PNEUMOTHORAX

by 1. Maharani Dewi Caropeboka, S.Ked 2. Widya Emiliana, S.Ked 3. Giska Tri Putri, S.Ked 4. Nora Ramkita, S.Ked Preceptor Dr. Dedi Zairus, Sp.P Internal Medicine Clerkship Program Division of Pulmonology Dr. Hi. Abdul Moeloek General Hospital Bandar Lampung

THEORY

PNEUMOTHORAX

Pneumothorax

- Pneumothorax is the presence of air within the pleural space -Due to disruption of parietal, visceral or mediastinal pleura -May also occur from spontaneous rupture of subpleural bleb -A tension pneumothorax occurs when pleura forms a one-way flap valve -Tension pneumothorax is a medical emergency.

Classification
1. Spontaneous pneumothorax Primary - no identifiable pathology Secondary - underlying pulmonary disorder 2. Catamenial 3. Traumatic Blunt or penetrating thoracic trauma 4. Iatrogenic Postoperative Mechanical ventilation Thoracocentesis Central venous cannulation

Diseases Associated with Pneumothorax

Chronic obstructive lung disease Asthma HIV infection PCP Necrotizing pneumonia Bronchogenic carcinoma Sarcomas metastatic to the lungs Tuberculosis Cystic fibrosis Interstitial lung diseases associated with connective tissue diseases Idiopathic pulmonary fibrosis Sarcoidosis Lymphangioleiomyomatosis Langerhans cell histiocytosis High-risk occupation (eg, diving, flying)

Primary Spontaneous Pneumothorax

Primary spontaneous pneumothorax Usually occurs in young healthy adult men 85% patients

are less than 40 years old Male : female ratio is 6:1 Bilateral in 10% of cases Occurs as result of rupture of an acquired subpleural bleb Blebs have no epithelial lining and arise from rupture of the alveolar wall Apical blebs found in 85% of patients undergoing thoracotomy Frequency of spontaneous pneumothorax increases after each episode Most recurrences occur within 2 years of the initial episode..

Secondary Spontaneous pneumothorax

Accounts for 10-20% of spontaneous

pneumothoraces can be due to: Chronic obstructive pulmonary disease with bulla formation Interstitial lung disease Primary and metastatic neoplasms

Risks factors for primary spontaneous pneumothorax (PSP)

Smoking

Of patients with PSP, 91% reportedly are smokers or were smokers . The risk of PSP is related to the intensity of smoking, with 102times higher incidence rates in males who smoke heavily (ie, >22 cigarettes/d), compared to a 7-fold increase in males who smoke lightly (1-12 cigarettes/d Tall, thin stature in a healthy person Marfan syndrome /EDS Pregnancy A 10-year retrospective series of 250 SP cases found 5 pregnant women, suggesting that pregnancy is an unrecognized risk factor . The cases were all managed successfully with simple aspiration or vacuum-assisted thoracostomy (VATS), and no harm occurred to mother or fetus.

Traumatic pneumothorax
Traumatic pneumothorax

can result from either blunt or penetrating trauma Tracheobronchial and esophageal injuries can cause both mediastinal emphysema and pneumothorax Iatrogenic pneumothorax is common to occur after : Pneumonectomy Thoracocentesis High-pressure mechanical ventilation Subclavian venous cannulation

Catamenial pneumothorax
Catamenial pneumothorax refers to the development of pneumothorax at the time of menstruation. represents 3-6% of spontaneous pneumothorax in women. Typically, it occurs in women aged 30-40 years with a history of pelvic endometriosis (20-40%). It usually affects the right lung (9095%) and occurs within 72 hours after the onset of menses.

