Pneumothorax (main): Difference between revisions
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**Displaced visceral pleural line w/o lung markings between pleural line and chest wall | **Displaced visceral pleural line w/o lung markings between pleural line and chest wall | ||
**Air fluid level with [[Pleural Effusion]] = ptx | **Air fluid level with [[Pleural Effusion]] = ptx |
Revision as of 06:27, 30 October 2014
Spontaneous Pneumothorax
Background
- Primary Pneumothorax
- Spontaneous ptx in pt w/o underlying pulm disease
- Secondary Pneumothorax
- Spontaneous ptx in pt w/ underlying pulm disease
- Worse prognosis
Causes
- Smoking
- COPD
- Asthma
- Cystic fibrosis
- Necrotizing pneumonia
- Lung abscess
- PCP PNA
- TB
- Neoplasm
- Interstitial lung disease
- Connective tissue disease
- Pulmonary infarct
Clinical Features
- Sudden onset pleuritic chest pain evolving to dull constant ache over days
- Most often occurs at rest, not during exertion
- Tachypnea, hypoxemia, increased work of breathing
- Reduced ipsilateral lung excursion
- Hypotension -> tension pneumothorax
Diagnosis
- Ultrasound: Lungs
- NO comet tail artifact
- No sliding lung sign
- Bar Code (instead of waves on the beach) appearance on M-mode
- CXR
- Displaced visceral pleural line w/o lung markings between pleural line and chest wall
- Air fluid level with Pleural Effusion = ptx
- Supine CXR view shows deep sulcus sign
- CT Chest
- Very sensitive and specific
- Size
- Large >3cm lung apex to cupola (chest wall)
- Small <3cm apex to cupola (chest wall)
Management
- Important considerations are:
- Stability
- RR<24, O2 Sat >90%, HR between 60-120, nl BP
- Can speak in full sentences
- Absence of hemothorax
- Size of ptx
- Primary or secondary pneumothorax
Special Instructions
Flying
- Patients can consider flying 1 week after resolution of pneumothorax [1]
General Treatment Options
- Observation alone
- Observation + oxygen,
- Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
- Needle or catheter aspiration
- Needle/catheter aspiration is as effective as chest tube for small ptxs
- Place in 2nd IC space in midclavicular line or 4th/5th IC space in ant axillary line
- If lung fails to expand can try 2nd aspiration attempt, Heimlich valve, or chest tube
- Needle/catheter aspiration is as effective as chest tube for small ptxs
- Tube thoracostomy
- Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated
- Underwater seal drainage is adequate (suction only necessary if persistent air leak)
Primary Spontaneous Pneumothorax
- Small size, clinically stable
- Option 1: Observe for 6hr; d/c if no sx and have pt return in 24hr for recheck
- Option 2: Small-size catheter (<14F) or needle aspiration with immediate catheter removal
- Then observe for 6h; d/c if no sx and have pt return in 24hr for recheck
- Option 3: Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
- Large size or bilateral
- Mod-size chest tube (16-22) and admit; large-size chest tube (24-36) if hemothorax
Secondary Pneumothorax
- Small size, clinically stable
- Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
- Observation alone associated with some mortality
- Large size or bilateral
- Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax
Tension Pneumothorax
- Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
Diagnosis
- Diminished or absent breath sounds
- Hypotension or e/o hypoperfusion
- Distended neck veins
- May not occur if pt is hypovolemic
- Tracheal deviation
- Late sign
Treatment
- Immediate needle decompression if unstable
- 14ga IV in midclavicular line just above the rib at the second intercostal space
- Always followed by Chest Tube placement
Traumatic Pneumothorax
Background
- Present in 25% of pts w/ chest trauma
- Rib fx and penetrating trauma most common causes
- Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied
Types
- Can be open, closed, or occult
- Open
- Communication between pleural space and atmospheric pressure (sucking chest wound)
- Occult
- PPV can convert an occult ptx to a tension ptx
- Open
Diagnosis
- Ptx after a stab wound may be delayed for up to 6 hr
- If pt decompensates obtain repeat imaging
- CXR
- Upright is best (esp expiratory film)
- Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
- No lung markings distal to white line
- Supine
- Look for deep sulcus sign
- Upright is best (esp expiratory film)
- US
- Absence of lung sliding; absence of seashore (M-mode)
Treatment
- Tension ptx
- Immediate needle thoracostomy
- Open ptx
- Cover wound with three-sided dressing
- Make sure to avoid complete occlusion (may convert injury to a tension ptx)
- Cover wound with three-sided dressing
- Tube thoracostomy indicated if:
- Pt cannot be observed closely
- Pt requires intubation
- Pt will be transported by air or over a long distance
- Observation alone ok if:
- Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
- Occult ptx (seen only on CT) unless pt requires mechanical ventilation
Special Instructions
Flying
- Can consider flying 2 weeks after full resolution of traumatic pneumothroax[1]
See Also
Source
- Roberts and Hedges Clinical Procedures in Emergency Medicine
- Rosen's
- American College of Chest Physicians Consensus Statement