PNEUMOTHORAX

It is the presence of air between the layers of pleura.

CLASSIFICATION I
a. Pneumothorax. d. Haemopneumothorax.
b. Hydropneumothorax. e. Artificial pneumothorax.
c. Pyopneu mothorax. f. Tension pneumothorax.
Classification II
a. Open pneumothorax b. Closed pneumothorax:
- Simple
- Tension
Open pneumothoraxis a sucking chest wound, with wound usually more than 3 cm
in size. Here lung collapses and causes severe hypoventilation. A large sized chest
tube should be placed; sucking wound is closed with creation of three side flutter
valve. Often thoracic tube may be connected to suction apparatus with a low
pressure to facilitate lung expansion. Additional drain is often justified. Respiratory
care, early mobilization and physiotherapy is useful
I Causes
Traumatic.
Spontaneous.
1. Tuberculous.
2. Non-tuberculous:
a. Rupture of emphysematous bullae.
b. Rupture of solitary lung cyst.
c. Honeycomb or cystic lung.
d. Idiopathic.
Spontaneous pneumothorax can be acute, chronic,
recurrent
Clinical Features
Hyperresonant, absence of breath sounds, tracheal
deviation. Radiolucency on the
affected side Absence of lung markings Collapsed lung
margin
Treatment
In tension pneumothorax, emergency needle aspiration
is done followed by ICT placement. The cause is treated
.
Often thoracotomy is required, if there is persistent
bronchopleural
fistula or ruptured cyst or bullae.
TENSION PNEUMOTHORAX
During inspiration, air is pumped into the pleural cavity
through a valvular opening in the visceral pleura and
underlying injured lung. Lung collapses first, and as air
continuously collects in the pleural cavity, mediastinum
shifts towards the opposite side, further decreasing the
volume of the functioning lung.
Further increase in the pleural pressure, reduces the
venous return, atrial filling , and ventricular filling and so
cardiac output and cardiac function.
It causes sudden death and hence emergency treatment
is required.
 clinical features
Tachypnoea and tachycardia Decreased/absent
breath sounds
• Resonant on percussion with severe
mediastinal/tracheal shift Cyanosis and
hypotension Chest pain, distended neck veins
Management
Once clinically diagnosed, a wide bore needle is
immediately placed in the second intercostal space in
midclavicular line, and a sterile glove is kept on the hub
(blunt) end of the needle to create a valve so as to
prevent inward sucking of air from outside-
thoracocentesis. Nasal oxygen is used. Once patient is
better, chest X-ray is done.
Later an intercostal tube is passed (ICT placement).
Antibiotic, analgesics are given.
In severe cases ventilator support with IPPV is required
HAEMOTHORAX
It is blood in pleural cavity. It causes pain, shock, as it is very irritant
to pleural cavity. It is a good culture media for bacteria and so
infection is quite common.
CAUSES - - ---- - -
Trauma.
Postoperative: Pulmonary, cardiac, oesophageal surgeries, cervical
sympathectomy, leak from CVP monitor line. Tumours of lung,
mediastinum, pleura. Leaking aneurysms.
Spontaneous.
There may be rib fractures in traumatic haemothorax.
Features: Pain in the chest, tenderness; Difficulty in
breathing, dullness on percusion diminished breath sounds;
Features of shock
Investigations: Chest X-ray; Aspiration (pleural tap); Chest
CT scan.
Treatment:
ICT placement in the mid-axillary line in the 5th intercostal space.
Initial chest tube output of 1500 ml of blood or
persistent drainage of 200-300 ml/hr.
Clotted haemothorax is difficult to manage. It
requires thoracotomy,
evacuation and decortication of lung. Initially
liquefaction of the clot is tried by infusing of
streptokinase and trypsin into the pleural cavity
Complications
Infection and empyema.
ARDS: respiratory failure.
