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 Pneumothorax MR 8/17/09 J.Chen

Chest Pain  Differential Diagnosis  Musculoskeletal  Cardiac  Gastrointestinal  Respiratory  Psychogenic  Miscellaneous

Musculoskeletal  Chest Wall Strain  Costochondritis  Direct Chest truama

Cardiac  Arryhthmia  SVT  PVC  Coronary Artery Aneurysm  Infection  Myocarditis  Pericarditis  Myocardial Infarction/Ischemia  Structural abnormalities  Aortic Stenosis  Hypertrophic Cardiomyopathy  Pulmonic Stenosis  Mitral Valve Prolapse  Severe Coarctation of the aorta

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 % 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  Chronic Obstructive Lung Disease  Asthma  Tuberculosis  Cystic Fibrosis  Marijuana, Cocaine  HIV/AIDS with PCP infection  Necrotizing PNA  Bronchogenic Carcinoma  Metastatic Malignancy  Sarcoidosis  Idiopathic Pulmonary Fibrosis  ARDS

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%