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PneumothoraxMR 8/17/09
J.Chen
Chest Pain
Differential Diagnosis Musculoskeletal Cardiac Gastrointestinal Respiratory Psychogenic Miscellaneous
Musculoskeletal
Chest Wall Strain
Costochondritis
Direct Chest truama
Cardiac
Gastrointestinal
Caustic Ingestion
Esophageal foreign body
Esophagitis
GERD
Respiratory
Asthma
Cough
Pleural Effusion
Pneumonia
Pneumothorax
Pneumomediastinum
Pulmonary Embolism
Psychogenic
Anxiety
Hyperventilation
Miscellaneous
Breast Mass
Shingles
Sickle Cell Crisis
Thoracic Tumor
Pneumothorax
Presence of air between the visceral and parietal pleura that leads to lung collapse
Pneumothorax
Traumatic
Iatrogenic
Spontaneous Primary Secondary
Traumatic Pneumothorax
Penetrating Trauma (eg Bullet, Knife) Air entering pleural space directly through chest wall
Blunt Trauma Rib Fracture Alveolar rupture from sudden compression
High Risk Occupations Diving Flying
Iatrogenic Pneumothorax
Transthoracic Needle Aspiration biopsy
Transbronchial Biopsy
Thracentesis
Central Venous Catheter Placement
Intercostal Nerve Block
Tracheostomy
CPR
Positive Pressure Ventillation
NG tube placement
Spontaneous Pneumothorax
Due to rupture of apical Blebs
PSP-Pt do not have clinically apparent lung disease
Subpleural bullae found in 76-100% of patients undergoing VATS
Risk Factors-PSP
Smoking
Tall, Thin stature
Marfan
Birt-Hogg Syndrome-AD, characterized by benign skin tumors, renal/colon cancer, Sp PTX
Pregnancy
Familial PTX
Conditions Associated with SSP
History
Usually occur while at rest
Acute onset of chest pain Severe Stabbing Radiates to ipsilateral shoulder Pleuritic
Sudden onset of SOB
Anxiety
Cough
Dyspnea
Physical Exam
Vital Signs: Tachypnea Tachycardia Hypotension Hypoxia Pulsus Paradoxus
General Appearance Diaphoretic Splinting Cyanotic
Physical Exam
Respiratory Decreased Breath Sounds Hyperresonance to percussion Decreased Tactile Fremitus “Scratch Sign”
Cardiovascular JVD Shift in PMI
Other Subcutaneous Emphysema Shifted Trachea Altered Mental Status
Laboratory Studies
ABG PO2 frequently decreased Increased A-a gradient PCO2:
Elevated with respiratory compromise Decreased from Hyperventilation
Imaging
CXR-confirmatory
CT Useful for finding small pneumothoraces Distinguish PTX from bleb or cyst Locating small blebs
US Increasing in use 95%sensitivity, 100%specificity
CT Scan
Managment
Small PTX (<3cm): Observation High Flow O2 No further management if CXR in 24 hr is
small/stable
Management
Large PTX Hospitalization Chest tube +/- suction until lung reexpands and air leak
resolves Chemical Pleuredesis
Talc Bleomycin, tetracycline, povidone iodine
Video Assisted Thorascopic Surgery (VATS) Removal of Blebs Surgical pleurodesis
Attach lung to intrathoracic chest wall Mechanical abrasion of the lung
Pleur-Evac
Recurrence rate based on intervention Overall between 16-52%