Urgent pleural disorders Aleš Rozman University Clinic of Respiratory Diseases and Allergy, GOLNIK, Slovenia Portorož – 8th May 2009

Pleural emergencies: haemorrhage - haemothorax elevated pleural pressure - tension pneumothorax - massive pleural effusion

1. Haemothorax = pleural fluid with Ht > 50% blood Ht CAUSES: chest trauma: penetrating / non – penetrating (lung blood vessels, chest wall, diaphragm, pleural adhesions, mediastinum, large vessels, abdomen) iatrogenic (pleural biopsy, subclavian or jugular CVC placement, thoracentesis, transthoracic or transbronchial NA, esophageal variceal TH,...) nonthraumatic ( pleural malignancy, anticoagulant TH, spontaneous rupture of vessel (AO aneurism), bleeding disorder, thoracic endometriosis,...)

1. Haemothorax DG: CXR chest CT – for all patients with severe chest trauma thoracentesis transudate haemothorax with higher attenuation (> 35 HU)

1. Haemothorax TH: immediate tube thoracostomy 1.evacuation of blood 2.stop bleeding by apposition of pleural surfaces 3.evaluation of blood loss 4.may decrease incidence of empiema or fibrothorax 5.autotransfusion possible thoracotomy (cca 15%) 1.immediate drainage of > 20 ml/kg of blood 2.persistent bleeding > 200 ml/h 3.cardiac tamponade, vascular injury, pleural contamination, major air leaks,... TH of shock, blood and fluid replacement,...

1. Haemothorax Complications: 1.retention of clotted blood (evacuation if > 30% of hemiTHX) 2.empyema (3 – 5%) – shock, contamination, prolongued drainage, abdominal injuries 3.exudative pleural effusion (15 – 30%) 4.fibrothorax (< 1%)

2. Tension PTHX = air in the pleural space, which pressure exceeds the atmospheric pressure throughout expiration (inspiration). CAUSES – any type of PTHX: 1.with mechanical ventilation / NIPPV 2.during cardiopulmonary resuscitation 3.in divers 4.in air travel 5.in spontaneously breathing person at constant pressures (airway, environment) 6.improper chest tube handling

Pneumoscrotum secondary to bilateral tension pneumothorax Di Capua-Sacoto C, Bahilo-Mateu P, Ramírez-Backhaus M, Gimeno-Argente V, Pontones- Moreno JL, Jiménez-Cruz JF Servicio de Urología. Hospital Universitario La Fe. Valencia. Spain Actas Urol Esp. 2008;32(7): ABSTRACT PNEUMOSCROTUM SECONDARY TO BILATERAL TENSION PNEUMOTHORAX We report a case of pneumoscrotum secondary to a large bilateral tension pneumothorax. Although pneumoscrotum is an infrequent clinical condition that is generally resolved by means of conservative management, it may be a symptom of a serious and potentially life-threatening process. The management of pneumoscrotum should be directed to resolve the underlying cause. Key words: Pneumoscrotum. Pneumothorax. Complications.

2. Tension PTHX Patophysiology: impaired venous return and decreased cardiac output V/Q mismatch - profound hypoxia Clinical manifestations: sudden deterioration dyspnoe, cyanosis, tachicardia, profuse sweating hypotension, low O 2 saturation, distended neck veins subcutaneous emphysema, unilateral hyperinflation respiratory acidosis, hypoxemia sudden increse in plateau and peak pressures (volume – type vent.) sudden drop of tidal volumes (pressure – type vent.)

2. Tension PTHX hyperinflation collapsed lung mediastinal shift low hemidiaphragm

TH: medical emergency – clinical diagnosis do not wait for CXR 100% O 2 observation, auscultation, percussion needle & syringe with saline – 2nd anterior ICS bubbles? – replace with large - bore needle prepare for tube thoracostomy 2. Tension PTHX

3. Massive pleural effusion CAUSES: malignant pleural effusion PATOPHYSIOLOGY: impaired venous return and decreased cardiac output V/Q mismatch - profound hypoxia

Clinical manifestations: gradual deterioration dyspnoe, cyanosis, tachicardia hypotension, low O 2 saturation, distended neck veins unilateral distension of THX, absent respiratory mobility 3. Massive pleural effusion

mediastinal shift distension

TH: thoracentesis for symptomatic relief (500 – 1000 ml) consider chest tube and pleurodesis avoid rapid evacuation of all pleural fluid (reexpansion lung edema, PTHX) 3. Massive pleural effusion

Haemothorax and tension pneumothorax can be iatrogenic. Careful monitoring of patients and early recognition of complications should be a standard after each invasive procedure. 3. Conclusions

Thank you. University Clinic Golnik, Slovenia