The site of insertion is in the triangle of safety which is
defined as the anterior border of the latissimus dorsi, the
posterior border of the pectoralis major and the superior
border of the fifth rib. The area chosen is infiltrated with
local anaesthetic and an incision is made in the skin and
subcutaneous tissues, sufficient to admit a finger easily.
The intercostal muscles are separated with artery forceps
and the pleura is punctured. The intercostal drainage tube
is inserted with the stylette withdrawn; so as not to damage
the underlying lung tissue. A large-bore tube is used for the
drainage of blood and fluids, whereas a smaller-bore tube
may be used for the removal of air.
PLEURAL TAP
Pleural effusion-both for diagnostic as well as therapeutic
purpose. The fluid is sent for culture, cytology, microscopy, specific
gravity, biochemical analysis of proteins for diagnosis of
tuberculosis, malignancy.
In empyema thoracis, for diagnostic purpose before placing an ICT.
Position: In sitting position, leaning forward over a wooden
support.
Site: Tip of scapula at 7th intercostal space (posteriorly).
Under local anaesthesia wide bore needle (Abraham needle)
is passed to tap the fluid.
Complications: Infection; Dry tap or bloody tap; Sudden vagal
shock; Pain and respiratory distress
Lung parenchyma
Lung contusion. The underlying lung is often
injured in moderate-to-severe blunt thoracic
trauma and the area of contusion may be extensive.
This usually resolves but lacerations with
persistent air leak may require exploration by
thoracotomy. It is important to prevent infection of
the underlying lung by early mobilisation (if the
patient’s condition permits), prophylactic
antibiotics, suction drainage and physiotherapy
Major airways
Injuries to major bronchi are infrequently seen as
the patient rarely survives the insult leading to
major airway disruption. There is usually a
combination of surgical emphysema, haemoptysis
and pneumothorax. Chest drainage in spite of the
addition of suction fails to reinflate the lung and a
persistent air leak may be present The injury may be
from direct trauma or the result of high intratracheal
pressure against a closed glottis. There is
hoarseness, dyspnoea and surgical emphysema. The
treatment is exploration and repair if possible
Diaphragm
Diaphragmatic rupture. The mechanism for diaphragmatic
rupture is high-speed blunt abdominal trauma with a
closed glottis. The sudden rise in intra-abdominal pressure
breaches the weakest part of the abdominal wall, namely
the diaphragm. This occurs much more commonly on the
left hemidiaphragm (the right is protected by the liver).
Colon and stomach may herniate into the thorax,
displacing the lung. Bowel sounds may be heard in the
chest and the chest radiograph may reveal bowel gas in the
lung fields. A contrast study will confirm the diagnosis.
Occasionally, the injury is overlooked and the patient
presents some time later with a diaphragmatic hernia
Cardiac injury
Major injuries to the heart and great vessels from blunt
trauma are frequently fatal and the patient rarely survives
long enough to reach
hospital.
Myocardial contusion. This must be suspected when the
sternum is fractured, although the true incidence is not
known. Myocardial damage from trauma will give an ECG
pattern similar to myocardial infarction and enzyme
changes may occur. In severe trauma there may be
arrhythmias and signs of heart failure. Patients with ECG
changes and enzyme rises even in the absence of any
problems should be nursed in a high-dependence area with
full monitoring and resuscitation equipment available.
Chamber rupture and valve blow-
out. This is well described and is thought to
occur if the ventricle is compressed just
before systole at the point of maximal
diastolic filling. Chamber rupture is likely to
be fatal and those that do survive are likely to
have an atrial rupture.
Treatment immediate thoracotomy and repair
Aorta
Aortic transection
This is usually the result of a major deceleration
injury (road traffic accident or a fall from a
height) and the patient often has other injuries.
