1. The Chest: Pneumothorax, Hemothorax, Effusions, & Empyema
Bradley J. Phillips, M.D.
Burn-Trauma-ICU
Adults & Pediatrics

2. definition, classification, & management
Pneumothorax
definition, classification,
& management

3. collection of air within the pleural space
Pneumothorax (1)
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

4. Pneumothorax (2) General Management First: evacuate the air
Second: address the underlying source
Third: promote pleural symphysis

5. Classification System
Pneumothorax (3)
Classification System
Spontaneous Pneumothorax
Primary
Secondary
Traumatic Pneumothorax
Pulmonary source
Tracheobronchial source
Esophageal source

6. Pneumothorax (4) 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

7. Pneumothorax (5) 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”
[Graeber ‘98]

8. Pneumothorax (6) when do you operate on a primary spontaneous

9. Pneumothorax (7) 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 (8) 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

11. Pneumothorax (9) The Tension Ptx The Open Ptx: sucking-chest wound
“path of least resistance”
life-threatening emergency…how do you treat a tension ptx ??
The Open Ptx: sucking-chest wound
intrinsic lung compliance creates complete collapse
3-sided dressing
thoracostomy away from the traumatic wound

12. Pneumothorax (10) 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

13. Pneumothorax (11)
Questions ?

14. Questions…well, I have some -
Pneumothorax (12)
Questions…well, I have some -
1. What is the best diagnostic study ?
2. What is the role of “100 % Oxygen” & “Conservative-mgmt” ?
3. How would YOU treat a small Ptx (1 cm) in acute trauma ?
4. What is the predicted recurrence rate for a spontaneous Ptx ?
5. What is a “deep sulcus sign” ?

15. what are they ? where do they come from ? & how do you treat them ?
Pleural Effusions
what are they ?
where do they come from ?
& how do you treat them ?

16. Definition the accumulation of excess fluid within the
pleural space in response to injury,
inflammation, or both
may represent a local response to disease
or may just be a manifestation of a systemic illness

17. Pathogenesis of Effusions
Rate of Fluid Rate of Fluid
Accumulation Removal
1. Altered Pleural Membrane Permeability
2. Decreased Intravascular Oncotic Pressure
3. Increased Capillary Hydrostatic Pressure
4. Lymphatic Obstruction
5. Abnormal Sites of Entry

18. Clinical Manifestations
Pain
Cough
Dyspnea
Dullness to Percussion
Diminished or Absent Vocal Resonance
Diminished or Absent Tactile Vocal Fremitus
Friction Rub

19. Clinical: A Few Points
Large Effusions that prevent contact between the
Visceral & Parietal Pleura during respiration are seldom
associated with pleuritic chest pain.
Tumors involving the parietal pleura generally produce constant dull pain (Remember Ben Daly, M.D.)
Large effusions interfere with expansion of the lung and produce dyspnea, shortness of breath, and atelectasis

20. Radiologic Assessment (1)
Chest X-Ray: PA & Lateral-Decub
blunting of either costophrenic angle is indicative of the
accumulation of between ml of fluid
Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening & fibrosis
Sub-Pulmonic Effusion: accumulation of fluid between the lung & the diaphragm which gives the false impression of an elevated hemi-diaphragm

21. Radiologic Assessment (2)
Ultrasound: Helpful in Confirming the Presence of a
Small Pleural Effusion & Identifying Loculations
C.T. : Extremely Sensitive !!
also helps to view the underlying lung (which may be obscured by pleural disease)
can distinguish between Lung Abscess & Empyema

22. Pleural Fluid Analysis
Thoracentesis = Pneumothorax

23. Pleural Fluid Analysis
Thoracentesis: Transudate vs. Exudate
1. Gross Appearance
2. Cell Count & Differential
3. Gm Stain, C & S
4. Cytology
5. LDH
6. Protein
7. Glucose, Amylase

24. straw-colored, clear, odorless fluid with a
Transudate
straw-colored, clear, odorless fluid with a
WBC less than 1000 / ul
Pleural Membranes are Intact
Secondary to Altered Starling Forces
Low in Protein & other Large Molecules
CHF, Cirrhosis, Nephrotic Syndrome
Hypoalbuminemia, Constrictive Pericarditis, SVC Obstruction, PE

25. Exudate Characterized by Increased Protein & LDH
[Pleural Fluid vs. Serum Levels]
Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic Drainage
Parapneumonic, Infections, Malignancy,
Vasculitic Disease, GI Disease, TB, PE

26. Criteria for “Exudative Effusion”
criteria value
1. Pleural Protein : Serum Protein > 0.5
2. Pleural LDH : Serum LDH > 0.6
3. Pleural LDH > 200
only need 1 critical value to establish the diagnosis of exudate

27. a bloody pleural effusion occurring in a patient without a history of trauma or pulmonary infarction is Indicative of Neoplasm in 90 % of cases!
Because a RBC count as low as ,000 /ul, can cause a pleural effusion
to turn red, the finding of blood-tinged fluid per se has little diagnostic
value (usually from needle trauma)
A True Hemothorax is when the Pleural Fluid Hct exceeds 50 %
of the Peripheral Blood Hct !

28. Treatment Transudative Effusion: focus on the systemic cause
Exudative Effusion: dependent on the exact sub-type
Consider Chest Thoracostomy
Gross Pus / Empyema
pH < 7.2
Hemothorax
Complicated Parapneumonic Processes
Malignant Effusions…but remember the role of pleurodesis!

29. appropriate treatment may produce dramatic symptomatic relief !
although pleural disease itself is rarely fatal, it may be a significant cause of patient morbidity
appropriate treatment may produce
dramatic symptomatic relief !

30. Pleural Effusions
Questions ?

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

32. Hemothorax (1) 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

33. The Pathophysiologic Process
Hemothorax (2)
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

34. The Pathophysiologic Process
Hemothorax (3)
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

35. Hemothorax (5) Goal of Treatment to remove the pleural blood
and allow for
complete lung re-expansion

36. Hemothorax (4) 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

37. Hemothorax (6) 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

38. Hemothorax (6) 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

39. Hemothorax
Questions ?

40. Questions…well, I have some –
Hemothorax
Questions…well, I have some –
When do YOU operate on a “Traumatic Hemothorax” ?
What options exist in trying to drain a hemothorax (chest tube placement) ?
What are the reported complications of chest tube placement ?

41. What is an Empyema ?

42. An Accumulation of Pus in the Pleural Cavity
Empyema Thoracis
An Accumulation of Pus in the Pleural Cavity
1-2 % incidence in the pediatric population
Up to 18 % in immunocompromised adults
General Management
Appropriate Antibiotic Coverage
Thoracostomy Drainage
Streptokinase / Urokinase
Surgical Intervention - Decortication

43. The Stages of Empyema Stage I - “Exudative”
sterile pleural fluid develops secondary to inflammation without fusion of the pleura
Stage II - “Fibrinopurulent”
a fibrinous peel develops on both pleural surfaces limiting lung expansion
Stage III - “Organizing”
in-growth of capillaries & fibroblasts into the fibrinous peel

44. Empyema: A Pediatric Review

45. Empyema...
Questions ?
“don’t let it happen !!!”

46. The Chest: Pneumothorax, Hemothorax, Effusions, & Empyema
Any Questions…?