Symptoms
Dyspnea Pleuritic chest pain
Nerve endings at pleural capsule

Sense of impending doom Sudden onset

Tension pneumothorax Spontaneous pneumothorax

Physical Exam - Signs

Unstable patients vs. Stable patients
Vital Signs

Asymmetric chest expansion Deviated trachea Diminished breath sounds unilaterally Hyper-resonance unilaterally Decreased tactile fremitus

Diagnosis
Unstable patient
Thoracentesis
Rapid release of air Vital signs stabilize rapidly

Stable patient
CXR
Monitor size by measuring distance from lateral lung margin to chest wall Be sure that pneumothorax is not expanding

Imaging
Plain Radiographs
Upright PA on inspiration Detect other pathologies: pneumonia, cardiac, etc.
Partially collapsed lung Tension Pneumothorax Trachea and mediastinum deviate contralaterally Ipsilateral depressed hemidiaphragm

Chest CT
Not routine Only to assess the need for

surgery (thoracotomy)

Management
1)Risk stratification 2)Interval of observation 3)Options to restore an air-free pleural space

1. Risk Stratification
The decision to observe or to treat with an

immediate intervention should be guided by a risk stratification that considers the patient's presentation and the likelihood of spontaneous resolution and recurrence

2. Interval of Observation
Monitoring pneumothorax size during this time is important . 0-6

hours : The ACCP Delphi consensus statement recommends observation in an ED for 6 hours, and discharge to home if a follow-up chest radiograph shows no enlargement of the lesion, in reliable patients Emergency room observation with a repeat radiograph 6 hours later used to be common but may be used less often now . 24-96 hours : Additional follow up in 2 days is recommended, with preference given to a 24-48 hour follow-up radiograph in the outpatient setting. Outpatient follow-up during the 96-h (4-d) window is essential to distinguish between a resolved pneumothorax and one that needs evacuation. 1 month: Full re-expansion can occur, on average, 3 weeks after the initial event .

Options to restore an airfree pleural space

Observation without oxygen Simple observation is appropriate for asymptomatic patients with a minimal pneumothorax (<15-20% by Light's criteria; 23 cm from apex to cupola by alternate criteria) with close follow-up, ensuring no enlargement. Air is reabsorbed spontaneously by 1.25% of size pneumothorax per day.

Options to restore an airfree pleural space

Supplemental oxygen : Oxygen administration at 3 L/min nasal canula or higher

flow treats possible hypoxemia and is associated with a 4fold increase in the rate of pleural air absorption compared with room air alone. Simple aspiration, recent ED study supports needle aspiration as safe and effective as chest tube for PSP, conferring the additional benefits of shorter length of stay and fewer hospital admissions. Chest tube for air removal: A tube inserted into the pleural space is connected to a device with one-way flow. Examples of such devices are Heimlich valves or water seal canisters , and tubes connected to wall suction devices. Thoracostomy with continuous (wall) suction.

Options to restore an airfree pleural space

Surgery is often indicated for : recurrent pneumothorax, bilateral pneumothorax, prolonged air leak (longer than five to seven days), or inability to fully expand the lung.

Options to restore an airfree pleural space

Sclerotherapy with doxycline or talc should be considered for poor surgical candidates, but this approach may complicate future surgical intervention or lung transplant. A thoracic surgeon should be consulted on these patients. If it is decided that the best treatment is surgical, the recent development of thoracoscopic intervention offers certain benefits. The surgeon can thoracoscopically visualize the full pleura, staple or resect blebs, apply electrocautery, laser, resect pleura or instill sclerosant (usually talc).:

Indications for surgical assistance

Persistent air leak for more than 7 days Recurrent ipsilateral pneumothorax Contralateral pneumothorax Bilateral pneumothorax First-time presentation in a patient with a high-risk occupation (eg, diver, pilot) Patients with AIDS often need this intervention because of extensive underlying necrosis. The risk of recurrent pneumothorax may also be unacceptable for patients with plans for extended stays at remote sites. Lymphangiomyomatosis , a condition causing a high risk of pneumothorax.

Video-assisted thoracoscopic surgery (VATS)

VATS is appropriate for recurrent primary spontaneous pneumothorax (PSP) or secondary spontaneous pneumothorax (SSP). VATS with resection of large bullous lesions is associated with a recurrence rate of 2-14%. VATS is done under general anesthesia using a camera and 2 trocar ports.

