Case Report Case Report Pneumology 2Pneumology 2

Dr. David TranDr. David TranA&E department FVHospitalA&E department FVHospital

Medical meeting 28/09/11Medical meeting 28/09/11

Japanese patient 55 Japanese patient 55 yearsyears

Transfert from SOS international clinic Transfert from SOS international clinic for management of a bilateral for management of a bilateral pneumothorax.pneumothorax.

At arrival, polypnea, shortness of breath, At arrival, polypnea, shortness of breath, SpO2 97% under O2 HCM 10l/min.SpO2 97% under O2 HCM 10l/min.

Blood pressure 110/57, Pulse 91/min., Blood pressure 110/57, Pulse 91/min., Temp 36.7,Pain score 0 (!?)Temp 36.7,Pain score 0 (!?)

Chest XrayChest Xray

Chest XrayChest Xray

After drainageAfter drainage

4th intercostal

space5th

intercostal space

Chest CT scanner: multiple Chest CT scanner: multiple emphysema bubblesemphysema bubbles

Chest CT scannerChest CT scanner

Definition & History of Definition & History of PneumothoraxPneumothorax

Pneumothorax is defined as air in the pleural Pneumothorax is defined as air in the pleural space that is, between the lung and the chest wall. space that is, between the lung and the chest wall.

Primary pneumothoraxPrimary pneumothorax arise in otherwise healthy arise in otherwise healthy people without any lung disease. people without any lung disease.

Secondary pneumothoraxSecondary pneumothorax arise in subjects with arise in subjects with underlying lung disease. underlying lung disease.

The term pneumothorax was first used by Itard, a The term pneumothorax was first used by Itard, a student of Laennec, in 1803, and Laennec himself student of Laennec, in 1803, and Laennec himself described the pneumothorax in 1819 described the pneumothorax in 1819

First clinical description of First clinical description of pneumothorax by Laennecpneumothorax by Laennec

in 1819in 1819

Risk factors / CausesRisk factors / Causes Despite the absence of underlying Despite the absence of underlying

pulmonary disease in patients with primary pulmonary disease in patients with primary pneumothorax, subpleural blebs and bullae pneumothorax, subpleural blebs and bullae are likely to play a role in the pathogenesis are likely to play a role in the pathogenesis since they are found in up to 90% of cases of since they are found in up to 90% of cases of primary pneumothorax at thoracoscopy or primary pneumothorax at thoracoscopy or thoracotomy and in up to 80% of cases on thoracotomy and in up to 80% of cases on CT scanning of the thoraxCT scanning of the thorax

Undoubtedly, smoking plays a role; the Undoubtedly, smoking plays a role; the lifetime risk of developing a pneumothorax lifetime risk of developing a pneumothorax in healthy smoking men may be as much as in healthy smoking men may be as much as 12% compared with 0.1% in non-smoking 12% compared with 0.1% in non-smoking men men

Recurrent risk after 1st Recurrent risk after 1st episodeepisode

The risk of recurrence of primary The risk of recurrence of primary pneumothorax is 54% within the first 4 pneumothorax is 54% within the first 4 years, with isolated risk factors years, with isolated risk factors including smoking, height in male including smoking, height in male patients,patients, and age over 60 years. and age over 60 years.

Risk factors for secondary Risk factors for secondary pneumothorax recurrence include age, pneumothorax recurrence include age, pulmonary fibrosis, and emphysema pulmonary fibrosis, and emphysema

DiagnosisDiagnosis In both primary and secondary spontaneous pneumothorax In both primary and secondary spontaneous pneumothorax

the diagnosis is normally established by plain chest the diagnosis is normally established by plain chest radiography. radiography.

In general, Expiratory chest radiographs are not In general, Expiratory chest radiographs are not recommended for the routine diagnosis of pneumothorax. recommended for the routine diagnosis of pneumothorax.

CT scanning is recommended when differentiating a CT scanning is recommended when differentiating a pneumothorax from complex bullous lung disease or when pneumothorax from complex bullous lung disease or when aberrant tube placement is suspected.aberrant tube placement is suspected.

