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PneumothoraxTanelLaisaar.LungClinic,TartuUniversityPneumothoraxisdefinedasthepresenceofairinthepleuralcavity(ie,thepotentialspacebetweenthevisceralandparietalpleuraofthelung),whichcanimpairoxygenationand/orventilation.Differenttypesofpneumothorax

• Spontaneous 723 60.3%o primary 218o secondary 505

• Traumatic 403 33.6%o blunttrauma 356o penetratingwounds 47

• Iatrogenic 73 6.1%• Total 1199 100%

(WeissbergD,RefaelyY.Chest2000;117:1279-85)

IatrogenicpneumothoraxIatrogenicpneumothoraxisinprincipleatraumaticpneumothoraxthatresultsfrominjurytothepleura,withairintroducedintothepleuralspacesecondarytodiagnosticortherapeuticmedicalintervention.Riskofiatrogenicpneumothoraxis1.36%whenperforminginvasiveprocedures(164/12 .010)

• Transthoraciclungbiopsy 6.7%• Thoracenthesis 3.7%• Cannulationofsubclavianvein 2.2%• Mechanicalventilation 0.41%(incaseofARDSupto87%)

Figure1.Left-sidedpartialpneumothorax.

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164patientswithiatrogenicpneumothorax:• Meanage49.27years(8months-93years)• Male101(61 %),female63(39 %)• Emergencyprocedure56.7 %,electiveprocedure43.3 %• Procedurewasperformedduetolungdiseasein69pt(42 %),otherdiseasesin95pt

(58 %)• Durationofpleuraldrainagewasmean6(1-46)days

Causes:• Cannulationofsubclavianvein 72(43.8%)• Thoracentesis 33(20.1%)• Lungbarotraumaduetomechanicalventilation 15(9.1%)• Diaphragmaticinjury 10(6.1%)• Pacemakerimplantation 8(4.8%)• Cannulationofjugularvein 8(4.8%)• Pleuralbiopsy 6(3.7%)• Tracheostomy 6(3.7%)• CTguidedtransthoracicbiopsy 5(3.1%)• Bronchoscopy 5(3.1%)• Others 4(2.5%)• TOTAL 164(100%)

(B.Çeliketal.ThoraccardiovascSurg2009;57(5):286-290)TraumaticpneumothoraxTraumaticpneumothoraxresultsfrombluntorpenetratingchesttraumathatdisruptstheparietalorvisceralpleura.Maincauses:

• Bluntchesttraumao Ribfractureso Ruptureofthelungo Tracheobronchialrupture

• Penetratingchestinjurieso Stabwoundo Gunshotinjuryo Otherwounds

• Oesophagealinjurieso Iatrogenico Boerhaavesyndrome

Diagnosticevaluation:

• Airleakfromthewound• Subcutaneousemphysema• Dyspnea,shortnessofbreath• Tachycardia• Hypotonia,extendedneckveins(tensionpneumothorax–pneumothoraxwhichisalife-

threateningandwhichdevelopswhenairistrappedinthepleuralcavityunderpositivepressure,displacingmediastinalstructuresandcompromisingcardiopulmonaryfunction)

• Hyper-resonanceonchestpercussion,decreasedorabsentbreathsoundsonauscultation(comparedtothecontralateralside)

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SpontaneouspneumothoraxSpontaneouspneumothorax(SP)developsinpeoplewithoutanincitingeventlikecoughing,traumaorphysicaleffort.

• Primaryspontaneouspneumothorax(PSP)occursinpeoplewithoutunderlyinglungdisease

• Secondaryspontaneouspneumothorax(SSP)occursinpeoplewithawidevarietyofparenchymallungdiseases.Theseindividualshaveunderlyingpulmonarypathologythataltersnormallungstructure

o COPDo Tumoro Tuberculosiso Cysticfibrosiso Catamenialpneumothoraxo AIDS+Pneumocystiscariniipneumonia

§ oftenbilateral!o Otherrarelungdiseases:

§ Lymphangioleiomyomatosis(LAM)§ HistiocytosisX

Incidence:• 5-15casesper100.000inhabitantsperyear1• 9.8casesinfemaleand24casesinmaleper100.000inhabitantperyear2

(1Nealetal.AmJSurg1979;2Guptaetal.Thorax2000)Catamenialpneumothorax

• Recurrentspontaneouspneumothoraxinwomen,relatedtomenses• Firstdescriptionin1958.(MaurerER,etal.JAMA1958;168:2013-4)• Definition-catamenialpneumothoraxbyLillingtonGA,etal.(JAMA1972;219:1328-32)• Symptomsdevelop24hbeforeorwithin72hfromtheonsetofmenses• 90-95%rightsided

