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

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

3. 1. Haemothorax CAUSES: chest trauma: penetrating / non – penetrating
= 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,...)

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

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

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

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

8. 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.

9. 2. Tension PTHX Patophysiology: Clinical manifestations:
impaired venous return and decreased cardiac output
V/Q mismatch - profound hypoxia
Clinical manifestations:
sudden deterioration
dyspnoe, cyanosis, tachicardia, profuse sweating
hypotension, low O2 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.)

10. 2. Tension PTHX mediastinal shift hyperinflation collapsed lung
low hemidiaphragm

11. 2. Tension PTHX TH: medical emergency – clinical diagnosis
do not wait for CXR
100% O2
observation, auscultation, percussion
needle & syringe with saline – 2nd anterior ICS
bubbles? – replace with large - bore needle
prepare for tube thoracostomy

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

13. 3. Massive pleural effusion
Clinical manifestations:
gradual deterioration
dyspnoe, cyanosis, tachicardia
hypotension, low O2 saturation, distended neck veins
unilateral distension of THX, absent respiratory mobility

14. 3. Massive pleural effusion
mediastinal shift
distension

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

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

17. University Clinic Golnik,
Slovenia
Thank you.