clinical aspects of penumothorax

What parts does the parietal pleura cover?

The chest wall, diaphragm and mediastinum

What parts does the visceral pleura cover?

The lungs and interlobar fissures

What is Pneumothorax?

Presence of air between visceral and

parietal pleura that leads to lung

collapse.

What are the classifications of pneumothorax?

1- Spontaneous (closed)

a. Primary

b.secondary

2- Traumatic (open)

a. Penetrating trauma

b. Blunt trauma

What are the causes of spontaneous PRIMARY pneumothorax?

1- young, slender, tall patients with healthy lung

What are the causes of spontaneous SECONDARY pneumothorax?

Patients with diseased lungs.

a. Emphysema (COPD)

b. Infections (pneumonia, TB)

c. Neoplasm (lung cancer)

What are the causes of traumatic pneumothorax?

1- Accidental

a. penetrating trauma

b. blunt trauma

2- latrogenic (caused by medical procedures)

a. lung or pleural biopsy

b. positive pressure ventilation

c. pleurocentesis

Explain tension pneumothorax

In tension pneumothorax, the injured tissue acts as a one way valve so air enters during inspiration but can’t exit during expiration so air is trapped inside the pleural space and inter pleural pressure accumulates

It can be developed by spontaneous or traumatic pneumothorax

What are the events in tension pneumothorax

Air compresses the lungs, shifts the trachea and the mediastinum

The affected lung on the ipslateral pneumothorax is collapse and the lung, heart, blood vessels contralateral are pressurised

What is the result of the events of tension pneumothorax?

Severe dyspnea (ipslateral lung is collapsed, contralateral lung is pressurized), cyanosis (heart is compressed so less O2) and hypotension (due to reduced venous return) leading to death

What is the pathophysiology of a closed pneumothorax?

The ruptured alveoli becomes connected with the pleural space so during inspiration air moves from the alveoli into the pleural space

What is the pathophysiology of open pneumothorax?

The pleural cavity becomes connected with the chest wall and air moves into the pleural cavity from the environment until the pressure difference reaches equilibrium or the opening is closed

What impairments does pneumothorax lead to?

1- loss of trans pulmonary negative pressure

2- lead to lung collapse

What does the clinical picture of pneumothorax depend on?

1- open or closed type

2- if it’s tension or not

What are the main SYMPTOMS of pneumothorax?

1- acute onset dyspnea (shortness of breath and difficulty breathing)

2- acute onset chest pain

3- tachypnea (increased respiratory rate)

4- asymmetric lung expansion: due to contralateral shift of mediastinum and trachea

What are the main SIGNS of pneumothorax?

Cyanosis: bluish discoloration of lips and nail beds due to decrease in O2 in blood

Inspection and palpation: chest not rising properly during inspiration

Percussion: hyper resonant note

Ascultation: diminished breathing sounds

What are the signs of special type pneumothorax?

• Hypotension

• Engorged neck veins

• Distant heart sounds

• Tracheal shift to the other side

These signs is the dangerous signs if

found in tension pneumothorax patients and

need urgent needle decompression

What are the investigations?

imaging

1- X-Ray ( best option )

2- CT scan

3- ultrasound scan

What are the signs of pneumothorax in chest x-ray?

1- absent lung markings

2- hyperlucent hemithorax (jet black)

3- presence of pleural line; The presence of a

pneumothorax is established by demonstrating a

white visceral pleural line on the chest radiograph.

What is the treatment steps of pneumothorax

1- first aid

2- definitive treatment

3- tension pneumothorax

Explain first aid

1- three sided occlusive dressing

2- treat shock if present

3- supplemental O2

Describe definitive treatment steps

1- supplemental oxygen and observation if patient is clinically stable and pneumothorax is small ( < 2-3 cm air between chest wall and lung on chest radiograph)

2- fine needle aspiration if patient is clinically stable but pneumothorax is large (> 3cm rim between lung and chest wall)

3- chest intubation with underwater seal in patients with a large amount of air and clinically unstable

What should you do in the case of tension pneumothorax?

• Chest tube insertion with underwater seal for clinically unstable patients

• If chest tube insertion is delayed, decompression can be preformed by placing needle into the pleural space at the midclavicular line opposite the second intercostal space at the lower border of the intercostal space

Explain needle aspiration site and indication

Site

§ 2nd intercostal space

§ Mid-clavicular line

§ Insert just above the upper border of the lower rib (to avoid intercostal vessels)

✅ Used in

Clinically Stable pneumothorax

Explain chest tube insertion (underwater seal) site and indication

Site

§ 5th intercostal space

§ Mid-axillary line

§ Insert just above the upper border of the Lower rib (to avoid intercostal vessels)

✅ Used in

• Failed needle aspiration

• Clinically unstable patient

• Tension pneumothorax (after

emergency decompression

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