Prof .Dr.K.H.NOORUL AMEEN’S Prof .Dr.K.H.NOORUL AMEEN’S unit M6unit M6

Dr.G ARUN KUMAR

• 30 YEAR OLD MALE CAME TO OPD WITH 30 YEAR OLD MALE CAME TO OPD WITH COMPLAINTS OF BREATHLESSNESS 1 COMPLAINTS OF BREATHLESSNESS 1 MONTH DURATION. NOW INCREASED MONTH DURATION. NOW INCREASED FOR 2 DAYSFOR 2 DAYS

• H/O COUGH WITH EXPECTORATION 1 H/O COUGH WITH EXPECTORATION 1 MONTHMONTH

• CHRONIC ALCOHOLIC AND SMOKER 15 CHRONIC ALCOHOLIC AND SMOKER 15 YEARSYEARS

COLLAPSED LUNG

COLLAPSED LUNG

HYDROPNEUMOTHORAX

CHEST X RAY PA VIEWCHEST X RAY PA VIEW

• ADEQUATE INSPIRATIONADEQUATE INSPIRATION• CENTRING, PATIENT POSITION - CENTRING, PATIENT POSITION - NORMALNORMAL• EXPOSURE/PENETRATION - EXPOSURE/PENETRATION - ADEQUQTEADEQUQTE• TRACHEA POSITION - TRACHEA POSITION - MIDLINEMIDLINE• HEART AND MEDIASTINUM – HEART AND MEDIASTINUM – NORMALNORMAL• PLEURAL SPACE PLEURAL SPACE – – HYDROPNEUMOTHORAX HYDROPNEUMOTHORAX ON THE LEFT SIDE ON THE LEFT SIDE EVIDENCED BY THE CONVEX OUTSIDE BORDER OF EVIDENCED BY THE CONVEX OUTSIDE BORDER OF LUNG WITH VISCERAL PLEURA AND AIR FLUID LEVELLUNG WITH VISCERAL PLEURA AND AIR FLUID LEVEL ??BULLAE/ ?LOCULATED HYDROPNEUMOTHORAXBULLAE/ ?LOCULATED HYDROPNEUMOTHORAX

SEEN SEEN ON RIGHT SIDE EVIDENCED BY CONVEX INWARDS ON RIGHT SIDE EVIDENCED BY CONVEX INWARDS MARGINS OF THEIR WALLS WITH AIR FLUID LEVELMARGINS OF THEIR WALLS WITH AIR FLUID LEVEL• COSTOPHRENIC ANGLES BLUNTED BILATERALLY COSTOPHRENIC ANGLES BLUNTED BILATERALLY • CARDIOPHRENIC ANGLES CARDIOPHRENIC ANGLES FREEFREE• HILA DENSITY, POSITION, SHAPE - HILA DENSITY, POSITION, SHAPE - NORMALNORMAL• SOFT TISSUES – SOFT TISSUES – NORMALNORMAL• BONES- BONES- NORMALNORMAL

Imp:LEFT HYDROPNEUMOTHORAX Imp:LEFT HYDROPNEUMOTHORAX RIGHT BULLOUS RIGHT BULLOUS

DISEASE/HYDROPNEUMOTHORAXDISEASE/HYDROPNEUMOTHORAX WITH ?PLEURAL THICKENINGWITH ?PLEURAL THICKENING

CT CHEST AFTER 10 DAYS

CT CHEST AFTER 10 DAYS

•RIGHT HYDROPNEUMOTHORAX

•EMPHYSEMATOUS BULLAE IN B/L LOWER LOBE, RIGHT MIDDLE LOBE

•B/L LOWER LOBE BRONCHIECTASIS

BULLAE

TENSION PNEUMOTHORAX

PneumothoraxPneumothoraxPneumothorax is the presence of air in the pleural cavityPneumothorax is the presence of air in the pleural cavity..