(JosephJ,etal.AmJMed1996;100:164-9;CarterE,etal.Chest1990;98:713-6)• Possiblemechanismsofcatamenialpneumothorax:

o transdiaphragmaticpassageofairfromthegenitaltractthroughdiaphragmaticperforationscausedbyendometrialimplants

o subpleuralendometriosis(ruptureofendometrioticfociduringmensesresultsinairleakanddevelopmentofpneumothorax)

o bronchiolarandvascularconstrictionsecondarytoincreasedlevelsofcirculatingprostaglandinF2couldbe,insomecases,thesourceofalveolarrupturewithsubsequentpneumothorax

(GerlinzaniSetal.SurgEndosc2002;JosephJ,etal.AmJMed1996;100:164-9;CarterE,etal.Chest1990;98:713-6)

Figure2.Intraoperativeviewofdiaphragmaticdefectsinapatientwithcatamenialpneumothorax

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Symptomatologyofspontaneouspneumothorax

• Sharppleuralpain• Dyspnea/shortnessofbreath• Non-productivecough• Tachycardia• Subcutaneousemphysema

SymptomatologyisrelatedtotheextentofpneumothoraxandlungfunctionofthepatientFirstsymptomofpneumothorax:

• pain66%• dyspnea16% (LaisaarT.etal.ERJ2008)

Spontaneouspneumothoraxdevelops:• atrestin90%ofcases• duringphysicalexertionin10%ofcases(Weissbergetal.Chest2000)

Tensionspontaneouspneumothoraxoccursin1-3%ofcases• inemergencyurgentdecompressionisneeded(conversiontoopenpneumothorax!)

Riskofspontaneouspneumothoraxisincreasedin:

• Smokers(riskofpneumothoraxinhealthysmokingmaleis12%comparedto0.1%riskinnon-smoker);riskisrelatedtotheintensityofsmoking

• Young,tall,slimmale(malefemaleratio3-4:1)o Meanage28years(range13-67)

§ PSPpatientsareyounger• Bronchialanomalies• Marfansyndrome• Heredity• DevelopmentofSPispredisposedbyfluctuationoftheatmosphericpressure

(Sassoon.CurrentOpinPulmMed1995;BenseLetal.Chest1987;92:1009-12)Diagnosisofpneumothorax

• Historyo Complaintso Previouspneumothorax?

§ whichside?• Physicalexamination

o Percussion–hyper-resonanceo Auscultation–absenceordecreasedbreath-sounds

Figure3.Surgicalbiopsyspecimenofapatientwithlymphangioleiomyomatosiscausingsecondaryspontaneouspneumothorax

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• Radiologicaldiagnosticmethodso ChestX-ray:

§ Standardinvestigationtodetectpneumothorax§ Itisdifficulttoestimatetheextentofpneumothorax§ Compareconsecutiveinvestigations!§ Differentialdiagnosis:

• largepulmonarycyst• skinfolds• medialsideofscapula• bandage,adhesivesontheskin• diagragmatichernia

Figure4.Recurrentspontaneouspneumothoraxinayoungtallman.Patienthadpneumothoraxonbothsides.Extentofpneumothorax

• 2cmofpneumothoraxonchestX-raycorrespondstoapproximately50%lungcollapse(whichislargepneumothorax)

• ExactvolumeofpneumothoraxispossibletoestimateonCT• Sizeofpneumothoraxandsymptomatologyisalwaysnotinagoodcorrelation.Treatment

isthereforemoredeterminedbysymptomatologyandconcomitant(lung)diseases(PSPversusSSP)

(MacDuffAetal.Thorax2010;65(Suppl2):ii18eii31.doi:10.1136/thx.2010.136986;TschoppJMetal.EurRespirJ2015;46:321-359)

Furtherinvestigationstodetectordetailpneumothorax?

• Computedtomography:o incomplicatedcaseso insuspectedchesttubemisalignment,

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o ifunderlyinglungdiseaseissuspected(SSP)§ emphysema§ otherlungdisease

o inpatientsrequiringsurgery(TschoppJMetal.EurRespirJ2015;46:321-59)

o toevaluateparenchymaofbothlungs§ bullaearefoundin78.6-80%

(Lesuretal.Chest1990,Benseetal.Chest1993)§ contralateralbullaearefoundin53.6%

• 26.7%ofthesedevelopcontralateralSP(Sihoeetal.Chest2000)

Figure5.CTfindingofpneumothoraxTreatmentofpneumothoraxAimofthetreatmentisto:

• evacuateairfromthepleuralspace• stoptheairleakfromthelung• avoidrecurrenceofpneumothorax

Treatmentisdeterminedbysymptomatologyofthepatient(dyspnea)andnotsomuchofthesizeofpneumothoraxRecurrenceofpneumothoraxRecurrenceusuallydevelopsduringfirstmonths(6months)Recurrenceduring5years:

