1. Diagnosis and Treatment of Pneumothorax
Souheil M. Abdel Nour, MD
Moderator: Thomas Roy, MD
Pulmonary and Critical Care
East Tennessee State University

2. Disclosure Statement of Financial Interest
I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Definitions Primary Spontaneous Pneumothorax (PSP)
No underlying lung disease
Secondary Spontaneous Pneumothorax (SSP)
Complication of underlying lung disease
Traumatic Pneumothorax
Caused by penetrating and or blunt trauma
Iatrogenic Pneumothorax
Complication of diagnostic or therapeutic intervention
Pneumomediastinum is the presence of gas in the mediastinal tissues occurring spontaneously or following procedures or trauma.
A tension pneumothorax is a life-threatening condition that develops when air is trapped in the pleural cavity under positive pressure, displacing mediastinal structures and compromising cardiopulmonary functio

5. Prognosis Prognosis varies among the pneumothorax classifications
Recurrence rate is about 28% for PSP and 43% for SSP over a period of 5 years.
Mortality rate of 1-17% in patients with COPD
5% of patients with COPD died before a chest tube was placed
Patients with AIDS: inpatient mortality rate of 25% and a median survival of 3 months after the pneumothorax.
Although some authors view PSP as more of a nuisance than a major health threat, deaths have been reported. SSPs are more often life threatening,
Difficult Decisions in Thoracic Surgery: An Evidence-based Approach, By Mark K. Ferguson.  2nd ed. 2011

6. Prognosis
The overall mortality was per million per year for males and 0.62 per million per year for females.
Death from pneumothorax is rare.
Epidemiology of pneumothorax in England.Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Thorax Aug; 55(8):

7. Primary Spontaneous Pneumothorax (PSP)
No precipitating event
No known lung disease
Actually most PSP have unrecognized lung disease (subpleural bleb)
The incidence: men 7.4 (USA) - 37 (UK) per 100,000 population per year
Women << men, 1.2 (USA) – 15.4 (UK) per 100,000 population per year

8. Matching?! Pneumatocoele Cavity Cyst Bleb Bulla
Thin-walled (< 1mm), gas-filled space in the lung developing in association with acute pneumonia
Intrapleural cystic space
Thin-walled, air- or fluid-filled, with a wall that contains respiratory epithelium, cartilage, and smooth muscle
Thin-walled(<1 mm), contained within the lung ,1 cm in size when distended-Walls may be formed by pleura, septa, or compressed lung tissue
Gas-containing space in the lung having a wall > 1 mm thick
Pneumatocoele
Cavity        
Cyst      
Bleb
Bulla

9. Air-containing Structures
Pneumatocoele: Thin-walled (< 1mm), gas-filled space in the lung developing in association with acute pneumonia, such as staph, and frequently transient
Cavity: Gas-containing space in the lung having a wall > 1 mm thick
Cyst: Thin-walled, air- or fluid-filled, with a wall that contains respiratory epithelium, cartilage, smooth muscle and glands
Bleb: Intrapleural cystic space          
Bulla  ≥2 bullae (pronounced bully): Thin-walled(<1 mm), contained within the lung ,1 cm in size when distended-Walls may be formed by pleura, septa, or compressed lung tissue

10. Which of these is NOT associated with an increased risk of recurrence?
Male gender
Tall stature in men
Low body weight
Failure to stop smoking

11. Recurrence of primary spontaneous pneumothorax.
Retrospective study of 275 episodes of PSP in 153 patients over a four year period
Incidence of recurrence (54.2%)
PSP was twice as common in men
Women were significantly more likely to develop a recurrence
Male height was the second most important factor
Smoking cessation the only variable which significantly influenced the risk of recurrence
Thorax. 1997;52(9):805

12. Increased incidence of PSP
Birt-Hogg-Dube syndrome
Marfan syndrome
Homocystinuria
Catamenial pneumothorax (PSP temporally related to menstruation)
Anorexia nervosa
The autosomal dominant Birt-Hogg-Dube syndrome(benign skin tumors and renal cancer

13. Which of the following is Not seen on physical exam?
Diminished breath sounds, absent fremitus, and hyperresonance to percussion on the affected side.
Decreased chest excursion on the opposite side
Subcutaneous emphysema may be present.
Tracheal deviation from the midline is a rare and typically late finding in pneumothorax .