• Spontaneous pneumothoraxSpontaneous pneumothorax• PrimaryPrimary• SecondarySecondary Airways disease (COPD, cystic fibrosis, acute severe Airways disease (COPD, cystic fibrosis, acute severe

asthma)asthma) Infectious lung diseaseInfectious lung disease Interstitial lung disease (e.g. sarcoidosis)Interstitial lung disease (e.g. sarcoidosis) Connective tissue disease (e.g. rheumatoid arthritis, Connective tissue disease (e.g. rheumatoid arthritis,

Marfan Marfan Malignancy (bronchial carcinoma or sarcoma)Malignancy (bronchial carcinoma or sarcoma) Thoracic endometriosisThoracic endometriosis

• Traumatic pneumothoraxTraumatic pneumothorax• Iatrogenic pneumothoraxIatrogenic pneumothorax Transthoracic needle Transthoracic needle

aspirationaspiration Subclavian vein punctureSubclavian vein puncture Thoracentesis and pleural Thoracentesis and pleural

biopsybiopsy PericardiocentesisPericardiocentesis Barotrauma related to mech Barotrauma related to mech ventilationventilation

• Because the normal pleural space contains a Because the normal pleural space contains a small volume of fluid , blunting of the small volume of fluid , blunting of the costophrenic angle by a short fluid level is costophrenic angle by a short fluid level is commonly seen in a pneumothoraxcommonly seen in a pneumothorax

• In a small pneumothorax this fluid level may be In a small pneumothorax this fluid level may be the most obvious radiological sign. A larger fluid the most obvious radiological sign. A larger fluid collection usually signifies a complication and collection usually signifies a complication and represents exudate, pus or blood, depending an represents exudate, pus or blood, depending an the aetiology of the pneumothorax. the aetiology of the pneumothorax.

• Pleural thickening may cause blunting of the Pleural thickening may cause blunting of the costophrenic angle, but is distinguished from costophrenic angle, but is distinguished from pleural fluid by the fact that it occurs as a linear pleural fluid by the fact that it occurs as a linear shadow ascending vertically and clinging to the shadow ascending vertically and clinging to the ribs. ribs.

Peripheral shadowing on the right

Loss of right lung volume Shadowing over the whole

right lung due to circumferential pleural

thickening

Pleural thickeningPleural thickening• Diffuse pleural thickening due to acute pleuritisDiffuse pleural thickening due to acute pleuritis::

     Pneumonia     Pneumonia     Tuberculosis     Tuberculosis     Empyema     Empyema     Connective tissue disease     Connective tissue disease     Drugs (eg. practolol, methysergide)     Drugs (eg. practolol, methysergide)     Fibrosing pleuritis     Fibrosing pleuritis     Post radiotherapy     Post radiotherapy     Post-traumatic diffuse pleural thickening eg. haemothorax     Post-traumatic diffuse pleural thickening eg. haemothorax     Post-surgery (particularly coronary artery bypass grafting     Post-surgery (particularly coronary artery bypass grafting

• Other diagnoses that may resemble diffuse pleural Other diagnoses that may resemble diffuse pleural thickeningthickening::Pleural plaques, Mesothelioma ,Other pleural- based tumours Pleural plaques, Mesothelioma ,Other pleural- based tumours

• Essentially all common causes of Essentially all common causes of nodular pleural nodular pleural thickeningthickening are malignant and include: are malignant and include: mesothelioma, , Lymphoma , , invasive thymoma ,metastatic pleural disease ,metastatic pleural disease particularly from adenocarcinomas particularly from adenocarcinomas

• Pleural thickening is best seen at the lung edges Pleural thickening is best seen at the lung edges where the pleura runs tangentially to the x-ray beam. where the pleura runs tangentially to the x-ray beam.

• Visible pleural edge & Lung markings not visible Visible pleural edge & Lung markings not visible beyond this edgebeyond this edge

• Localized pleural thickening often occurs at the lung Localized pleural thickening often occurs at the lung apices with increasing age, forming an apical cap. apices with increasing age, forming an apical cap. This may be uni- or bilateral and is usually of This may be uni- or bilateral and is usually of homogeneous, soft tissue density, usually less than 5 homogeneous, soft tissue density, usually less than 5 mm thick, with a well-defined inferior margin. It mm thick, with a well-defined inferior margin. It should be distinguished from a superior sulcus should be distinguished from a superior sulcus neoplasmneoplasm

• The most useful signs in predicting the presence of malignancy The most useful signs in predicting the presence of malignancy areare

1. Circumferential thickening1. Circumferential thickening 2. Nodularity2. Nodularity 3. Thickening of greater than 1cm 3. Thickening of greater than 1cm 4. Involvement of the mediastinal 4. Involvement of the mediastinal pleura. pleura.

