A 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

General Management:

• First - evacuate the air

• Second - address the underlying source

• Third - promote pleural symphysis

Classification System

1. Spontaneous Pneumothorax

2. • Primary

   • Secondary

3. Traumatic Pneumothorax

4. • Pulmonary source

   • Tracheobronchial source

   • Esophageal source

5. Primary Spontaneous Ptx

6. • a disease of younger individuals (15 - 35 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. “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. Question: when do you operate on a primary spontaneous pneumothorax?

9. Secondary Ptx (due to underlying pulmonary disease)

10. • COPD / Asthma / Cystic Fibrosis

    • Immunocompromised Infections

    • • Tb & Cocci

      • PCP (becoming more common)

    • Treatment: Closed Thoracostomy

    • • Water-seal

      • Heimlich-Flutter Valve

      • V.A.T.S.

11. Traumatic Ptx: Parenchymal Injury vs. Tracheobronchial vs. Esophageal

12. • • 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

    • The Tension Ptx

    • • “path of least resistance”

      • life-threatening emergency

      • Remember: Large-bore needle, 2nd Intercostal Space followed by Thoracostomy

13. • The Open Ptx: sucking-chest wound

    • • intrinsic lung compliance creates complete collapse

      • 3-sided dressing

      • thoracostomy away from the traumatic wound (NEVER through the wound)

14. • Treatment Options

    • • Observation: Inpatient vs. Outpatient

      • Thoracostomy Drainage

      • • 3rd Interspace/5th Interspace

        • Negative Suction/Water-seal

    • • V.A.T.S.

      • Muscle-sparing Thoracotomy

      • Posterolateral & Anterolateral Thoracotomy

    • Complications of Tube Thoracostomy:

    • • Hemorrhage (laceration of intercostals artery, muscle or vein)

      • Parenchymal Laceration

      • Bronchpleural fistula

      • Cardiac injury

      • Subcutaneous tube placement (poor technique)

      • Intraperitoneal tube placement (liver, stomach, colon, spleen injury)

      • Infection (cellulites, empyema) one study showing a slight benefit with routine Abx prophylaxis

A collection of blood between the visceral and parietal pleura

• 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

• 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

• • 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

• Goal of Treatment: to remove the pleural blood and allow for complete lung re-expansion

• • 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 150 solution

• • 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 are indicated while the tubes are in

    • Chest tubes removed: 100 -150 cc's/day

An 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.”]

• Computed tomography is the diagnostic procedure of choice

An accumulation of fluid in the pleural space

Pathophysiology:

• altered pleural membrane permeability

• decreased intravascular oncotic pressure

• increased pleural capillary hydrostatic pressure

• lymphatic obstruction

• abnormal sites of entry

Clinical Features:

• Pain and breathlessness

• Dullness to percussion

• Diminished or absent breath sounds

• Decreased or absent vocal resonance

• Decreased or absent tactile vocal fremitus

• Egophony at level of meniscus

Diagnostic Approach:

• Confirm by Radiographic Imaging

• Posteroanterior chest radiograph

• Lateral decubitus chest radiographs

• Ultrasound (loculations)

• CT Scan

Once presence is confirmed radiographically, then perform Thoracentesis to differentiate: Transudate vs. Exudate

Laboratory Studies:

• Cell count and differential

• Gram stain, culture and sensitivity

• Cytology

• Protein, LDH

• Other-glucose, amylase, afb

Criteria for Exudate:

• fluid-to-serum ratio of total protein > 0.5

• fluid-to-serum ratio of LDH > 0.6

• fluid LDH concentration > 2/3 upper limit of normal for serum LDH

Transudative Effusions result from:

• Increased capillary hydrostatic pressure

• Reduced colloid osmotic pressure

Transudative Effusions, Differential Diagnosis:

• Heart failure (usually presents as a bilateral effusion)

• Hepatic cirrhosis (usually is Right-sided)

• Nephrotic Syndrome (due to hypoalbuminemia)

• Ascites (usually is Right-sided)

• Constrictive pericardial disease

• SVC obstruction

• Pulmonary Embolism

Exudative Effusions result from:

• Disruption of pleural membrane

• Obstruction of lymphatic drainage

Exudative Effusions, Differential Diagnosis:

• Infections (parapneumonic, t.b.)

• Malignant disorders (primary or metatstatic disease)

• Vasculitic disease (R.A., S.L.E.)

• Gastrointestinal disease (pancreatitis, esophageal rupture, hepatic abscess)

• Pulmonary Embolism

Treatment depends on the underlying pathophysiologic process

If exudative, usually thoracostomy tube drainage. THE GOAL is to prevent an empyema or a “trapped lung”

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

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

Treatment: AVOID !!!

• (aggressive drainage...early VATS)