CASE REPORT

The history taking and physical examination were done on 1st of July, 2013 in Pulmonary Ward (Melati) Dr. Hi. Abdul Moeloek General Hospital, Bandar Lampung.

Identification of Patient Name : Mr. Nuryanto Age : 40 Gender : male Address : Jl. Jati Tanjung Raya, Bandar Lampung Profesion : Merchant Education : Elementary school Marriage status : Married Religion : Moslem Admission date : June 30th 2013

HISTORY

Anamnesis : Autoanamnesa Chief Complaint : Shortness of breath Secondary Complaint : Cough, chest pain History of Present Illness : The patient came to the hospital with shortness of breathe for 3 months. The shortness of breathe occured gradually then suddenly developed rapidly into severe breathlessness and get worse for the past 5 days, so that the shortness of breathe felt in rest position. He didnt notice any wheezing or weird breath sounds. He was doing his job (merchant) when he felt the rapidly progreessing shortness of breathe. He also already had a wet cough with colorless phlegm for the last 6 months. The phlegm never mixed with blood nor changed in color. The cough occured gradually and not affected by time (no difference in the morning or night ) or cold air. There was slight fever, and felt mostly in the evening for the last 6 months and then he was sweaty at night. The fever never gets high, and not accompanied with symptoms of common cold like rainy nose or fatigue. He also felt lost in appetite, and he lost weight drastically since the last 1 year. He didnt have difficulty swallowing or have choke episode. After having severe breathlessness, he was brought to Bintang Amin Hospital, and he was told that there was air trapped in his left lung. Four days ago, the doctor put a tube into his chest to rescue the air that trapped and he felt a little relieve. His phlegm had been evaluated and positive for acid bacilli. He has been diagnosed as diabetes for a year and receive oral medicine from public health centre.

 History of Past Illness His past illness is unremarkable. He never had asthma or severe breathlessness before. He also never took any 6 months regiments / antituberculosis drug. History of Family Illness

There was no family member who diagnosed as tuberculosis, or having wet cough more than 2 weeks. Lifestyle and Activity The patient was an active smoker for more than 10 years, a pack a day. The patient is a merchant, and still able to do his work before the worsening of his breathlessness.

Physical Examination

General appearance : Looks ill Consciousness : Compos mentis, E4V5M6 Height : 158 cm Weight : 40 kg BMI : 16.06 kg/m2 Blood Pressure : 100/70 mmHg Pulse : 84 bpm , regular Temperature : 36.80 C Respiration Rate : 24x/minute

 Head

: Normocephali, atraumatic, normal hair distribution, hair not easily revoked Eye : isochor pupils, anemic conjuctiva +/+, icteric sclera -/- visual field intact, Nose : Symmetrical, septum deviation (-), discharge (-), concha oedem (-) Mouth : caries , stomatitis (-) Throat : tonsil T1-T1 calm, hyperemis pharing (-) Neck : thyroid gland normal size, lymph nodes not palable, deviation of trachea (-)

 Thorax Lung Inspection : symmetrical shape, asymetrical chest movement, decreased left hemithorax movement, accessory muscle use (-), WSD placed in axillary anterior line 5th intercostal

space Palpation : Subcutaneous crepitation (+), absent vocal fremitus on the left hemithorax, no tenderness. Percussion : hypersonor on left hemithorax Auscultation : absent breathe sounds of the left hemithorax, vesicular breath sound on the right hemithorax. Wheezing (-), Crackles (-)

 Heart

Inspection Palpation Percussion Auscultation gallop(-)

Abdomen

: ictus cordis not visible : ictus cordis not palpable : heart boundary difficult to assess : S1/S2 heart sounds, regular , murmur (-),

Inspection : abdomen flat, no tension, no dilated veins Palpation : no percussion pain, no defense muscular, no enlarged liver Percussion : timpanic, shifting dullness (-) Auscultation : bowel movement (+), normal
Extemity

: warm , oedem (-), cyanosis (-)