Signs of tension pneumothorax

Pleuritic chest painRespiratory distress (dyspnea, tachypnea, ability to speak only in shortsentences or single words,

agitation, sweating)• Falling arterial oxygen saturation• Ipsilateral hyperexpansion, hypomobility, hyperresonance with decreased BS • Tachycardia• Hypotension • Tracheal deviation • Elevated jugular venous pressure

Needle aspiration of Needle aspiration of pneumothoraxpneumothorax

• Identify the 3rd to 4th intercostal space in the midaxillary lineIdentify the 3rd to 4th intercostal space in the midaxillary line• Infiltrate with lidocaineInfiltrate with lidocaine• Connect a 21 G (green) needle to a three-way tap and a 60 ml Connect a 21 G (green) needle to a three-way tap and a 60 ml

syringesyringe• With the patient semirecumbent, insert the needle into the With the patient semirecumbent, insert the needle into the

pleural space. Withdraw air and expel it via the three-way tappleural space. Withdraw air and expel it via the three-way tap• Obtain a chest X-ray to confirm resolution of the Obtain a chest X-ray to confirm resolution of the

pneumothoraxpneumothorax• If a If a Heimlich flutter valveHeimlich flutter valve, which allows one-way passage of , which allows one-way passage of

gas, is attached to the catheter, a series of coughs or Valsalva gas, is attached to the catheter, a series of coughs or Valsalva maneuvers will allow almost complete evacuation of the maneuvers will allow almost complete evacuation of the remainder of the pneumothorax that is not under tension. remainder of the pneumothorax that is not under tension.

ReccurenceReccurence• Idiopathic spontaneous pneumothorax often recurs. Idiopathic spontaneous pneumothorax often recurs.

At least 20% to 30% of patients with idiopathic At least 20% to 30% of patients with idiopathic spontaneous pneumothorax will experience an spontaneous pneumothorax will experience an ipsilateral recurrent pneumothorax within the ipsilateral recurrent pneumothorax within the ensuing 5 years; most recurrences occur within a ensuing 5 years; most recurrences occur within a year after the initial event. Recurrences are more year after the initial event. Recurrences are more common in women and taller men and are reduced common in women and taller men and are reduced by smoking cessation. Ninety percent or more of by smoking cessation. Ninety percent or more of recurrences are ipsilateral, despite the fact that the recurrences are ipsilateral, despite the fact that the underlying abnormality (i.e., apical subpleural blebs) underlying abnormality (i.e., apical subpleural blebs) is bilateral in more than half the cases.is bilateral in more than half the cases.

• Simultaneous bilateral idiopathic spontaneous Simultaneous bilateral idiopathic spontaneous pneumothoraces are fortunately infrequent, pneumothoraces are fortunately infrequent, occurring in approximately 1% of cases; surprisingly, occurring in approximately 1% of cases; surprisingly, when they do occur, they are rarely fatal. After the when they do occur, they are rarely fatal. After the first ipsilateral recurrence of a pneumothorax, first ipsilateral recurrence of a pneumothorax, subsequent recurrences become increasingly likely.subsequent recurrences become increasingly likely.

Supine chest radiograph of Supine chest radiograph of

an intubated patient. Therean intubated patient. There

is a skin fold projected overis a skin fold projected over

the right lung apex the right lung apex

simulating a pneumothorax simulating a pneumothorax

(arrows). Close (arrows). Close

inspection reveals lung inspection reveals lung

markings extending beyond markings extending beyond

the skin fold, and no fine the skin fold, and no fine

pleural line that should be pleural line that should be

visible with a genuine visible with a genuine

pneumothoraxpneumothorax