1. Pneumothorax

2. Pneumothorax Defined Definition – “What?” Pathophysiology – “How?
“Pneumo”- gas “Thorax” – chest cavity
Analagous to Pleural Effusion
Pathophysiology – “How?
Pleural space
Baseline (-) pressure space
Parietal Pleura
Visceral Pleura
Normal inspiration
Diaphragm
Transmit (-) Pressure
Pathologic inspiration
XS gas disrupts transmission of (- ) pressure

3. Types of Pneumothorax Spontaneous Pneumothorax Traumatic Pneumothorax
Primary - rupture of subpleural bleb
“Jimmy is a tall, wiry, 21-year old male, who plays trombone in the marching band….”
Secondary - underlying lung/pleural disease
#1 – emphysema
Chronic bronchitis, asthma, TB, …
Traumatic Pneumothorax
Open
Chest wall is penetrated : outside air enters pleural space
Closed
Chest wall is intact Ex. Fractured rib

4. Types of Pneumothorax 2 Tension Pneumothorax Variations
“Ball-valve mechanism”
Injury to pleura creates a tissue flap that opens on inspiration and closes on expiration
One of our own patients
Variations
Hemo-thorax
Chylo-thorax
Injury to thoracic duct
Empyema
Parapneumonic effusions in community- acquired pneumonia

5. Symptoms Dyspnea Pleuritic chest pain Sense of impending doom
Nerve endings at pleural capsule
Sense of impending doom
Sudden onset
Tension pneumothorax
Spontaneous pneumothorax

6. Physical Exam - Signs Unstable patients vs. Stable patients
Vital Signs
Asymmetric chest expansion
Deviated trachea
Diminished breath sounds unilaterally
Hyper-resonance unilaterally
Decreased tactile fremitus

7. Diagnosis Unstable patient Stable patient Thoracentesis CXR
Rapid release of air
Vital signs stabilize rapidly
Stable patient
CXR
Monitor size by measuring distance from lateral lung margin to chest wall
Be sure that pneumothorax is not expanding

8. Imaging Plain Radiographs Chest CT Upright PA on inspiration
Detect other pathologies: pneumonia, cardiac, etc.
Partially collapsed lung
Tension Pneumothorax
Trachea and mediastinum deviate contralaterally
Ipsilateral depressed hemi- diaphragm
Chest CT
Not routine
Only to assess the need for surgery (thoracotomy)

9. Treatment Small pneumothorax Tension pneumothorax
Resolve over days to weeks
Supplemental oxygen and observation
Tension pneumothorax
Immediate decompression via chest tube or needle thoracostomy
Spontaneous pneumothorax
Asymptomatic – outpatient, f/u with serial CXR
Symptomatic – inpatient, chest tube
Recurrent pneumothorax – CT to evaluate need for thoracotomy

10. Tube Thoracostomy
a.k.a. Chest tube