1. PNEUMOTHORAX AND HEMOTHORAX
Dr Eshwar Kanse

2. 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

7. Pneumothorax Primary Spontaneous Ptx
a disease of younger individuals ( 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

8. 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”

9. 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.

10. 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

23. SIGNS OF PNEUMOTHORAX IN SUPINE POSITION

33. 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

37. 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

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

44. 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

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

46. 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

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

48. 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

49. 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

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

51. 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

52. 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: cc’s / day

53. 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

54. 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.

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

56. 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

57. Operative technique

58. 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

59. 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

60. Operative technique

61. 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

62. THANK YOU.