Mortality ● Males 1.26 / 10 6 / yr ● Females 0.62 / 10 6 / yr ● Sub-pleural blebs and bullae present in 80% on CT or thoracoscopy ● Risk factors ● Smoking (males) – lifetime risk 12% v 0.1% ● Height ● Primary recurrence risk ● 54% in 4yrs : Smoking / age > 60 / height (males) ● Secondary recurrence risk ● Age, pulmonary fibrosis, emphysema ● No association with exertion

8. Signs & symptoms: tension Symptoms & signs ● Awake / ventilated ? ● Hypoxia (PaO 2 < 10.9kPa in 75%) [Henry 2003] Leigh-Smith 2005

9. Investigations Diagnosis Respiratory failure Cardiovascular failure

10. Management Diagnostic investigations ● CXR ● PA / AP ● Erect / supine / decubitus ● Lateral ● USS ● CT

11. Primary Management ● TENSION ? ● Oxygen ● Decompress ● Drain ● Simple ● Symptoms ● Oxygen ! ● Primary / Secondary ● Small / Large

12. Secondary Primary pneumothorax ● Often delay presentation ● 75 – 80% of small pneumothoraces have NO persistent air-leak. ● Lower recurrence rate without intervention ! ● 1.25 – 1.8% reabsorption / 24% (* 4 with oxygen)

13. Tension Secondary pneumothorax ● Symptoms generally dysproportionate

14. CXR1 Tension pneumothorax ● One-way valve communicates with the pleural space ● IPP +ve throughout respiratory cycle ● Expiratory tension pneumothorax ● Pressure lowest during inspiration ● SV – MUST be < AP to grow (Normal -5 to -8 cmH 2 O) ● IPPV – Can rise to P max Clinical diagnosis !

15. CXR 2

16. CXR 3

17. CT 1

18. Tension Rx

19. Chest drain Needle thoracostomy Lifesaving technique ● 2 nd ICS – MCL ● Cannula ● Significant rate of: [Ferrir 2005] ● Failure ● Complications

20. Underwater drain Tube thoracostomy

21. Complications Tube thoracostomy

22. RPO Tube thoracostomy ● Damage to major organs: ● Lung ● Liver ● Spleen ● Stomach ● Heart ● Great vessels ● Empyema - 1-6% Complications ● RPO

23. Pleuradhesis Re-expansion Pulmonary Oedema ● Rapid reinflation of lung in established pneumothorax ● More likely < 40 yrs and large pneumothoraces ● Lung damage → capillary leak ● May be CXR finding in up to 14% ● IF symptomatic – mortality high (20% BUT small numbers reported) ● Delay suction

24. Pleuradhesis ● Medical ● Tetracycline ● Talc ● Later recurrence 10-20% ● Surgical ● VATS ● Pleural abraision ● Pleurectomy ● Surgery if: ● Second ipsilateral ● First contralateral ● Bilateral spontaneous ● Persistent air leak (>5-7 days) ● Spontaneous heamothorax ● Professions at risk (pilots / divers)

25. Easy diagnosis ? ● 1.1 – 3.8% of undiagnosed ICU deaths have shown TP at PM ● Any 'classical' symptom may be absent ● Secondary pneumothoraces and ventilated patients do worse.

26. References ● BTS – Pneumothorax management http://www.brit- thoracic.org.uk/Portals/0/Clinical%20Information/Pleural%20Disease/Guidelines/PleuralDiseaseSpontaneous.pdfhttp://www.brit- thoracic.org.uk/Portals/0/Clinical%20Information/Pleural%20Disease/Guidelines/PleuralDiseaseSpontaneous.pdf ● BTS Guidelines for the management of spontaneous pneumothorax. Henry M, Arnold T, Harvey J. Thorax 2003;58(Suppl II):ii39–ii52 ● Tension pneumothorax – time for a rethink ? Leigh-Smith S, Harris T. Emerg Med J. 2005;22:8-16 ● The right place in the right space ? Awareness of site for needle thoracocentesis. Ferrir EP, Collum N & McGovern S. Emerg. Med. J. 2005;22:788-789 mjiCunningham@mikrocom.ne t

28. BTS Guidelines