Laboratory ang Imaging

Hb 11.2 g/dl Leucocyte 10.000/ml Diff count 0/1/1/83/11/4 ESR 40 mm/jam Thrombocyte 423.000 SGOT 90 U/L SGPT 52 U/L Ureum 25 mg/dl Creatinine 0.5 mg/dl Postero-anterior chest X ray ( June 30th 2013)

Irregular luscent area in the soft tissue Bones and joints (clavicula, scapula, costae, vertebrae) are intact Deviation of trachea to the right side Clear pleural line Avascular and hyperluscent area in left lung field Deviation of mediastinal structure to the right Blunting of left costophrenic angle (air fluid level form)

Conclusion : Left hydropneumothorax

RESUME
40 year old male was admitted to the hospital because of worsening of shortness of breathe for the past week. Four days ago, he had a tube inserted into the left side of his chest to rescue the air that trapped in his lungs. After the procedure, he felt a little relieve. He had felt mild shortness of breathe for about 3 months before it got worse suddenly. He also have wet cough with colourless phlegm for 6 months.. A mild fever, night sweat, and rapid decrease of body weight (+).The phlegm had been tested last week, and positive for acid fast bacilli. He was diagnosed diabetes for a year and taking 1 tablet for the diabetes.

 Physical examination revealed the patient looks ill but not in acute distress, compos mentis,

afebris, BP 110/70 mmHg, Pulse 84 bpm reguler, respiration rate 24 x/minute, IMT 16.06. Anemic conjunctiva +/+. Chest examination revealed WSD tube inserted into fifth intercostal space, left axillary line. A subcutaneous crepitation observed. Decreased left side thoracic expansion and absent breath sound on the left side. Laboratory findings revealed mild anemia (Hb 11,9 g/dl), total leucoocyte count of 10.000 , and increased ESR (45 mm in the end of 1st hour) . The posteroanterior chest x ray revealed a left pneumothorax with subcutaneous emphysema.

 Diagnosis

Pulmonary tuberculosis with positive acid fast bacilli + hydropneumothorax + type II diabetes normoweight

Treatment

O2 2 Litres/minute Massage IVFD RL gtt X/minute Dexamethasone 5 mg/ 8h (IV) OBH 3x1C Rifampicin 1x450 mg Isoniazid 1x300 mg Ethambutol 1x750 mg Pyrazinamide 1x 750 mg Ceftriaxone 1 gram/12 hours Ranitidine 40 mg/12 hours

Prognosis
Quo ad vitam

: dubia ad bonam Quo ad functionam : dubia ad bonam Quo ad sanationam : dubia ad bonam

DISCUSSION
What are the problems of the patient ? The problem of the patient that we found

including : Hydropneumothorax ec pulmonary tuberculosis Subcutaneous emphysema Type II diabetes melitus

The patient was admitted to the hospital because of worsening of shortness of breathe for the past few days. He already felt mild shortness of breathe for 3 months, until it suddenly got worse and made him dyspneic even in resting state. There was some possible cause of sudden onset severe breathlessness. But with deeper history taking, it might be possible to distunguish the likely cause of severe breathlessness. This patients symptomp including productive cough for 6 months along with night sweat, prolonged mild fever, and decreased body weight make pulmonary tuberculosis is likely. Besides, the absence of weird breath sounds (like wheezing) and no history of asthma attack make asthma is unlikely. The absence of high fever makes pneumonia is unlikely too. The patient was a moderate smoker ( Brinkman index 200-600), then the very severe of COPD exacerbation or pulmonary carcinomas should be kept in mind.. Another cause that come from outside the respiratory organs (i.e. cardiovascular, neurological, metabolism) must be evaluated.

