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Diagnosis and Treatment of Pneumothorax
Souheil M. Abdel Nour, MD Moderator: Thomas Roy, MD Pulmonary and Critical Care East Tennessee State University
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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.
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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
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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
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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):
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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
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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
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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
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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
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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
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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
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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 .
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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
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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
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Tension Pneumothorax
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Evidence Based Medicine
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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
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Underestimate or overestimate?!
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USA: over- vs. UK: underestimate
Guidelines from the USA (ACCP-Chest 2001) overestimate the volume in a localised apical pneumothorax.
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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!
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Secondary Spontaneous Pneumothorax (SSP)
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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.
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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
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Less common causes of SSP
Histiocytosis X Interstitial lung disease Lymphangioleiomyomatosis Metastatic sarcoma Sarcoidosis
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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!
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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
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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*)
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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
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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):
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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
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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
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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
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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
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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.
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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):
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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
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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
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Am J Respir Crit Care Med. 2000;162(6):2023.
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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,
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Tube Thoracostomy Management
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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!
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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
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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.
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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.
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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
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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.
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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
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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
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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).
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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
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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.
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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.
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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
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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
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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!
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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
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Herniated gas filled stomach through left hemidiaphragm –mimicking left sided tension ptx
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Thank You
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