Complete right Complete right pneumothoraxpneumothorax

Compressive pneumothoraxCompressive pneumothorax

Complete right Complete right pneumothoraxpneumothorax

Compressive pneumothoraxCompressive pneumothorax

Particular pneumothoraxParticular pneumothorax

ClassificationClassification The previous classification of the size of a pneumothorax The previous classification of the size of a pneumothorax

tends to underestimate its volume. In these new guidelines tends to underestimate its volume. In these new guidelines

the size of a pneumothorax is divided into “small” or the size of a pneumothorax is divided into “small” or

“large” depending on the presence of a visible rim of <2 “large” depending on the presence of a visible rim of <2

cm or ≥2 cm between the lung margin and the chest wall.cm or ≥2 cm between the lung margin and the chest wall.

A large space > 2cm is equivalent to a 50A large space > 2cm is equivalent to a 50% pneumothorax % pneumothorax

= indication for drainage= indication for drainage

Size of a pneumothoraxSize of a pneumothorax

Management of small Management of small pneumothorax pneumothorax ((<2cm<2cm))

Observation should be the treatment of choice for small Observation should be the treatment of choice for small

closed pneumothorax without significant breathlessness. closed pneumothorax without significant breathlessness.

Patients with small (<2 cm) primary pneumothorax not Patients with small (<2 cm) primary pneumothorax not

associated with breathlessness should be considered for associated with breathlessness should be considered for

discharge with early outpatient review. These patients discharge with early outpatient review. These patients

should receive clear written advice to return in the event should receive clear written advice to return in the event

of worsening breathlessness. of worsening breathlessness.

Simple AspirationSimple Aspiration Simple aspiration is recommended as first line treatment Simple aspiration is recommended as first line treatment

for all primary pneumothorax requiring intervention. for all primary pneumothorax requiring intervention. Simple aspiration is less likely to succeed in secondary Simple aspiration is less likely to succeed in secondary

pneumothorax and, in this situation, is only recommended pneumothorax and, in this situation, is only recommended as an initial treatment in small (<2 cm) pneumothorax in as an initial treatment in small (<2 cm) pneumothorax in minimally breathless patients under the age of 50 years. minimally breathless patients under the age of 50 years.

Patients with secondary pneumothorax treated successfully Patients with secondary pneumothorax treated successfully with simple aspiration should be admitted to hospital and with simple aspiration should be admitted to hospital and observed for at least 24 hours before discharge. observed for at least 24 hours before discharge.

Intercostal drainageIntercostal drainage If simple aspiration or catheter aspiration drainage of If simple aspiration or catheter aspiration drainage of

any pneumothorax is unsuccessful in controlling any pneumothorax is unsuccessful in controlling symptoms, then an intercostal tube should be inserted. symptoms, then an intercostal tube should be inserted.

Intercostal tube drainage is recommended in secondary Intercostal tube drainage is recommended in secondary pneumothorax except in patients who are not breathless pneumothorax except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax. and have a very small (<1 cm or apical) pneumothorax.

A bubbling chest tube should never be clamped. A bubbling chest tube should never be clamped. A chest tube which is not bubbling should not usually be A chest tube which is not bubbling should not usually be

clamped. clamped.

Placement of an Placement of an intercostal drainintercostal drain

33rdrd to 5 to 5thth intercostal intercostal space on the space on the medium axillary linemedium axillary line

22ndnd intercostal space intercostal space on the medium on the medium clavicular lineclavicular line

Procedure for intercostal Procedure for intercostal drainagedrainage

1.1. Infiltrate local anesthesic (Xylocaine 2%) in the Infiltrate local anesthesic (Xylocaine 2%) in the appropriate location (3appropriate location (3rdrd to 5 to 5thth intercostal space) intercostal space)

2.2. Make an incision through the skin and subcutaneous Make an incision through the skin and subcutaneous tissue along the superior border of the lowermost rib tissue along the superior border of the lowermost rib of the chosen intercostal spaceof the chosen intercostal space

3.3. Perform blunt dissection through the chest wallPerform blunt dissection through the chest wall4.4. Insert the chest drain Insert the chest drain 5.5. Connect the intercostal drain to the drainage system Connect the intercostal drain to the drainage system 6.6. Fix the drain to the skin with a stitch and apply gauze Fix the drain to the skin with a stitch and apply gauze

dressing.dressing.