14. Physical Exam!!!
Place your hands on the patient's back with thumbs pointed towards the spine. Your hands should lift symmetrically outward when the patient takes a deep breath.
Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree

15. Typical Clinical Presentation
Occurs at rest
Early 20s (rarely after age 40)
Sudden onset of dyspnea and pleuritic chest pain
Decreased chest excursion on the affected side, diminished breath sounds, and hyperresonant percussion
+/- Subcutaneous emphysema
Labored breathing + hemodynamic => tension PTX
Hypoxemia is common
hypercapnia is unusual
Acute respiratory alkalosis

17. Tension Pneumothorax

18. Evidence Based Medicine

20. Supine and lateral XR: trauma Pts- less sensitive
Expiratory films: no additional benefit
US: supine trauma
CT : ‘gold standard’ (small PTX/size estimate)
These may provide additional information when a suspected
pneumothorax is not confirmed by a PA chest film33

22. Underestimate or overestimate?!

23. USA: over- vs. UK: underestimate
Guidelines from the USA (ACCP-Chest 2001) overestimate the volume in a localised apical pneumothorax.

28. Which of the following is the right answer?
The O2 does not help if the patient is not hypoxic
It helps symptomatically but it delays the resorption of the pleural air
No effect on the resorption of the pleural air
The rate of resorption can be markedly increased if supplemental oxygen is administered
Normal rate of resorption is approximately 1.25% of the volume of the hemithorax per 24 hours. However, the rate of resorption increases six-fold if humidified 100 percent oxygen is administered!

29. Secondary Spontaneous Pneumothorax (SSP)

30. Secondary Spontaneous Pneumothorax (SSP)
COPD is the most common cause of SSP, ~50- 70%
Severity of COPD correlates with likelihood of SSP
Cystic fibrosis:
3 to 4% of all patients with CF will have an episode of SSP
Primary and metastatic lung malignancy (COPD often co- exists)
Necrotizing pneumonia
Pneumocystis jirovecii
Tuberculosis
Catamenial pneumothorax
PTX as a complication of underlying lung disease
Other factors associated with an increased risk of pneumothorax included infection with Pseudomonas aeruginosa, Burkholderia cepacia complex, or Aspergillus species, as well as a prior episode of massive hemoptysis. These factors may reflect disease severity, rather than being independent risk factors.

31. MATCHING COPD CF PCP TB Rupture of apical subpleural cysts
Rupture of apical blebs
Rupture of a cavity into the pleural space
Alveolar and pleural tissue invasion and rupture of large subpleural cysts that are caused by tissue necrosis.
1 - b
2 - a
3 - d
4 - c

32. Less common causes of SSP
Histiocytosis X
Interstitial lung disease
Lymphangioleiomyomatosis
Metastatic sarcoma
Sarcoidosis

33. Clinical Presentation
Depends upon:
Symptoms:
Volume of air
Rapidity of onset
Tension within the pleural space
Age and respiratory reserve
Dyspnea
Chest pain
More severe than PSP
Infectious cause of SSP may have cough, fever, chills, or fatigue!

34. Could it be a routine CXR? Y/N
Chest radiograph shows large bilateral collections of gas devoid of any vascular structures with a sharp edge concave laterally, which is a differentiating feature from pneumothorax. The functioning lung is retracted to the bases

37. Small bore catheters can be safely used in all the following cases of SSP except?
PTX in a pt with advanced emphysema
In COPD with AE.
Pts receiving mechanical ventilation
Iatrogenic PTX (s/p FNA*)

38. Thoracostomy tube size in SSP
Small bore catheters have advantages over larger tubes
Ease of insertion
Patient comfort
Equally efficacious in most patients in retrospective studies
One possible exception to the use of small bore tubes for SSP would be patients receiving mechanical ventilation.
Large bore tubes (24 to 28 fr) in patients receiving mechanical ventilation
However, there is one retrospective study of 62 patients with pneumothoraces complicating mechanical ventilation, small bore tubes were successful in 69 percent of pneumothoraces

39. Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adult
]. Successful treatment was reported in 72 percent of both patient groups. No significant differences were noted in terms of length of hospital stay, extubation time, recurrence rate, and complications.
Am J Emerg Med Nov;24(7):

