so for this chest tube series here i want to do quick reviews over these different disturbances to that normal pleural physiology that we often treat with the chest tubes the first to discuss here is actually going to be our pneumothorax [Music] all right you guys welcome back to another video lesson from icu advantage my name is eddie watson and my goal is to give you guys the confidence to succeed in the icu by making these complex critical care subjects easy to understand i truly hope that i'm able to do just that and if i am i do invite you to subscribe to the channel down below when you do make sure you hit that bell icon and select all notifications so you never miss out when i release a new lesson as always the notes for this lesson as well as all the previous videos are available exclusively to the youtube and patreon members you can find links to join both of those down in the lesson description below also don't forget to head over to icuadvantage.com or follow that link down in the lesson description to take a quiz on this lesson test your knowledge while also being entered into a weekly gift card as well as don't forget that you can help support this channel through the purchase of an icu advantage sticker again those are found at the website icuadvanage.com forward slash support link down in the description now for these lessons it's helpful to have a good understanding of the mechanics behind how we breathe if you do need a review on this i am going to link to a lesson up above where i cover just that so let's actually start off talking about what is pneumothorax if we break the word down we have pneumo meaning air and thorax meaning chest and so essentially this is an abnormal collection of air in the chest or more specifically in the pleural space as you can see here again we have our patient their thorax and their lungs the over exaggerated pleural space here and so for a pneumothorax we're going to have this abnormal collection of air you see here now this air in here disrupts the normal relatively negative intrapleural pressure which is what's resisting that elastic recoil force of the lung tissue keeping them expanded and against the chest wall so disrupting this negative pressure as well as the presence of the air taking up space and putting pressure on the lung can actually lead to the lung decreasing in size and collapsing the degree of this collapsing is really what leads to the clinical presentations that we see in our patients obviously a collapsed lung is not going to be able to exchange gas very well now there's a few different ways that we can type and classify our pneumothoracies so when it comes to how air enters the chest it can really get there one of two ways it can either enter from the outside through the chest wall because of some trauma or it can enter from the rupture of lung tissue and visceral pleura and then we have a few different types of pneumothoracies the first type is actually going to be our traumatic and as the name suggests this is caused by some sort of traumatic injury so this can either be blunt or penetrating trauma and examples here would be like a penetrating stab wound or a blunt injury that causes rib fractures which then damage the lung but also some other examples of traumatic pneumothoracies would be our iatrogenic pneumothoracies and so these are going to be the result of things secondary to invasive procedures in surgery examples here include like thoracic surgery lung biopsies central line insertion can even do this tracheostomy or positive pressure mechanical ventilation and this is actually a really important one for you to know and to be aware of and to be always having in the back your mind because for our patients in the icu specifically especially if they're requiring higher pressures and higher peep and they have developing either acute or chronic lung disease that this can become a potential complication now after our traumatic pneumothoracies we also have our non-traumatic pneumothoracies and essentially these are going to be our spontaneous ones and we have two types are primary and secondary so for our primary spontaneous pneumothorax so a psp that this can result from normal lung tissue really without any known cause for our secondary spontaneous pneumothorax or ssp that this results from lung tissue that has some sort of underlying disease so this can be the result of things like copd ards asthma tb fibrosis cancer pneumonia and even endometriosis just to name a few now in addition to our types we can actually classify a pneumothorax in four different ways we have our simple versus tension and our open versus closed now a simple pneumothorax that this is going to be one that does not have any shift of any of the structures in the mediastinum it's essentially just the accumulation of air for the tension though that this type does actually shift the mediastinal structures and this is going to be something i'm going to talk about more in just a minute here the open pneumothorax is going to be where we have an open wound of the chest wall to the outside and here air is going to be moving in and out this is also something that's often referred to as a sucking chest wound and then finally for the closed here essentially the chest wall remains intact so let's actually talk about some of the signs and symptoms of a patient with a pneumothorax and first to start out for patients that actually have small primary spontaneous pneumothorax or the psp that they can actually present asymptomatic sometimes or they may exhibit some mild symptoms such as chest pain or shortness of breath now for patients