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Pneumothorax
definition, classification, & management
Pneumothorax
(1)
Pneumothorax
General Management
First: Second: Third: evacuate the air
(2)
Pneumothorax
Classification System
Spontaneous Pneumothorax
Primary Secondary
(3)
Traumatic Pneumothorax
Pulmonary source Tracheobronchial source Esophageal source
Pneumothorax
Primary Spontaneous Ptx
males > females tall, slim body habitus cigarette smoking implicated usual cause: parenchymal blebs apex of the upper lobe superior segment of the lower lobe
(4)
Pneumothorax
Primary Spontaneous Ptx:
(5)
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)
Pneumothorax
COPD / Asthma / Cystic Fibrosis Immunocompromised Infections
Tb & Cocci PCP (becoming more common)
(7)
Pneumothorax
Traumatic Ptx
(8)
Pneumothorax
The Tension Ptx
(9)
Pneumothorax
Treatment Options
Observation: Inpatient vs. Outpatient Thoracostomy Drainage
3rd Interspace / 5th Interspace Negative Suction / Water-seal
(10)
V.A.T.S. (becoming the standard) Muscle-sparing Thoracotomy Posterolateral & Anterolateral Thoracotomy
Pneumothorax Questions ?
(11)
Pneumothorax
(12)
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 ?
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 Accumulation
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
Large effusions interfere with expansion of the lung and produce dyspnea, shortness of breath, and atelectasis
Radiologic Assessment
Chest X-Ray: PA & Lateral-Decub
(1)
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 hemidiaphragm
Radiologic Assessment
(2)
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
Exudate
Characterized by Increased Protein & LDH
[Pleural Fluid vs. Serum Levels]
value
> 0.5 > 0.6 > 200
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 Effusionsbut remember the role of pleurodesis!
although pleural disease itself is rarely fatal, it may be a significant cause of patient morbidity
Pleural Effusions
Questions ?
Hemothorax
the collection of blood between the visceral and parietal pleura
Hemothorax
Pulmonary:
(1)
Pleural: torn adhesions, endometriosis Neoplastic: primary, metastatic (melanoma) Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation Thoracic Pathology: ruptured aorta, dissection Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum
Hemothorax
(2)
Hemothorax
(3)
Hemothorax
(5)
Goal of Treatment
to remove the pleural blood and allow for complete lung re-expansion
Hemothorax
General Management Options
(4)
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
Dual Chest Tube Management
(6)
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 ccs / day
Hemothorax
(6)
Hemothorax
Questions ?
Hemothorax
Questionswell, I have some
1. 2. 3.
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 ?
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
Stage II - Fibrinopurulent
a fibrinous peel develops on both pleural surfaces limiting lung expansion
0
Strep pneumo Staph aureus # of Positive Cultures # of Cases
Empyema...
Questions ?
The Chest:
Pneumothorax, Hemothorax, Effusions, & Empyema
Any Questions?