40. Chest Tube Management Water seal device is preferable
No suction due to the risk of RPE
Failure of PTX to resolve => suction if it was not initially applied.
Keep the chest tube until a procedure is performed to prevent recurrent SSP
Pt declines preventive interventions => clamp tube 12hrs after the lung has expanded radiographically and no further air leak is detected via the chest tube.
RPE: re-expansion pulmonary edema
water seal device is preferable as it allows monitoring of the rate of air leakage.
A chest radiograph should be performed 12 to 24 hours after the chest tube is clamped and, if the pneumothorax has not recurred, the chest tube can be removed

41. Heimlich Valve
Stable patients & >90% expanded, but + air leak => Heimlich Valve and discharge
Advantage: avoid a long- term hospitalization
However, a separate procedure to prevent a recurrent SSP is typically performed in patients who are surgical candidates

42. Persistent air leakage
More common and persist longer in SSP
Persistent air leaks may be due to subpleural bullae or cysts or to necrotic lung
Air leak > 3 days => spontaneous closure is less likeley and need additional interventions

43. For surgical candidates
Persistent air leakage
VATS or open thoracotomy
Blood patch or chemical pleurodesis
For surgical candidates
Persistent leak and/or incomplete expansion (<90%)
Preferred procedure is stapling or resection of blebs + mechanical pleurodesis
Not candidates for surgery
Pleural blood patch: persistent air leak complicating ARDS
Chemical pleurodesis via chest tube-tetracycline  derivative or talc
Success is much lower than with VATS
VATS: As pleurodesis is performed as part of the procedure, the two goals of closure of the air leak and prevention of recurrence are accomplished with one operation.
Blood patch pleurodesis is performed by drawing approximately 100 mL of the patient's venous blood under sterile conditions and instilling it into the pleural space through the chest tube. Empyema is a possible complication
Some patients with severe underlying lung disease who are poor surgical candidates may prefer a longer period of conservative management with supplemental oxygen and chest tube drainage
Conservative management: Spontaneous resolution has been described with conservative management after as long as 14 days

44. Preventing recurrence
Recurrence of SSP is common and life-threatening 
50% recurrent SSP over 3 years among patients with a SSP due to COPD
Intervention in almost all patients treated for an initial SSP (even if with full re-expansion and no evidence of persistent air leak)
Intervention=control the leak + prevent recurrence (pleurodesis)
Performed within 3 to 5 days of hospitalization
3 options: thoracotomy, VATS and chemical pleurodesis.
For patients with full re-expansion and no evidence of persistent air leak, surgery to prevent recurrence is typically performed during the same hospitalization prior to removal of the chest tube, as recurrence tends to occur relatively early.
The decision among these options depends on the preferences of the surgical team and whether the patient is an operative candidate at present or a lung transplant candidate in the future.

45. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces:
a systematic review of randomised and non-randomised trials.
Lancet Jul;370(9584):

46. Surgical options: open thoracotomy vs. VATS
Lower recurrence rates with open procedures (1 % vs. 5% with VATS)
Greater blood loss, more postoperative pain, and longer hospital stays with open thoracotomy
Preferred intervention in most patients: VATS with stapling of blebs followed by obliteration of the pleural space
Emphysema + meet inclusion and exclusion criteria for LVRS=> LVRS at the same time

47. Nonsurgical chemical pleurodesis
For patients who refuse VATS or are not operative candidates=> chemical pleurodesis (better than no further intervention)
Not as effective as the VATS
Reduces the SSP recurrence to ~ 15 %
Choice of a sclerosant is controversial
we prefer doxycycline over talc, because we believe it is the safer option [51-53]. The usual intrapleural dose of doxycycline is 500 mg. Technical aspects of chemical pleurodesis are discussed in detail elsewhere

48. Am J Respir Crit Care Med. 2000;162(6):2023.

49. Other potential questions!!
Air travel
Lung transplant candidates
Avoid chemical pleurodesis
It does not preclude future lung transplantation
VATS-apical pleurodesis.
Air travel is postponed for at least two weeks in PSP.
In SSP ? not known.
Simple drainage vs. pleurodesis influences the risk of recurrence
Potential in-flight hypoxemia.
Chemical pleurodesis increases the risk of excessive bleeding during transplantation,

50. Tube Thoracostomy Management

51. Some physiology!!
The mechanics of ventilation relate to the negative intrathoracic pressure that draws air into the lungs during spontaneous respiration.
This negative pressure is best maintained in the pleural space.
Collections of air, fluid, or blood in the pleural space not only compress the lung tissue but also cause the pleural pressures to become positive, causing inappropriate ventilation!