However, only about 15 per cent of patients with
aortic transection survive long enough to reach
hospital. Of these, two-thirds would die of late
rupture within 14 days and the remainder would be
at risk from rupture of a developing chronic false
aneurysm. The site is remarkably consistent
The vessel is relatively fixed at the site of the ligamentum
arteriosum, just distal to the left subclavian artery, and
from there down is tethered to the vertebral column by
intercostal arteries and mediastinal pleura. The shear
forces from a sudden impact disrupt the intima and media,
resulting in retraction. If the intima is not breached, the
patient may be stable but the development of a left-sided
pleural effusion is an ominous sign. Transection of the
aorta must be suspected in all high-speed deceleration
incidents. The clinical signs may be masked by concurrent
injury but include intrascapular pain, a murmur, hoarseness
and radiofemoral delay of the arterial pulse.
Diagnosis
. Chest radiography : widening of mediastinum.
Enhanced chest CT
Aortography
treatment : immediate repair
Management of blunt chest trauma
Most chest injuries where the heart is not injured are managed
conservatively with underwater seal drainage if necessary, and
oxygen and physiotherapy to help the patient to expectorate while
the underlying lung parenchyma heals. In about 10 per cent of cases
a thoracotomy is required. The indications for thoracotomy
following blunt thoracic trauma are the following:
•50—1000 ml of blood at the time of initial drainage is common
and may need no further action, but greater volumes, especially if
the blood is fresh, require intervention;
•continued brisk bleeding (>100 mI/15 minutes) from the intercostal
drains indicates a serious breach of the lung parenchyma and urgent
exploration is required;
• continued bleeding of >200 ml/hour for 3 or more hours may
require thoracotomy under controlled conditions;
• rupture of the bronchus, aorta, oesophagus or diaphragm;
• cardiac tamponade (if needle aspiration is unsuccessful).
All explorations following trauma should have
double-lumen tube endotracheal intubation to
facilitate surgery on the injured side and to protect
the undamaged lung.
If transfer is undertaken, the patient must be
stabilised before the journey. All lines must be
secured and ECG monitoring available. Chest
drains must not be clamped during transfer and a
medically qualified person should accompany the
patient.
Penetrating injury
In some aspects, penetrating thoracic injury is simpler to
deal with than blunt trauma because the wound is visible
and the structures at risk can be quickly assessed. A defect
in the chest wall through to the pleura is a ‘sucking
wound’. The underlying lung collapses and air moves in
and out of the thorax with each breath. Emergency
treatment involves sealing the wound and intercostal
drainage. Definitive treatment may then follow. It is
important to establish the path or track of bullet and stab
wounds in the chest as there may be damage to the heart,
great vessels, and the diaphragm and abdominal viscera in
addition to the lung injury.
Postoperative care
•Lung function is rarely assessed before urgent
thoracotomy for trauma but it is a vital part of the patient’s
preoperative work-up before elective thoracotomy.
•These patients have limited respiratory reserve following
lung resection, so infection and fluid overload are to be
avoided.
•Chest drains placed at the time of surgery drain blood
collections and cope with air leaks if present. Once the air
leaks have settled and any remaining lung is re-expanded,
the drains are removed.
•Mobilization, breathing exercises and regular
physiotherapy are begun as soon as the patient’s condition
permits.
Postoperative pain
It is important to deal with post-thoracotomy pain
effectively so that a normal breathing pattern and gas
exchange are achieved in the early postoperative period.
Patient-controlled analgesia is an important development
but still requires regular nursing and anaesthetic
supervision.
Internally placed catheters delivering local anaesthetic
into the wound and beneath the pleura may also be
effective. Long-term post-thoracotomy pain can be
avoided by careful attention to detail during the
operation.
BRONCHOSCOPY
Indications:
, Diagnostic: To take biopsy in conditions like carcinoma lung, lung
abscess, pulmonary tuberculosis. ,- Therapeutic: To remove foreign
body, to suck out the bronchial secretions.
