Disease Process

Air leaks can be defined as any extrusion of

air from normal gas-filled cavities including the
upper airway, sinuses, tracheobronchial tree, and
gastrointestinal (GI) tract. Clinical conditions of
relevance in anaesthesia and critical care include
pneumothorax, pneumomediastinum,
pneumopericardium, pneumoperitoneum, and
subcutaneous emphysema. This review will cover
those related to the chest; of these, pneumothorax is
the most common serious complication. In critically
ill patients, the diagnosis of pneumothorax is often
complicated by other disease processes and the
limitations of bedside imaging.

Pneumothorax is the presence of air in the pleural cavity with associated lung collapse. It
is classified into spontaneous (occurring without an obvious preceding event), traumatic (direct
or indirect), and iatrogenic. Spontaneous is the commonest condition in general medicine and is
sub-classified as: (i) primary spontaneous pneumothorax (PSP) occurring in the absence of
obvious lung disease and (ii) secondary spontaneous pneumothorax (SSP) complicating a pre-
existing lung disease.

Pneumothorax is caused by a rupture of a cyst or a small sac (bleb) on the surface of the
lung. Pneumothorax may also occur following an injury to the chest wall such as a fractured rib,
any penetrating injury (gun shot or stabbing), surgical invasion of the chest, or may be
deliberately induced in order to collapse the lung. A pneumothorax can also develop as a result
of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease
(COPD), lung cancer, asthma, and infections of the lungs.

Spontaneous pneumothorax affects about 9,000 persons each year in the U.S. who have
no history of lung disease. This type of pneumothorax is most common in men between the ages
of 20 and 40, particularly in tall, thin men. Smoking has been shown to increase the risk for
spontaneous pneumothorax.
 Examination of the chest with a stethoscope reveals decreased or absent breath sounds
over the affected lung. The diagnosis is confirmed by chest x-ray. Symptoms of a pneumothorax
include chest pain that usually has a sudden onset. The pain is sharp and may lead to feelings of
tightness in the chest. Shortness of breath, rapid heart rate, rapid breathing, cough, and fatigue
are other symptoms of pneumothorax. The skin may develop a bluish color (termed cyanosis)
due to decreases in blood oxygen levels.

Risk factors for pneumothorax include:

• Your sex. In general, men are far more likely to have a pneumothorax than women are,
though women can develop a rare form of pneumothorax (catamenial pneumothorax)
related to the menstrual cycle.

• Smoking. This is the leading risk factor for primary spontaneous pneumothorax. The risk
increases with the length of time and the number of cigarettes smoked.

• Age. Primary spontaneous pneumothorax is most likely to occur in people between 20

and 40 years old, especially if the person is very tall and underweight.

• Lung disease. Having another lung disease, especially emphysema, makes a collapsed
lung more likely.

• A history of pneumothorax. If you've had one pneumothorax, you're at increased risk of

another, usually within one to two years of the first episode. This may occur in the same
lung or the opposite lung.

ANATOMY AND PHYSIOLOGY

 The primary function of the respiratory system is to supply the blood with oxygen in
order for the blood to deliver oxygen to all parts of the body. The respiratory system does this
through breathing. When we breathe, we inhale oxygen and exhale carbon dioxide. This
exchange of gases is the respiratory system's means of getting oxygen to the blood.

Respiration is achieved through the mouth, nose, trachea, lungs, and diaphragm. Oxygen
enters the respiratory system through the mouth and the nose. The oxygen then passes through
the larynx (where speech sounds are produced) and the trachea which is a tube that enters the
chest cavity. In the chest cavity, the trachea splits into two smaller tubes called the bronchi. Each
bronchus then divides again forming the bronchial tubes. The bronchial tubes lead directly into
the lungs where they divide into many smaller tubes which connect to tiny sacs called alveoli.
The average adult's lungs contain about 600 million of these spongy, air-filled sacs that are
surrounded by capillaries. The inhaled oxygen passes into the alveoli and then diffuses through
the capillaries into the arterial blood. Meanwhile, the waste-rich blood from the veins releases its
carbon dioxide into the alveoli. The carbon dioxide follows the same path out of the lungs when
you exhale.

The diaphragm's job is to help pump the carbon dioxide out of the lungs and pull the
oxygen into the lungs. The diaphragm is a sheet of muscles that lies across the bottom of the
chest cavity. As the diaphragm contracts and relaxes, breathing takes place. When the diaphragm
contracts, oxygen is pulled into the lungs. When the diaphragm relaxes, carbon dioxide is
pumped out of the lungs.
PATHOPHYSIOLOGY
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