that are having pain from a pneumothorax that this is usually going to be a pleuritic pain sharp it can be severe it can even radiate to the shoulder on that same side now for a patient with a secondary or traumatic pneumothorax that dyspnea is often going to be more severe now along with that discomfort or pain shortness of breath and dyspnea we can also see things like increased respiratory rate hypoxemia hypercapnia subcutaneous emphysema or sub-q air we can see asymmetric lung expansion potentially decreased or even absent breath sounds on the affected side there can be hyper resonance on percussion again on the affected side as well as decreased tactile feminists and vocal resonance once again on that affected side now if a patient has a pneumothorax that is large enough and a one-way valve exists that's allowing air into that pleural space but not out it can actually lead to significant impairment of respiration and cardiac function this is something that we refer to as a tension pneumothorax and this one is potentially life-threatening and does require immediate intervention so here the pressure or the tension caused by the pneumothorax puts pressure on the mediastinal structures and this includes the heart and the vena cavas ultimately this can result in a type of obstructive shock that leads to decreased cardiac output and potentially cardiac arrest now if your patient does develop this and they are becoming unstable make sure that you guys are not delaying the treatment for this waiting on some diagnostic imaging this is something that we've got to treat right away again because it's potentially life-threatening and this is also something that can result from mechanical ventilation so if you have a patient who's on the ventilator and they're sedated then it may be a little bit more difficult to spot this one at least early on we do have some additional things to look for though for a patient that does have attention pneumothorax and that's going to be things like tachycardia from the compensation of that decreased cardiac output we can see tracheal deviation so this is where it's going to move over to the opposite side that is affected by the tension we can see jvd they can have cyanosis really profound hypoxemia and hypotension ultimately respiratory failure and cardiac arrest so now let's actually talk about some of the ways that we can diagnose this and typically the symptoms that we're going to see for pneumothorax are often going to be vague and inconclusive especially for patients that have small primary ones they even may be asymptomatic and so usually we're going to require some sort of imaging to find and diagnose them so the first is going to be our x-ray and really this is going to be our gold standard and it's something that's quick and easy to do so here we're going to be doing a posterior anterior or pa chest x-ray and this is going to be the primary x-ray that we use now if we don't observe one on a pa x-ray but we are still suspecting the pneumothorax then we can get a lateral view as well now usually our x-rays are going to be obtained at the peak of inspiration during that inspiratory pause but an x-ray at the end of expiration may also be helpful here because the lungs are going to be smaller because they're more compressed they're going to show up wider and we may actually be able to visualize the air easier also the pocket of air compared to the smaller lungs is going to appear much larger as well now what we're looking for really on x-ray are going to be areas where the lung markings are not present so here's an example here of a chest x-ray of a patient that has a pneumothorax and i've actually zoomed in here in order to help you to be able to distinguish what i'm talking about here so if you look on our left the patient's right that there's going to be a line demarking the edge of the lung tissue essentially being our visceral pleura as you can see over on this side here we have all of our lung markings whereas up here it's blank and there's nothing this is a little bit easier to see if we kind of compare it over to the patient's other side where you see those lung markings going all the way to the edge here now because air rises typically we're going to see our pneumothorax being superior and near the apex of the lung but as the pneumo grows that it can actually start to move laterally and then inferiorly on the lung as well depending on its size now also an ipsilateral deep sulcus sign might also be indicative of a pneumo as well on that side now attention pneumothorax which here's an example of this here is actually going to be a little bit more obvious as the lung as you can see here is going to be either almost completely or completely collapsed leaving all of this area here of air and then we're also going to be able to observe the mediastinal shift and the tracheal deviation away from that affected side all right so in addition to x-ray we can also do the computerized topography or ct scan now the ct scan is not something that we routinely use but it can actually give us a much better gauge of the location and the size of the pneumothorax also abnormal lung tissue can sometimes appear as a pneumo on x-ray and for patients that are lying down which is oftentimes going to be a lot of our patients in the icu that the pneumos can be missed as well on x-ray and so our ct is going to be much more sensitive for identifying the pneumothorax as you can see an example of this here it's pretty clear pretty obvious the black area is going to be where the air is and it's going to be really obvious on the ct compared to an x-ray