Pneumothoraks

Farah Asnely Putri

PPDGS Bedah Mulut dan Maksilofasial
Definitions

Air within the pleural

cavity (i.e. between
visceral and parietal
pleura)

The air enters via :

- a defect in the visceral
pleura (e.g. ruptured
bulla) or
- the parietal pleura (e.g.
puncture following rib
fracture)


CL

GA

DD

Figure 22-1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed

diaphragm;
CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of
the lungs.
Anatomic Alterations of
the Lungs

Lung collapse Atelectasis

Compression of
the great veins
Chest wall
and decreased
expansion
cardiac venous
return
Etiology

From the lungs through a perforation of the

visceral pleura

From the surrounding atmosphere through a

perforation of the chest wall and parietal pleura or,
rarely, through an esophageal fistula or a perforated
abdominal viscus

From gas-forming microorganisms in an

empyema in the pleural space (rare)
Etiology
Spontaneous
Rupture of an apical bleb
Traumatic
With rib fractures
Penetrating chest trauma
Pre-existing lung abnormality
Pulmonary fibrosis
Asthma
Vasculitis
Pulmonary metastases close to edge of lung
 General
Classifications

Closed Open Tension

pneumotho pneumotho pneumotho
rax rax rax
 Based on Origin
Spontaneou
Traumatic Iatrogenic
s
pneumothor pneumothor
pneumothor
ax ax
ax
Closed Open Iatrogenic
Pneumothorax Pneumothorax Pneumothorax
No opening Opening from Puncture or
from external external chest laceration of
chest. wall into visceral pleura

6/4/17
pleura. during medical
tx
Occurs in Occurs in Occurs in
crashes, falls, stabbings, central line
MVAs, CPR, gunshot placement,
fractured ribs wounds, thoracentesis,
that penetrate impalement lung biopsy,
the pleura. injury. bronchoscopy,
& mechanical 9
ventilation
Figure 22-3. Closed (tension) pneumothorax
produced by a chest wall wound.
Figure 22-4. Pneumothorax produced by a rupture in the visceral
pleura that functions as a check valve.
Types of Pneumothorax
Simple Tension

Mediastinum Progressive build

remains central up of air in the
Clinical condition pleural space,
stable causing a shift of
Can wait for CXR the heart and
to confirm mediastinal
diagnosis structures away
from side of
pneumothorax
Clinical condition
unstable
Do not wait for
 Clinical Data Obtained at the
Patients Bedside

Vital signs
Increased respiratory rate
Stimulation of peripheral chemoreceptors
Other possible mechanisms
Decreased lung compliance
Activation of the deflation receptors
Activation of the irritant receptors
Stimulation of the J receptors
Pain/anxiety
Increased heart rate, cardiac output, blood
pressure
Figure 22-5. Venous admixture in pneumothorax.
 Clinical Data Obtained at the
Patients Bedside
Cyanosis
Chest assessment findings
Hyperresonant percussion note over the
pneumothorax
Diminished breath sounds over the pneumothorax
Tracheal shift
Displaced heart sounds
Increased thoracic volume on the affected side
Particularly in tension pneumothorax
Figure 22-6. Because the ratio of extrapulmonary gas to solid tissue increases in a
pneumothorax, hyperresonant percussion notes are produced over the affected area.
Figure 22-7. Breath sounds diminish as gas accumulates in the
intrapleural space.
Figure 22-8. As gas accumulates in the intrapleural space, the chest
diameter increases on the affected side in a tension pneumothorax.
Clinical Data Obtained
from Laboratory Tests
and Special Procedures
Pulmonary Function Study:
Lung Volume and Capacity Findings

VT RV FRC TLC
N or

VC IC ERV RV/TLC%

N
Arterial Blood Gases
Small Pneumothorax
Acute alveolar hyperventilation with hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)
 Time and Progression of Disease

Disease Onset Alveolar Hyperventilation

100

9 Point
Point at
at which
which
0 PaO
PaO22 declines
declines
80 enough
enough toto
stimulate
stimulate
7 peripheral
peripheral oxygen
oxygen
PaO22 or PaCO2

0 receptors
receptors
6
0 PaO2
5
0
40

30 PaC
O
2
20

10

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar

hyperventilation.
Arterial Blood Gases
Large Pneumothorax
Acute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)
 Time and Progression of Disease
Disease Alveolar Hyperventilation Acute Ventilatory Failure
Onset
100

9 Point at which disease

0 becomes severe and
Point at which
patient begins to become
80 PaO22 declines
fatigued
enough to
7 stimulate
Pa022 or PaC022

0 peripheral oxygen O 2
6 receptors a C
0
P
5
0
40

30 Pa
O
2
20

10

0
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
Radiologic Findings

Chest radiograph
Increased translucency
Mediastinal shift to unaffected side in
tension pneumothorax
Depressed diaphragm
Lung collapse
Atelectasis
Figure 22-9. Left-sided pneumothorax (arrows). Note the shift of the
heart and mediastinum to the right away from the tension
pneumothorax.
 A B

Figure 22-10. A, Development of a small tension pneumothorax in the lower part of the
right lung (arrow). B, The same pneumothorax 30 minutes later. Note the shift of the
heart and mediastinum to the left away from the tension pneumothorax. Also note the
depression of the right hemidiaphragm (arrow).
Simple Left Pneumothorax
Simple Left Pneumothorax

Visceral
pleural line
(zoomed
view on next
slide)

Small pleural
No mediastinal shift effusion
(common
finding)
Note absence of
lung markings
lateral to this line
Pneumothorax with rib
fractures
 Pneumothorax with rib
fractures
Right pneumothorax

Surgical emphysema

Rib fractures
Tension right
pneumothorax
Tension right
pneumothorax

Mediastinal shift
to left
Pneumothorax Calculation
Pneumothorax Calculation
Pneumothorax Calculation
General Management of
Pneumothorax
>20%gas should be evacuated
Negative pressure5 to 12 cm H2O
Should not exceed negative 12 cm H2O
General Management
 Therapeutic Interventions for
Pneumothorax
High Fowlers position

6/4/17
O2 as ordered
Rest to decrease O2 demand
Chest tube insertion
Pleurodesis
Surgery: Thoracotomy to remove blebs, partial
excision of parietal pleura done using VATS (video
assisted thoracoscopic surgery)

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Thank You