1. Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDs), FCCP
Hemopneumothorax
Iskander Al-Githmi, MD, FRCSC, FRCSC (Ts & CDs), FCCP
Consultant Cardiothoracic Surgeon
Asst. Professor of Surgery
Division of Cardiothoracic Surgery
King Abdulaziz University

3. Definition
A pneumothorax is a collection of free air in the chest outside the lung that causes the lung to collapse.

4. incidence
Spontaneous pneumothorax affects about 9,000 persons each year in the U.S. who have no history of lung disease. This type of pneumothorax is most common in men between the ages of 20 and 40, particularly in tall, thin men. Smoking has been shown to increase the risk for spontaneous pneumothorax

5. Etiology
Spontaneous pneumothorax is caused by a rupture of a cyst or a small sac (bleb) on the surface of the lung (apical segment of upper lobe and or superior segment of lower lobe)
May also occur following an injury to the chest wall such as a fractured rib, any penetrating injury (gun shot or stabbing),

6. Etiology
A pneumothorax can also develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive pulmonary disease (COPD), lung cancer, and infections of the lungs (pnemocysts carinii).

7. Types of pneumothorax
A spontaneous pneumothorax, also referred to as a primary pneumothorax, occurs in the absence of a traumatic injury to the chest or a known lung disease
A secondary (also termed complicated) pneumothorax occurs as a result of an underlying condition

8. Tension Pneumothorax
Tension pneumothorax: The accumulation of air under pressure in the pleural space.
The air enters the pleural cavity and is trapped there during expiration so the air pressure within the thorax mounts higher than atmospheric pressure, compresses the lung, may displace the mediastinum and its structures (including the lung) toward the opposite side, and cause cardiopulmonary impairment (decrease cardiac output)

9. Clinical Presentation
Sudden onset chest pain sharp in nature .
Shortness of breath
Tachypnea
Tachycardia
Cyanosis
Decrease or abscent breath sounds

10. Diagnosis
Clinical presentation
Chest X-ray

11. Radiographic Picture

12. Radiographic Picture

13. Treatment
A small pneumothorax without underlying lung disease may resolve on its own.
A large pneumothorax and a pneumothorax associated with underlying lung disease often require placement of a chest tube to evacuate the air

14. Thoracostomy Tube

15. Hemothorax
Hemothorax refers to a collection of blood within the pleural cavity.

16. Etiology Traumatic Nontraumatic or spontaneous Blunt trauma
Penetrating trauma (including iatrogenic)
Nontraumatic or spontaneous
Neoplasia (primary or metastatic)
Blood dyscrasias, including complications of anticoagulation
Pulmonary embolism with infarction
Torn pleural adhesions in association with spontaneous pneumothorax

17. Clinical Presentation
Hemodynamic changes vary depending on the amount of bleeding and the rapidity of blood loss
Shock (blood loss > 750cc)
A large enough collection causes the patient to complain of dyspnea

18. Workup Chest radiography CT scan
The upright chest radiograph is the ideal primary diagnostic study in the evaluation of hemothorax
- Hemothorax is noted as a meniscus of fluid blunting the costophrenic angle
CT scan
CT scan is a highly accurate diagnostic study for pleural fluid or blood

19. Radiographic Picture

20. Treatment
If a hemothorax is equal to or greater than the amount required to obscure the costophrenic sulcus or is found in association with a pneumothorax based on chest radiograph findings, it should be drained by tube thoracostomy

21. Treatment
Surgical exploration in cases of traumatic hemothorax should be performed in the following circumstances:
Greater than 1000 mL of blood is evacuated immediately after tube thoracostomy. This is considered a massive hemothorax.
Bleeding from the chest continues, defined as mL/h for 2-4 hours.
Persistent blood transfusion is required to maintain hemodynamic stability