Types:
Rigid bronchoscopy-it is used for removal of foreign body and
bronchial wash. It reaches up to third generation bronchi. It is used
to take biopsy from carcinoma of proximal divisions but not from
carcinoma of peripheral lung. Rigid scope has got multiple holes to
allow ventilation during the procedure (Oesophagoscope does not
have side holes). It is done under general anaesthesia.
,- Flexible bronchoscopy-it reaches up to 5th generation bronchi. It
can be done under local anaesthesia. It is mainly used for diagnosis
and biopsy.
Complications: Bleeding; Infection; Perforation; Bronchospasm
EMPYEMA THORACIS
It is collection of pus in pleural cavity.
Causes
An empyema is never primary.
Secondary causes are:
From chest wall: Wounds, osteomyelitis of ribs.
From lung: Pneumonia, abscess, bronchiectasis,
tuberculosis, growth.
Postoperative: After thoracotomy.
From oesophagus: Perforations, carcinoma.
From below diaphragm: Subphrenic abscess.
Tuberculosis and pneumonia are common causes in
developing countries.
Pathology
Initially serous fluid collects, which eventually becomes purulent.
lntrapleural clotting of pus occurs with thickening of pleura and
later fibrinous adhesion forms resulting in matured empyema.
Chest is withdrawn inwards and is immobile, mediastinum
is drawn inwards, diaphragm gets elevated.
It leads to rigid contracted immobile chest with functionless
lung underneath-frozen chest. Often pus perforates through
intercostal space and forms empyema necessitans
Stages of empyema
Acute
Subacute
chronic
.
Organisms:
Initially staphylococci, streptococci, pneumococci, and later
Escherichia coli, Pseudomonas, drug-resistant staphylococci.
CLINICAL TYPES
Acute empyema
Acute fulminant toxic empyema
Subacute empyema
Chronic empyema
Latent empyema
Persistent empyema
Empyema necessitans
Chronic empyema with sinus
lnterlobar empyema
Pathological types
Exudative
Fibrinopurulent
Orgnized
Features
Pain in the chest, tenderness, fever.
Difficulty in breathing .
Features of toxicity in acute type of empyema.
Dullness on percussion, absence of breath sounds.
Decreased chest wall movement.
Complications: Frozen chest (functionless lung); Empyema
necessitans; Osteomyelitis/chondritis of ribs or vertebra;
Pericarditis; Mediastinitis; Bronchopleural fistula; Dissemination
of infection
Investigations: Chest X-ray, ESR; Peripheral smear; Diagnostic
aspiration; Pus C/S, AFB; Bronchoscopy; CT scan and
MRI.
Treatment:
Stage 1: Antibiotics; Repeated aspirations; lntercostal tube
drainage; Antituberculous drugs.
Stage 2: ICT drainage; Rib resection (Eloiser's methocf); Antibiotics,
antituberculous drugs; Respiratory physiotherapy.
Stage 3: Decortication is very useful and favourable method.
Here, thickened pleural sac is stripped off from the lung
through thoracotomy approach; Often lobectomy may be
required, rarely pneumonectomy is done; Physiotherapy,
antibiotics, ATD'S are also essential.
EMPYEMA NECESSITANS
It is a complication of empyema thoracis, wherein empyema
which is not drained perforates through the chest wall
presenting as subcutaneous collection of pus communicating
directly or often with a tortuous route with the pleural cavity.
Causes:
Neglected empyema either of tuberculous or nontuberculous
aetiology.
Features
A diffuse, tender, smooth, soft, fluctuant, swelling in the
intercostal space having impulse on coughing.
FEATURES OF EMPYEMA NECESSITANS
Bulge in the intercostal space; Impulse on coughing
Restricted movement of chest wall; Tenderness
Dullness on percussion without breath sounds
Investigations: Chest X-ray; Total count is increased; ESR.
Treatment:
Antibiotics.
;... Empyema is drained by placing an ICT. Pus is sent for
C/S and AFB.