and then lastly we have our ultrasound as this is actually a pretty quick method for checking for a pneumo and is pretty helpful in cases of trauma or emergency situations and it may actually be more sensitive than a chest x-ray as well all right so now let's talk about our different treatment options and the treatment options really are gonna depend on the size of the pneumo as well as the associated symptoms so first we have our conservative treatment and this is really going to be for those small primary pneumothoracies that are really asymptomatic and in these cases we're really just going to watch and keep an eye on them one of the things that we can do is actually deliver oxygen therapy and this is helpful in resolving these we do have studies that show the benefit of resolving these pneumothoracies quicker and really the thought here is that by delivering the oxygen that's going to create a higher partial pressure of oxygen in the alveoli this is going to create a pressure gradient of nitrogen which is the most abundant component of air and that's going to help to draw that nitrogen out of the pleural space back into the alveoli helping to resolve that pneumothorax now another potential treatment option is going to be needle aspiration and so here for our larger primary or primary that has the shortness of breath or the moderately sized secondary pneumothoracies that needle aspiration might be something that we consider but this really isn't something that's commonly performed for hospitalized patients so then from here we have the chest tube and this is really the gold standard for treatment of pneumothorax and this is especially going to be true for the larger pneumos as well as those that are associated with symptoms including our tension pneumo now when it comes to tension we can also do something called needle decompression and this is if we're unable to get a chest tube placed quickly but again this usually isn't something that's commonly done in the hospital setting now when using a chest tube for pneumothorax typically we're going to insert it slightly higher and this is going to be in the fourth intercostal space and this is usually either mid or anterior axillary line and then typically they're going to be inserted going superiorly and then for our spontaneous pneumos usually a smaller size chest tube is used so something like a 14 or 16 french and then for our traumatic pneumos here we're going to use a little bit larger of our chest tube and typically this is going to be like 24 26 28 frames something like that and then oftentimes we are going to have the chest tube to suction initially which is going to help to resolve the pneumo a little bit quicker now real quickly here one thing i did want to mention was our treatment for the open pneumothorax and this is typically something that you're just gonna see if you're working in the ed or like in a trauma bay but this is essentially for the sucking chest wound we've got that air that's being pulled in with each breath and so we actually have to get this sealed off and the way we do this is with some sort of occlusive dressing that we're going to tape down on three sides and essentially this is going to seal off the wound on inspiration but still have the force side that is available for air to escape on expiration and then ultimately we're going to wait for surgical repair and then chest to placement to be achieved and then finally our last option for treatment is really going to be surgery and so sometimes we have a pneumo that just doesn't resolve and we have a continued air leak in these cases a more invasive measure is going to be needed and this is also the case for some trauma related injuries as well and so here your patient may need to go to the or for a thoracotomy now this can either be an open thoracotomy or a video-assisted thoracotomy or a vat which has the benefits of smaller incisions and a little bit quicker recovery that said our outcomes tend to be a little bit better with the open thoracotomy now here during the thoracotomy the site of the air leak can be identified and a repair can be attempted and this may also involve something like a pleurectomy so this is where we strip the pleural lining and or a pleural abrasion the point of doing these two things is that during the healing of these the lung is going to adhere to the chest wall temporarily and this is going to temporarily eliminate that pleural space and then really sealing off the source of the leak while it heals pleurodesis is also something that can be performed and this is essentially permanently eliminating the pleural space and attaching the lung to the chest wall so this can be done during a thoracotomy but if a patient does have a chest him in place this is also something that can be performed by administering different agents such as talc through that chest tube all right and that was our review of the pneumothorax i really hope that there was some good information here for you guys that you guys have a little bit better understanding of what this is how it comes about how we diagnose it and ultimately what we do to treat it here so i hope that you guys found this information useful if you did please leave me a like on the video down below it really helps youtube know to show this video to other people out there as well as leave me a comment down below i love reading the comments that you guys leave and i try to respond to as many people as i can make sure you subscribe to this channel if you haven't already and a special shout out to the awesome youtube and 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