Pneumothorax (main)

Revision as of 03:40, 18 July 2011 by Jswartz (talk | contribs)

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

  1. COPD/Asthma
  2. Cystic fibrosis
  3. Necrotizing pneumonia
  4. Lung abscess
  5. PCP
  6. TB
  7. Neoplasm
  8. Interstitial lung disease
  9. Connective tissue disease
  10. Pulmonary infarct

Diagnosis

Presentation

  • Sudden onset of pleuritic chest pain evolving to dull constant ache over days
  • Most often occurs at rest, not during exertion

Physical Exam

  • Reduced ipsilateral lung excursion
  • Hyperresonance
  • Tachypnea
  • Hypoxia
  • Increased work of breathing
  • Hypotension -> tension pneumothorax

Imaging

  • Ultrasound
    • 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
  • Size
    • Large >3cm apex to cupola
    • Small <3cm apex to cupola
  • Air fluid level with pleural effusion = ptx
  • Deep sulcus sign
  • CT Chest
    • Very sensitive and specific

Treatment

Important features are:

  1. Stability of the patient
    1. 2001 ACP Guidelines for stability:
      1. RR<24, O2 Sat >90%, HR between 60-120, nl BP
      2. Can speak in full sentences
      3. Age <50yo
  2. Size of pneumothorax
  3. Primary or secondary pneumothorax
  4. Time course unimportant

Primary Spontaneous Pneumothorax

  1. Clinically stable and small pneumothorax
    1. Observe in ED at least 6hr
    2. Repeat CXR shows stable or smaller pneumothorax then no chest tube required
    3. May DC home with f/u in 12-24 hr
    4. If no f/u or unreliable admit, high-flow O2
    5. If ptx enlarges then place chest tube
  2. Clincally stable & large pneumothorax
    1. Place Chest Tube and admit
  3. If pt refuses admission:
    1. 14Fr catheter to Heimlich valve
    2. 12 hour f/u

Secondary Spontaneous Pneumothorax

  1. Clincally stable and small pneumothorax
    1. Chest Tube
    2. Observation alone associated with some mortality
    3. Admit
    4. Do not simply aspirate or ED observe
  2. Clincically stable and large pneumothorax
    1. Chest Tube
    2. Admit

Tension Pneumothorax

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 (clinical = decreased BS or US findings)
    • Wait for CXR confirmation if stable
    • 14ga IV in midclavicular line just above the rib at the second intercostal space
  • Followed by Chest Tube

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

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
  • 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)
  • 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

See Also

Chest Tube

Thoracic Trauma

Hemothorax

Source

Tintinalli