• PSP-28%• SSP-43%(incaseofCFupto80%)

(Baumannetal.Chest2000;Edenboroughetal.Thorax1994;49:1178-9)Risk↑after1.recurrence-50% (Lightetal.JAMA1990)Contralateralpneumothoraxdevelopsin5.2-14.6%(inadolescentsupto41%) (Lightetal.JAMA1990,Ikedaetal.JThoracCardiovascSurg1988)Treatmentmethodsforpneumothorax

• Observationo volumeofpneumothorax<15%ofthehemithoraxo athome/inhospital?o speedofairreabsorptionis1.25%ofthehemithoraxvolumedaily(50-75ml)

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• Oxygen(nasalcannula,mask)o tocorrecthypoxemiao tospeedupairreabsorptionfromthepleuralspace

• Thoracentesiso recommendedasfirsttreatmentmethodaccordingtoBTSguideline(2010)

§ effectiveness59-80%(TschoppJMetal.EurRespirJ2015;46:321-359)§ PSPinupto75%§ SSPinupto37%(Baumannetal.Chest1997)

o highriskofrecurrence• Pleuraldrainage

o recommendedasfirsttreatmentmethodaccordingtoCHEST(2001)guidelineo sizeofthechesttube?

§ expectedextentofairleak§ causeofpneumothorax§ needformechanicalventilation§ concomitantfluidothorax§ PSP:12Fr§ patientonmechanicalventilation:24Fr§ concomitanthemothorax,empyema:24-28Fr

o Whichisthebestlocationtoinsertachesttube?§ IIintercostalspacemidclavicularline§ III-IVintercostalspacemidaxillaryline§ V-VIintercostalspacemidaxillarylineincaseofconcomitantfluidothorax

o Heimlichvalve/Bülaudrainage/digitaldrainage?§ One-,two-andthree-bottlecollectionsystems§ Digitalpleuraldrainagesystem§ Suction/nosuction?

o Treatmentinhospital/outpatient?o Durationofdrainage?

§ 3-5daysàsurgicaltreatment§ airleakstopsduring48hin60%ofcases,rarelylater

(Schoenenbergeretal.ArchSurg1991)o Criteriatoremovechesttube?

§ noairleakduring24-48hversus4-6h(advantageofdigitaldrainage)§ drainclamping?

o Re-expansionpulmonaryedema14-29.8%§ causes:freeO2radicals,mechanicallunginjury,increaseinpulmonary

vascularpermeability§ predisposingfactors:durationoflungatelectasis>3days,patientage<40

years,totallungatelectasis,fastre-expansionofatelectaticlung§ treatment:oxygen,diuretics,supportofhaemodynamics,mechanical

ventilationwhenneeded(Matsuuraetal.Chest1991,Shawetal.Chest1984,KimYKetal.AmJEmergMed2009)

• Surgicaltreatmento Indications:

§ recurrentpneumothorax § peristentair-leak>3-5days§ hemopneumothorax§ bilateralpneumothorax§ occupationalrisk

(TschoppJMetal.EurRespirJ2015;46:321-359)

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o Accesstothethoraciccavity§ Videothoracoscopy

o Typeoftheoperation§ Lungresection

• Wedgeresectionofbullae§ Thermo-orlasercoagulationofbullae§ Pleurodesis

• chemicalpleurodesiso talcumpowder

• mechanicalpleurodesiso pleuralabrasiono pleurectomy

Figure6.IntraoperativefindingofbullaeattheapexofrightlunginapatientwithrecurrentprimaryspontaneouspneumothoraxandsurgicalspecimenTreatmentschemeforspontaneouspneumothoraxSmallptx: àthoracentesis àobservationinhospitalduring1-2days

ptxdiminishesàdischargehomeptxincreasesand/ordyspneadevelopsàinsertchesttube

Largeptxand/ordyspnea: àhospitalizepatient+insertchesttube

continuousair-leakover3-5daysàsurgicaltreatment(VATS)Recurrentptx:àhospitalizepatient+insertchesttubeàVATSChesttube:14-18FrRemovedrainif: -noair-leakover12-24hoursand -lungre-expandedaccordingtochestX-rayLiterature

• MacDuffA,etal.onbehalfoftheBTSPleuralDiseaseGuidelineGroup.Managementofspontaneouspneumothorax:BritishThoracicSocietypleuraldiseaseguideline2010.Thorax2010;65(Suppl2):ii18eii31.doi:10.1136/thx.2010.136986

• BaumannMH,etal.Managementofspontaneouspneumothorax.AnAmericanCollegeofChestPhysiciansDelphiConsensusstatement.Chest2001;119:590-602

• TschoppJMetal.ERSTaskForcestatement:diagnosisandtreatmentofprimaryspontaneouspneumothorax.EurRespirJ2015;46:321-359