Pneumothorax Review

Jul 13, 2024

Pneumothorax Review

Introduction

  • Series on disturbances to normal pleural physiology.
  • Discussion focused on pneumothorax.
  • Presented by Eddie Watson from ICU Advantage.
  • Goals: Make complex critical care subjects easy and provide confidence in the ICU.
  • Resources and notes available for YouTube and Patreon members.
  • Visit icuadvantage.com for quizzes and other resources.

Pneumothorax Basics

  • Definition: Abnormal collection of air in the chest (pleural space).
  • Impact: Disrupts negative intrapleural pressure, leading to lung collapse.

Types of Pneumothorax

Entry of Air

  • Air enters either through the chest wall (trauma) or lung tissue (rupture).

Classification

  1. Traumatic Pneumothorax
    • Caused by injury (blunt or penetrating)
    • Examples: Stab wounds, rib fractures, iatrogenic causes (surgery, central line insertion, positive pressure ventilation)
  2. Non-Traumatic Pneumothorax (Spontaneous)
    • Primary Spontaneous Pneumothorax (PSP): No known cause
    • Secondary Spontaneous Pneumothorax (SSP): Underlying lung disease (COPD, ARDS, asthma, etc.)

Four Classifications

  1. Simple vs. Tension
    • Simple: No mediastinal shift
    • Tension: Mediastinal shift, life-threatening, immediate intervention
  2. Open vs. Closed
    • Open: Chest wound open to the outside (sucking chest wound)
    • Closed: Chest wall intact

Signs and Symptoms

  • Small PSP: Asymptomatic or mild symptoms (chest pain, shortness of breath)
  • Secondary/Traumatic: Severe dyspnea, pleuritic pain, chest pain radiating to shoulder
  • Other Symptoms: Increased respiratory rate, hypoxemia, hypercapnia, subcutaneous emphysema, asymmetric lung expansion, decreased/absent breath sounds, hyper resonance, decreased tactile femitus
  • Tension Pneumothorax: Significant respiratory/cardiac impairment, obstructive shock, cardiac arrest
    • Look for: Tachycardia, tracheal deviation, JVD, cyanosis, hypotension, respiratory failure

Diagnosis

  1. X-ray
    • Gold standard, quick, non-invasive
    • Look for absence of lung markings
    • Tension Pneumothorax: Mediastinal shift, collapsed lung
  2. CT Scan
    • More precise, not routine
    • Identifies location and size
  3. Ultrasound
    • Quick, increasingly sensitive

Treatment Options

Conservative Treatment

  • Monitoring, oxygen therapy to expedite resolution

Needle Aspiration

  • For larger primary or moderately sized secondary pneumothorax

Chest Tube

  • Gold standard, particularly for larger pneumo or tension pneumo
    • Needle Decompression: Temporary measure if chest tube delayed
  • Placement: 4th intercostal space, mid or anterior axillary line, directed superiorly
  • Sizes: Smaller (14–16 Fr) for spontaneous, larger (24–28 Fr) for traumatic
  • Initial suction to expedite resolution

Open Pneumothorax

  • Occlusive dressing taped on three sides to allow air exit on expiration
  • Await surgical repair and chest tube placement

Surgery

  • For unresolved pneumo/continued air leak
  • Options: Open thoracotomy, video-assisted thoracotomy (VAT)
    • Procedures: Pleurectomy, pleural abrasion, pleurodesis (using talc)

Conclusion

  • Hope the review helps in understanding pneumothorax.
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Additional Resources

  • Recommended further readings and lessons linked in the video.