Then, it could be confirmed by physical examination. The absence of breath sound in one side of the chest along with decreased expansion movement , decreased vocal fremitus, and hyperresonance percussion could lead to the pneumothorax diagnosis. Beside, there was absence heart dullness that supposed to be found in chest percussion on the left side of the chest. That might be because of shift of mediastinal structure due to enforcement of the trapped air. The trachea couldve been deviated too. If the patient is stable, we could use chest x ray to confirm. But in emergency setting, confirming chest x ray is not mandated. Pneumothorax itself is one of the complication of pulmonary tuberculosis. Seaton et al recorded that 1.4% of people with pulmonary tuberculosis can have pneumothorax, and with the cavity can increase the risk up to 90%. Pneumothorax that caused by TB can be classified as secondary spontaneous pneumothorax. We also found subcutaneous crepitation, that might be due to subcutaneous emphysema. Subcutaneus emphysema is the accumulation of air in the soft tissue. Most cases of subcutaneous emphysema are benign. The patient also diagnosed as diabetes for a year and have taken oral medicine to control the blood glucose. Further evaluation of patients blood glucose profile (fasting blood glucose, glucose tolerance test) should be performed.

Is the management of the patient ?

O2 2 Litres/minute IVFD RL gtt X/minute OBH 3x1C Rifampicin 1x450 mg Isoniazid 1x300 mg Ethambutol 1x750 mg Pyrazinamide 1x 750 mg Ceftriaxone 1 gram/12 hours WSD

 Oxygen administration at 3 L/min nasal canula or higher flow

treats possible hypoxemia and is associated with a 4-fold increase in the rate of pleural air absorption compared with room air alone. There is no need for the patient to receive intravenous fluid deliveries. The antituberculosis regimen given is 1st category, dosage for weight between 40 to 60 kgs. The patient given 1st category because he has never taken any antituberculosis regiment (new case) and his sputum evaluation show positive result for acid fast bacilli. He weighs 40 kg. So in this patient, whom given 450 mg of rifampicin; 300 mg of isoniazid; 750 mg of pyrazinamide; and 750 mg of ethambutol, the antituberculosis drug is adequate. The antituberculosis given to the patients for 2 months. This called intensive phase. This patients laboratory result showed 2-fold increase of SGOT/SGPT. This patient still can receive the antituberculosis therapy but with strict supervision. The ceftriaxone used as the empiric therapy because of invasive procedure done and possibility concordance of bacterial infection that causing hydropneumothorax. The dosage of ceftriaxone is 50-100 mg/kg/day, divided into 2 doses. This patient weighs 40 kg so the dosage was 2 grams, divided into 2 dose.

WSD in pneumothorax is indicated if pneumothorax >25%. In this patient, the pneumothorax is more than 25%. There are currently two methods described in adults: If lateral edge of lung is > 2cms. from thoracic cage at the level of the hilum, then this implies pneumothorax is at least 50%, and hence large in size. or Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed). To express the pneumothorax size as a percentage, multiply the fractional size by 100. Regarding the patients condition of having type II diabetes melitus, the diet of the patient shouldve been changed to the DM diet, for kcal. If the patient given sulfonyl urea, the dosage should be given more because of its interaction with the antituberculosis drugs. Rifampicin could decrease effectivity of sulfonyl urea. The use of ethambutol can increase the risk of visual impairment caused by diabetic retinopathy.

 REFERENCES Sahn, SA, Heffner, JE. Spontaneous Pneumothorax NEJM, 2000;

342:868 Light, Richard W. 2007. Pleural Diseases. Lippincolt William & Wilkins : Philadelphia. Accessed from http://books.google.co.id/books?id=vHEpRHQXaKU C&pg=PA309&lpg= PA309&dq=calculate+percentage+pneumothorax&source=bl&ot s=iSN6UtpPG&sig=rXuS9ComWd4Y8CaX4HXNeplzSts&hl=id&sa=X &ei=OJ7dUdmdGMiHrgeU3ICgBg&ved=0CFQQ6AEwBQ#v=one page&q=calculate%20percentage%20pneumothorax&f=false July 8th 2013. Anonym. 2013. Primary Spontaneous Pneumothorax. Accessed from http://www.rch.org.au /clinicalguide/guideline_index/Primary_Spontaneous_Pneumoth orax/ July 8th 2013. Daley, Brian James MD,FACS,FCCP,CNSC et al. 2013. Pneumothorax. Accessed from http://emedicine.medscape.com/article/424547-overview July 8th 2013.