52. How Chest Tubes Work?!
Chest drainage systems work by combining the following 3 efforts:
Expiratory positive pressure from the patient helps push air and fluid out of the chest (eg, cough, Valsalva maneuver).
Gravity helps fluid drainage as long as the chest drainage system is placed below the level of the patient’s chest.
Suction can improve the speed at which air and fluid are pulled from the chest

53. Few points!! Contraindications Radiography Antibiotics
No absolute contraindications exist for chest drain insertion.
Radiography
Serial chest radiographs are needed to monitor and confirm the expansion of the lung.
Antibiotics
Antibiotics are not needed during the presence of a chest drain for a simple pneumothorax or hydrothorax.
The antibiotic cephalexin can be used to prevent the development of an empyema when a chest drain has been used in thoracic trauma.

54. Positioning: Emergent and elective chest drains are usually placed in the triangle of safety 
The “safe triangle” is the area bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and apex below the axilla
This corresponds to an insertion area between the midaxillary and anterior axillary lines at the level of the nipple. 

55. Drainage System: underwater Seal Bottle
The underwater seal bottle is the most important element in pleural drainage.
Low -resistance, one-way valve.
The underwater seal is an anti-reflux valve.
Water can be drawn up the tube only to the height equal to the negative intrathoracic pressure (usually up to -20 cm of water).
The underwater seal is also an anti-reflux valve. Re-entry of air into the pleural space when intrapleural pressures become negative (eg, inspiration), is blocked by the underwater seal. Water can be drawn up the tube only to the height equal to the negative intrathoracic pressure (usually up to -20 cm of water). Therefore, the apparatus must be kept far enough below the patient to prevent water from being sucked up into the chest (100 cm is sufficient).[5] The water in this tube is referred to as the "column" of water; it reflects the changes in intrathoracic pressure with each inspiration and expiration.
The end of the tube in the underwater seal bottle must remain covered with water at all times. When a broad-based bottle (eg, Tudor-Edwards) and a narrow tube are used, elevation of the water column in the tube lowers the level in the reservoir by only a very small amount, keeping the seal intact.
The end of the tube must not be kept too far below the surface of water because the resistance to expulsion of air from the chest is equal to the length of tubing that is underwater. Keeping the tip of the tube 2-3 cm below the surface of water should be enough to act as a constant valve.[6, 2]
The whole system is placed erect, 100 cm below the level of the patient’s chest. This placement aids gravity drainage of chest contents into the bottle and prevents reentry of fluid into the chest during the upward swing of the fluid in the tube during inspiration

56. Drainage System :Trap Bottle
When excessive fluid drains from the chest, the level of fluid in the underwater seal is raised. This increases resistance to further outflow of fluid from the chest.
To decrease this resistance, a trap bottle is introduced between the chest tube and the underwater seal.

57. Drainage System: suction Regulator Bottle
To obtain a suction of -20 cm of water, set the tip of the tube 20 cm below the surface of the fluid. Now, increase the vacuum gradually until air bubbles gently and constantly through the atmospheric vent in the water during both phases of respiration.
The role of suction is now being debated. Some schools of thought say suction delays the sealing of air leaks from the underlying lung
Suction hastens the expansion of the lung. Another bottle is needed to introduce suction regulation to this system.
The suction regulator bottle has a 3-hole stopcock. Short tubes are passed through 2 of the holes. One short tube connects to the underwater seal bottle’s vent tube and the other short tube connects to the suction source. An atmospheric vent runs through the 3rd hole, passing below the level of water in this bottle.
When suction is applied, air is drawn down the atmospheric vent in this bottle, equal to the pressure inside the bottle that is decreased by the vacuum. Under stronger vacuum, airflow through the atmospheric vent commences, and air bubbles through the water in the bottle, but the level of suction in the bottle remains the same.
This constant level of low pressure suction is now transmitted to the underwater seal bottle and then into the pleural cavity, thus aiding evacuation of contents there, allowing a quicker reexpansion of the underlying lung. The maximum force of suction is determined by the depth of the atmospheric vent underwater in the suction regulation bottle.[2]
To obtain a suction of -20 cm of water, set the tip of the tube 20 cm below the surface of the fluid. Now, increase the vacuum gradually until air bubbles gently and constantly through the atmospheric vent in the water during both phases of respiration. A constant pressure of -20 cm of water is now transmitted to the underwater seal and on to the chest drain.
The role of suction is now being debated. Some schools of thought say suction delays the sealing of air leaks from the underlying lung