,,. If it is tuberculous, antitubercular drugs are started.
Empyema necessitans subsides on its own when
empyema is treated.
, But often may require separate incision and drainage
when track is tortuous.
LUNG ABSCESS
It is localised suppuration in the lung with tissue necrosis.
It is end-stage of suppurative pneumonitis with thrombosis
of associated artery.
Aetiology
Pneumonias due to Streptococcus, Pneumococcus,
Haemophi/us, Staphylococcus, anaerobic and other
bacteria.
Other causes
Bronchial obstruction due to tumours or foreign body.
Chronic upper respiratory infection due to sinusitis,
tonsillitis and dental infection (anaerobic infection).
Septicaemia.
Aspiration.
As pus accumulates, tension increases inside the abscess
cavity causing spread into other areas of the lung or may rupture
into the bronchus.
CLINICAL FEATURES
Acute onset of fever, but often it is recurrent in nature
Cough with expectoration; Pleuritic pain
Haemoptysis with foul smelling sputum
Chronic illness with debilitation
COMPLICATIONS
•Spread into other areas of the lung.
•Metastatic cerebral abscess.lung abscess is the commonest
focus for metastatic cerebral abscess. Occurs as a result of
pyaemic emboli through paravertebral veins.
•Haemorrage, may be torrential due to erosion of the vessel in
the abscess wall.
•Empyema thoracis.
Differential Diagnosis: Pulmonary tuberculosis,
Carcinoma lung; Fungal infections like aspergillosis;
Pneumoconiosis; Lung cysts.
Investigations:
Chest X-ray shows localized opacity with smooth margin
and fluid level.
> Bronchoscopy and biopsy is done to rule out carcinoma.
> Sputum for culture, AFB and cytology.
CT scan is diagnostic .
Treatment
Medical: Appropriate high dose antibiotics are started
depending on sputum culture like penicillins, third generation
cephalosporins like , cefitriaxone for 3-6 weeks. Postural drainage
is done for 2-3 hours, 3 times daily.
Periodic culture of sputum is done to study the response of
treatment. 80-90% of acute abscesses resolve by medical
therapy.
Surgical: External surgical drainage with rib resection is
done in severe acute lung abscess only. Not commonly
used procedure; Lobectomyis done when medical treatment
fails.
PULMONARY EMBOLISM (PE)
It is due to deep venous thrombosis (DVT) which gets
detached to cause pulmonary embolism.
It may be from femoropopliteal or ileofemoral region.
The thrombi most commonly develop in the leg veins due to
stasis and hypercoagulable state. They subsequently enlarge and
propagate proximally, dislodge to form emboli.
Types
Small emboli: Causes pulmonary hypertension with features of
of bronchopneumonia.
Medium emboli lodges in branches of pulmonary artery
causing chest pain, haemoptysis, dyspnoea.
Large (massive) emboli causes block at bifurcation of
pulmonary artery trunk or right/left pulmonary artery leading
to sudden chest pain, severe dyspnoea, shock, raised venous
pressure and sudden death.
Effect:
Decreased cardiac output
Pulmonary vasospasm and pulmonary hypertention
Bronchospasm
Defective oxygenation of blood
Risk factors:
Postoperative and trauma patients who are bed ridden.
Pregnant women; Old age; Obesity and heart disease;
Varicose veins.
All aetiologies which cause DVT; Carcinoma.
CLINICAL FEATURES
Dyspnoea, chest pain and haemoptysis
Tachycardia, tachypnoea and cyanosis
Pleural rub and cardiac gallop
Investigations
Chest X-ray PA view-hyperlucency in an area of oligaemia-
Westermark sign.
CT scan and MRI-can detect PE.
Pulmonary angiography: It is diagnostic (100%).
Arterial blood gas analysis.
Isotope radionuclide ventilation-perfusion (V/Q) lung
scanning:While normal scan rules out PE, evidence of V/O
mismatch is highly suggestive of pulmonary embolism.