Fixation of the chest tubeFixation of the chest tube

Interest of Heimlich Interest of Heimlich valvevalve

The Heimlich valve is a one-way, rubber flutter The Heimlich valve is a one-way, rubber flutter valve. The proximal end attaches to the chest tube, valve. The proximal end attaches to the chest tube, and the distal end connects to a suction device or is and the distal end connects to a suction device or is left open to the atmosphere.left open to the atmosphere.

Interest of Fuhrman Interest of Fuhrman draindrain

Used for evacuation of air from the pleural space. Used for evacuation of air from the pleural space. Standard percutaneous entry (Seldinger techniqueStandard percutaneous entry (Seldinger technique)) facilitates controlled, atraumatic catheter introduction. facilitates controlled, atraumatic catheter introduction. Catheter material is radiopaque polyurethane.Catheter material is radiopaque polyurethane.

Size of the intercostal Size of the intercostal tubetube

There is no evidence that large tubes (20–There is no evidence that large tubes (20–24 F) are any better than small tubes (10–24 F) are any better than small tubes (10–14 F) in the management of 14 F) in the management of pneumothorax.pneumothorax.

The initial use of large (20–24 F) The initial use of large (20–24 F) intercostal tubes is not recommended, intercostal tubes is not recommended, although it may become necessary to although it may become necessary to replace a small chest tube with a larger replace a small chest tube with a larger one if there is a persistent air leak one if there is a persistent air leak

Suction to the intercostal Suction to the intercostal tubetube

Suction to an intercostal tube should not be applied Suction to an intercostal tube should not be applied directly after tube insertion, but can be added after 48 directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of a hours for persistent air leak or failure of a pneumothorax to re-expand. pneumothorax to re-expand.

High volume, low pressure (−10 to −20 cm H 2 O) High volume, low pressure (−10 to −20 cm H 2 O) suction systems are recommended.suction systems are recommended.

Patients requiring suction should only be managed on Patients requiring suction should only be managed on lung units where there is specialist medical and nursing lung units where there is specialist medical and nursing experienceexperience

Referral to thoracic Referral to thoracic surgeonsurgeon

In cases of persistent air leak or failure of the lung to re-In cases of persistent air leak or failure of the lung to re-expand, the managing respiratory specialist should seek expand, the managing respiratory specialist should seek an early (3–5 days) thoracic surgical opinion.an early (3–5 days) thoracic surgical opinion.

Open thoracotomy and pleurectomy remains the Open thoracotomy and pleurectomy remains the procedure with the lowest recurrence rate for difficult or procedure with the lowest recurrence rate for difficult or recurrent pneumothox. Minimally invasive procedures, recurrent pneumothox. Minimally invasive procedures, thoracoscopy (VATS), pleural abrasion, and surgical talc thoracoscopy (VATS), pleural abrasion, and surgical talc pleurodesis are all effective alternative strategies. pleurodesis are all effective alternative strategies.

Indication for surgical Indication for surgical managementmanagement

Second ipsilateral pneumothoraxSecond ipsilateral pneumothorax

First contralateral pneumothoraxFirst contralateral pneumothorax

Bilateral spontaneous pneumothoraxBilateral spontaneous pneumothorax

Persistent air leak (>5–7 days of tube drainage; air Persistent air leak (>5–7 days of tube drainage; air

leak or failure to completely re-expand)leak or failure to completely re-expand)

Spontaneous haemothoraxSpontaneous haemothorax

Management of primary Management of primary pneumothoraxpneumothorax

Management of secondary Management of secondary pneumothoraxpneumothorax

ReferencesReferences British Thoracic Society guidelines British Thoracic Society guidelines

2003 for the management of 2003 for the management of spontaneous pneumothoraxspontaneous pneumothorax

M HenryM Henry, , T ArnoldT Arnold, , J HarveyJ Harvey, , http://pneumologic.com/Pneumologie/Imagerie/Pages/http://pneumologic.com/Pneumologie/Imagerie/Pages/

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