58. Multifunction Chest Drainage System
Follow the manufacturer’s instructions for adding water to the chambers.
This is usually 2 cm in the water seal chamber and 20 cm in the suction control chamber.
Slowly increase vacuum until gentle bubbling appears in the suction control chamber.
Follow the manufacturer’s instructions for adding water to the chambers. This is usually 2 cm in the water seal chamber and 20 cm in the suction control chamber.
Connect the 6-ft patient tube to the thoracic catheter.
Connect the drain to vacuum.
Slowly increase vacuum until gentle bubbling appears in the suction control chamber.
Be sure not to allow too much bubbling in the suction control chamber. Excessive bubbling is not needed clinically in 98% of patients. Vigorous bubbling is loud and disturbing to most patients. Vigorous bubbling also causes rapid evaporation in the chamber, which lowers the level of suction

60. Pearls!
The collection chamber should be kept below the level of the patient’s chest at all times.
Absence of fluid oscillations may indicate obstruction of the drainage system by clots or kinks, loss of subatmospheric pressure, or complete reexpansion of the lung.
Persistent bubbling indicates a continuing bronchopleural air leak.
Clamping a pleural drain in the presence of a continuing air leak results in a tension pneumothorax.
Clamp tubes only for procedures related to the tube or bottle (eg, to change the tube or bottle, to empty the bottle, to reconnect an accidental disconnection of the tube at any of the joints).

61. Troubleshooting chest drain management
Column is not oscillating:
Tube has been blocked
Restore patency by squeezing, milking, and even flushing the drainage tubing
Restoration of patency= respiration-related swing in the draining tube
Tubes got disconnected:
Not a great disaster!
Reconnect the tubes and ask the patient to cough
Reconnect the tubes and ask the patient to cough; any air that has entered the chest is forced out

62. Troubleshooting chest drain management
Leak around the tube:
First r/o partial block in the draining system
A single suture may need to be placed along the side of the tube to narrow the wound and seal the leak
Use of tapes and heavy dressings to occlude such leaks is not useful
Underwater seal bottle broken:
A broken bottle has to be replaced immediately
Then ask the patient to cough.

63. Chest Drain Complications
Blocked tube due to poor positioning:
Trapped in the major fissure of the lung
Tube needs to be withdrawn and reinserted
Cardiac dysrhythmia:
The tube abut the mediastinum
Try withdrawing the tube 2-3 cm.
If this does not resolve the problem=> reinserted at a separate location.

64. Chest drain complications
Persistent pneumothorax:
Clear any obstructions and seal any leaks in the drainage system.
If no leak or obstruction is found, apply suction of up to -20 cm of water to the drainage system.
Infections:
Range from wound infection to empyemas.
Reflect breaks in sterility and incorrect management of the chest drain.
Re-expansion pulmonary edema:
Large effusions are drained in a short period of time
Prevented by gradual decompression

65. Fibrinous "peel" (cortex) over the lung
Failure of the lung to fully reexpand (rarely due to blockage of the tubes)
Bronchial blockage
Fibrinous "peel" (cortex) over the lung
Collapse , usually by retained sputum
Fiberoptic bronchoscopy helps clear secretions and rule out other causes of bronchial obstruction [eg, tumor]
Thickened visceral pleura over the collapsed lung tissue
Delayed treatment of an empyema
Decortication

67. Chronic left ptx s/p cabg due to trapped lung
Chronic left ptx s/p cabg due to trapped lung. Ct shows left ptx with chest tube in place + adhesions+ thick visceral pleura encasing the collapsed left lung!

68. Ptx ex vacuo: Cxr with rul atelectasis and ptx surrounding strictly the atelectatic lobe.
After broch and removal of the mucus plu, the ptx disappeared

69. Herniated gas filled stomach through left hemidiaphragm –mimicking left sided tension ptx

70. Thank You