Doppler study and venogaphy-to rule out DVT.
Management
Thrombolytics: Streptokinase, 600000units to begin with
and later 100000units hourly.
Pulmonary embolectomy with or without bypass by
immediate thoracotomy.
Venous thrombectomy using Fogarty catheter.
Ventilator support.
To prevent further embolisation of embolus into the
lungs,
IVG filters can be placed.
Treatment of DVT.
Note:
Heparin should not be combined with thrombolytics.
SURGICAL EMPHYSEMA
It is collection of gas/air in the subcutaneous or and fascial
planes.
Causes: Lung injury; Tracheal injury; Chest wall injury; After
laparoscopic procedure.
Types:
;.. Localised-observed at the site of trauma.
,, Generalised-extensive in the neck, face, eyelids, chest
wall, etc.-in the injury of bronchus, oesophagus and
mediastitum.
I Features
Pain, diffuse swelling of the subcutaneous region.
Palpable crepitus is diagnostic.
X-ray chest and neck is confirmatory.
Lung cystes
Types
Epithelial cyst
Emphysematous cyst
Parasitic ( hydatid) cyst
Psudocyst
Epithelial Cyst
It is of developmental origin.
It can be large single cyst or small, multiple cysts.
It is lined by respiratory epithelium.
It is often associated with cervical rib or cardiac anomalies.
It is common in infants and children.
Usual clinical features are dyspnoea and chest pain. When
infected, presents with fever, cough and haemoptysis.
, Treatment is excision of the cyst. Antibiotics are given
when infected.
;... Here spontaneous pneumothorax is uncommon. Infection
and haemorrhage are common
Emphysematous Cyst
It is a progressive disease of lung with rupture of alveolar
wall and distension with air.
It is an acquired condition.
Cyst does not have epithelial lining.
Compression of adjacent lung tissue with poor gaseous
exchange is common.
Usual clinical features are dyspnoea and severe, persistent
cough.
Pseudocyst of the lung: It occurs in a cavity due to
tuberculosis, lung abscess or Staphylococcus pneumonia.
Complications: Spontaneous pneumothorax; Severe
chronic bronchitis.
Treatment
Localised cyst is excised.
Generalised cysts are treated conservatively.
Pleurodesis is often required.
Hydatid Cyst of the Lung
It is caused by the parasite, Echinococcus granulosus.
It is often associated with hydatid cysts of the liver.
Incidence is 15%.
It is usually single. But multiple hydatids can occur.
Presentations
Dyspnoea, chest pain and haemoptysis.
Rupture into bronchial tree causes anaphylaxis.
Rupture also causes expectoration of fluid and grape skins
(vesicles).
Fever, cough and expectoration due to secondary infection.
Asymptomatic hydatid, identified during chest X-ray.
Investigations
Chest X-ray:
1. Dense homogenous opacity.
2. Collapsed laminated membrane produces an irregular
projections in a fluid level due to rupture of the cyst-Water lily
appearance.
3. Crescentic cap of air, when it communicates into bronchial
tree.
Positive Casoni's test.
Blood shows eosinophilia.
Complement fixation test.
Indirect haemagglutination test.
CT scan-diagnostic.
Complications: Rupture of the cyst; Anaphylaxis; Secondary
infection; Collapse of lung; Pleural effusion; Secondary
pleural hydatid formation; Hepatobronchial fistula formation
(produces bilious sputum)
Differential diagnosis: Lung abscess; Epithelial lung cysts;
Aspergillosis
Treatment
Thoracotomy and enucleation of the cyst: It is achieved by taking
a good anaesthetist's help by creating positive pressure ventilation.
Cyst extrudes intact. It should not be held with forceps to
avoid rupture.
Lobectomyis done in cases with difficulty and complications.
Drugs like praziquantelor albendazoleis given for a long period.