PNEUMOTHORAX AND HEMOTHORAX Dr Eshwar Kanse

collection of air within the pleural space Pneumothorax collection of air within the pleural space transforms the potential space into a real one may lead to various degrees of respiratory compromise with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario impairs respiratory function decreases venous return to the right-side of the heart

Pneumothorax Primary Spontaneous Ptx a disease of younger individuals (15 - 35 yrs of age) males > females tall, slim body habitus cigarette smoking implicated usual cause: parenchymal blebs apex of the upper lobe superior segment of the lower lobe

Pneumothorax Primary Spontaneous Ptx: “in most instances, the treatment of a first-occurrence consists of hospitalization, tube-thoracostomy to closed drainage, lung-re-expansion against the chest wall, and control of any persistent air-leak”

Pneumothorax Secondary Ptx: due to underlying pulmonary disease COPD / Asthma / Cystic Fibrosis Immunocompromised Infections Tb & Cocci PCP (becoming more common) Treatment: Closed Thoracostomy Water-seal Heimlich-Flutter Valve V.A.T.S.

Pneumothorax Traumatic Ptx Parenchymal Injury vs. Tracheobronchial vs. Esophageal Blunt or Penetrating Iatrogenic central lines / thoracentesis / biopsy endotracheal tube placement (esp. dual-lumen tubes !) endoscopy / dilational techniques Barotrauma Ventilation / blast injury / Boerhave’s syndrome Operative

SIGNS OF PNEUMOTHORAX IN SUPINE POSITION

Options Benefit Risk Cost Availability X-Ray Ultrasound CT-Scan Sensitivity:20.9 % Pneumothorax: (+) Hemothorax:(+) Specificity: 98.7 % Exposure to radiation Rs300 available Ultrasound Sensitivity:48.8% Pneumothorax: (++) Specificity: 99.6% No radiation exposure Rs1600 CT-Scan Sensitivity:100% Pneumothorax: (+++) Hemothorax: (+++) Specificity: 100% Rs3000 Not readily available

Pathophysiology of Tension Pnemothorax Increase in Intrapleural pressure Compression of lung to other side Compresses against trachea, heart, aorta, esophagus Ventilation and Cardiac Output greatly compromised

Clinical Manifestations/Complications of Tension Pneumo Severe Dyspnea Tracheal Deviation Decreased Cardiac Output Distended Neck Veins RR, pulse, blood pressure Shock

Pneumothorax Treatment Options Observation: Inpatient vs. Outpatient Thoracostomy Drainage 3rd Interspace / 5th Interspace Negative Suction / Water-seal V.A.T.S. (becoming the “standard”) Muscle-sparing Thoracotomy Posterolateral & Anterolateral Thoracotomy

“ the collection of blood between the visceral and parietal pleura…” Hemothorax “ the collection of blood between the visceral and parietal pleura…”

Hemothorax Causes of a Spontaneous Hemothorax Pulmonary: bullous emphysema, PE, infarction, Tb, AVM’s Pleural: torn adhesions, endometriosis Neoplastic: primary, metastatic (melanoma) Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation Thoracic Pathology: ruptured aorta, dissection Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum

SIGNS AND SYMPTOMS Anxiety / restlessness Tacypnea Signs of shock Frothy ,bloody sputum Diminished breath sounds on affected side Tacycardia FLAT NECK VEINS

The Pathophysiologic Process Hemothorax The Pathophysiologic Process the accumulation of pleural blood forms a stable clot overall ventilation & oxygenation becomes impaired mechanical compression of the lung parenchyma mediastinal shift flattening of the hemidiaphragm

The Pathophysiologic Process Hemothorax The Pathophysiologic Process over time, the clot is partially-absorbed, leaving behind loculated fluid and fibrinous septations macro-fibrin deposition begins to provide a structural framework this “peel” slowly contracts to entrap the underlying lung

Hemothorax Goal of Treatment to remove the pleural blood and allow for complete lung re-expansion

Hemothorax General Management Options thoracentesis: bedside / ultrasound-guided / C.T.-guided thoracostomy drainage: the mainstay thorascopic surgery: less than 2 wks. & use a 30-degree scope thoracotomy: massive hemothorax / instability / chronic hemothorax local fibrinolytic therapy: urokinase (1000 IU/ml) in 150cc solution

Hemothorax Often, there is an accompanying pneumothorax Dual Chest Tube Management Superior-Apical: Ptx Diaphragmatic-posterior: Htx Consider targeted-drainage into a loculated collection All tubes to negative suction with protective water-seal Prophylactic antibiotics may be indicated while the tubes are in (controversial!!) Chest tubes removed: 100 -150 cc’s / day

Hemothorax Undrained hemothorax increases the risk of empyema & fibrothorax Large collections should be drained slowly to minimize the development of re-expansion-pulmonary-edema [“R.E.E.P.”] (stop after 2 liters…wait 6-8 hrs, then drain out another 1-2 liters, etc) Computed tomography is the diagnostic of choice

Chest Tube Insertion Pneumothorax: Chest tube will be placed at 2nd intercostal space since air accumulate in apical portion of lung. Hemothorax: Chest tube will be placed in the 5th/6th or 8th/9th intercostal space since blood and fluid accumulate in dependent part.

Preoperative Preparation Informed consent Provide psychosocial support Optimize patient condition Hydration Antibiotics ATS 6000 units TIM ( ) ANST TT 0.5 ml TIM

Operative technique Patient semi-sitting with the ipsilateral arm placed above the head to expose the lateral aspect of the chest chest prepared with antiseptic solution draped to create a sterile field large bore chest tube (F36) placed to facilitate adequate drainage

Operative technique

Operative technique 5th ICS midaxillary line identified and skin, periosteum, and pleura anesthesized with 1% lidocaine transverse incision made over the underlying space blunt dissection continued with Kelly clamp clamp passed adjacent to the superior surface of the rib to prevent injury to the intercostals neurovascular bundle

Operative technique entry into the pleural space confirmed with rush of blood-filled fluid finger inserted into the pleural space to identify any pleural adhesions Fr 36 chest tube inserted into the pleural space on a Kelly clamp and directed posteriorly tube secured with a silk 0 suture

Operative technique

Operative technique attached to a water sealed thora-bottle insertion site dressed gauze and covered with air-tight dressing initial and subsequent drainage recorded post-procedure chest film obtained

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