Diagnosis and Treatment of Pneumothorax Souheil M. Abdel Nour, MD Moderator: Thomas Roy, MD Pulmonary and Critical Care East Tennessee State University 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. 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 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. Difficult Decisions in Thoracic Surgery: An Evidencebased Approach, By Mark K. Ferguson. 2nd ed. 2011 Prognosis The overall mortality was 1.26 per million per year for males and 0.62 per million per year for females. Epidemiology of pneumothorax in England.Gupta D, Hansell A, Nichols T, Duong T, Ayres JG, Strachan D. Thorax. 2000 Aug; 55(8):666-71. 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 Matching?! 1. 2. 3. 4. 5. Pneumatocoele Cavity Cyst Bleb Bulla a) b) c) d) e) 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 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 Which of these is NOT associated with an increased risk of recurrence? Male gender 2. Tall stature in men 3. Low body weight 4. Failure to stop smoking 1. 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 Increased incidence of PSP Birt-Hogg-Dube syndrome Marfan syndrome Homocystinuria Catamenial pneumothorax (PSP temporally related to menstruation) Anorexia nervosa Which of the following is Not seen on physical exam? 1. Diminished breath sounds, absent fremitus, and hyperresonance to percussion on the affected side. 2. Decreased chest excursion on the opposite side 3. Subcutaneous emphysema may be present. 4. Tracheal deviation from the midline is a rare and typically late finding in pneumothorax . 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 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 Tension Pneumothorax Evidence Based Medicine Supine and lateral XR: trauma Pts- less sensitive Expiratory films: no additional benefit US: supine trauma CT : ‘gold standard’ (small PTX/size estimate) Underestimate or overestimate?! USA: over- vs. UK: underestimate Guidelines from the USA (ACCP-Chest 2001) overestimate the volume in a localised apical pneumothorax. Which of the following is the right answer? The O2 does not help if the patient is not hypoxic 2. It helps symptomatically but it delays the resorption of the pleural air 3. No effect on the resorption of the pleural air 4. The rate of resorption can be markedly increased if supplemental oxygen is administered 1. 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! Secondary Spontaneous Pneumothorax (SSP) 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 MATCHING COPD 2. CF 3. PCP 4. TB 1. 1-b 2-a 3-d 4-c Rupture of apical subpleural cysts b. Rupture of apical blebs c. Rupture of a cavity into the pleural space d. Alveolar and pleural tissue invasion and rupture of large subpleural cysts that are caused by tissue necrosis. a. Less common causes of SSP Histiocytosis X Interstitial lung disease Lymphangioleiomyomatosis Metastatic sarcoma Sarcoidosis Clinical Presentation Depends upon: Symptoms: Volume of air Dyspnea Rapidity of onset Chest pain Tension within the More severe than PSP pleural space Age and respiratory reserve Infectious cause of SSP may have cough, fever, chills, or fatigue! Could it be a routine CXR? Y/N Small bore catheters can be safely used in all the following cases of SSP except? PTX in a pt with advanced emphysema 2. In COPD with AE. 3. Pts receiving mechanical ventilation 4. Iatrogenic PTX (s/p FNA*) 1. 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 Pigtail catheters vs large-bore chest tubes for management of secondary spontaneous pneumothoraces in adult Am J Emerg Med. 2006 Nov;24(7):795-800. 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. Heimlich Valve Stable patients & >90% expanded, but + air leak => Heimlich Valve and discharge Advantage: avoid a longterm hospitalization However, a separate procedure to prevent a recurrent SSP is typically performed in patients who are surgical candidates 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 Persistent air leakage VATS or open thoracotomy Blood patch or chemical pleurodesis For surgical candidates Not candidates for surgery Persistent leak and/or Pleural blood patch: persistent incomplete expansion (<90%) Preferred procedure is stapling or resection of blebs + mechanical pleurodesis air leak complicating ARDS Chemical pleurodesis via chest tube-tetracycline derivative or talc Success is much lower than with VATS Conservative management: Spontaneous resolution has been described with conservative management after as long as 14 days 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. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and nonrandomised trials. Lancet. 2007 Jul;370(9584):329-35. 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 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 Am J Respir Crit Care Med. 2000;162(6):2023. Other potential questions!! Lung transplant candidates Air travel Avoid chemical Air travel is postponed pleurodesis It does not preclude future lung transplantation VATS-apical pleurodesis. for at least two weeks in PSP. In SSP ? not known. Simple drainage vs. pleurodesis influences the risk of recurrence Potential in-flight hypoxemia. Tube Thoracostomy Management 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! 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). 2. Gravity helps fluid drainage as long as the chest drainage system is placed below the level of the patient’s chest. 3. Suction can improve the speed at which air and fluid are pulled from the chest 1. Few points!! Contraindications 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. 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 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). 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. 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 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. 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). 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 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. 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. 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 Failure of the lung to fully reexpand (rarely due to blockage of the tubes) Bronchial blockage Collapse , usually by retained sputum Fiberoptic bronchoscopy helps clear secretions and rule out other causes of bronchial obstruction [eg, tumor] Fibrinous "peel" (cortex) over the lung Thickened visceral pleura over the collapsed lung tissue Delayed treatment of an empyema Decortication http://www.surgicalcriticalcare.net/Guide lines/chest_tube_2009 Thank You