Pneumothorax [CVT Lecture]

Pneumothorax PTX (CVT lecture2017)

CLASSIFICATION:

1. Spontaneous:

                     i.      Primary

                     ii.      Secondary: COPD/Bullous Empysema, AIDS, Sarcoidosis, CVD, EG, Asthma, IPF, LAM, Malignancy, Catanemial …

2. Traumatic: blunt, penetrating, iatrogenic

-CXR: visceral pleural line เข้ามา 2cm=20%, 3cm=30%
-if >30% ต้องมี intervention(ICD,...)

Management
-Monitor & follow up CXR 6-12hr if ดีขึ้น D/C ได้
-Oxygen 100% increase pleural air absorption
     (100% O2 to enhance absorption to increase the N2 gradient b/w alv and pleural air)

-Intervention(ICD): ใส่ ICD ที่่ 4th ICS เพราะหายใจออก diaphragm จะยกไม่เกิน 4thICS
           -Spontaneous[patho มันมักเกิดจาก bleb คือมันมีขนาดของมันอยู่แล้ว]
                      Primary/Secondary: ดู %pneumothorax >30%(2-3cm) Or Clinical แย่ๆ
           -Traumatic: ต้องใส่ ICD ทุกเคส
                      ในเคส iatrogenic ก็เป็น trauma ต้องใส่ ICD (ถ้ามีอะไรเกิดขึ้นมา แล้วไม่ใส่ โดนฟ้องแพ้คดีแน่)

-Advise การปฏิบัติตัว
             1. มาตามหมอนัด 24-48hr for CXR
             2. ระวังการเกิด Recurrent ให้อยู่ใกล้ๆที่ๆมีหมอ อย่าไปที่ทรุกันดาน เข้าป่า
1st-->2nd episode recurrent rate 30%
             3. ระวังการขึ้นที่สูง ในช่วง 1-2wk แรก *นักบิน นักดำน้ำ

Indication for Surgery ***เคสที่ต้อง refer for surgical pleurodesis or others Surgery
เพื่อ หา lesion & obliterate pleural space

1. Second episode ipsilateral (recurrent rate 50%)
2. First episode contralateral
3. Bilateral spontaneous PTX ถ้าเป็นพร้อมกันจะเป็นปัญหา ไม่เหลือปอดไว้หายใจ
4. Persistent air leak: มี bleb ที่ปิดไม่สนิท
    โดย lung ควรจะ fully expand ใน 24hr
    ไอแรงๆ แล้วยังมีลม leak
     ดู 7 วัน if not fully expand, persistent air leak
5. อาชีพ, Pilot/diver

#Medical pleurodesis ใน CVT ไม่แนะนำให้ทำ เนื่องจาก success rate ต่ำ

ถ้ามา surgical หลังทำ medical pleurodesis แล้วมันจะยาก คือมันเยินไปแล้ว

คือหายแล้วก็ D/C ไป หากมี recurrent มาให้ส่งมาทำ surgical pleurodesis ดีกว่า

PULMONARY BOARD REVIEW:   PNEUMOTHORAX

Management of Spontaneous PTX: An ACCP Delphi Consensus Statement. Chest 2001; 119:590-602.

1. CLASSIFICATION:
1. Spontaneous:

                                                              i.      Primary

                                                            ii.      Secondary: COPD/Bullous Empysema, AIDS, Sarcoidosis, CVD, EG, Asthma, IPF, LAM, Malignancy, Catanemial …

2. Traumatic: blunt, penetrating, iatrogenic

2. PRIMARY SPONTANEOUS PTX:
1. rupture of small apical subpleural blebs
2. apical blebs? : higher transpulmonary pressures at apices resulting in overdistension of alveoli, or apices represent areas of relative ischemia in asthenic individuals, or rapid atmospheric pressure changes
3. CXR: usual diagnosis, may need expir and inspir films if small

3. DEFINITIONS:
1. PTX size: distance form lung apex to thoracic cupola

                                                              i.      Small: <3 cm

                                                            ii.      Large: >3 cm

2. Stable: RR <24, HR >60 or <120, normal BP, SaO2>90%, speak in full sentences
3. Small size CT = <14F
4. Moderate size CT = 16-22F

4. TREATMENT OF PRIMARY SPONTANEOUS PTX:
1. Small and Stable: monitor 3-6 hours à f/u CXR before discharge and then repeat over next 12 to 48 hours

                                                              i.      100% O2 to enhance absorption to increase the N2 gradient b/w alv and pleural air

                                                            ii.      normally air is reabsorbed from pleural space at rate of 1.25%/24° (= 2 wks for 20%)

                                                          iii.      if not resorbed in 2 wks need definitive management b/c at risk for developing trapped lung b/c of fibrous peel being laid down on visceral pleura

2. Large and Stable:

                                                              i.      CT (<14 or 16-22F) and Hospitalize OR Heimlich valve (~8-12F) and Discharge

1.      no further air leak à stop sxn à repeat CXR in 5-12 hours à D/C CT if no recurrence

2.      persistent air leak à monitor for 3-5 days à thoracoscopic correction if air leak continues

3. Large and Unstable: CT (<14 or 16-22F) and hospitalize à as above
4. PTX recurrence prevention: persistent air leak, second PTX, scuba diving, flying

                                                              i.      Thoracoscopy preferred intervention – success rate = 95-100%

1.      intra-op bullectomy if bullae visualized

2.      intra-op pleurodesis with pleural abrasion vs. talc?

                                                            ii.      Sclerosing Agent if not surgical candidate or decline surgery – success rate = 78-91%

5. Chest CT Scan:

                                                              i.      not recommended for first time PTX

                                                            ii.      unclear for recurrent PTX, persistent air leak, planned surgical intervention

5. TREATMENT OF SECONDARY SPONTANEOUS PTX:
1. Small and Stable: hospitalize AND observe OR place CT (<14 or 16-22F)

                                                              i.      No further air leak à stop sxn à repeat CXR in 13-23 hours à D/C CT if no recurrence

                                                            ii.      Persistent air leak à monitor for 4-7 days à thoracoscopic correction if air leak continues

2. Large and Stable: hospitalize and CT (<14 or 16-22F) à as above
3. Large and Unstable: hospitalize and CT (24-28F) à as above
4. PTX recurrence prevention: intervention warranted after first PTX

                                                              i.      Surgery (bullectomy and pleural symphysis) >> sclerosing agent

                                                            ii.      may use sclerosing agent by CT alone  if contraindication to surgery, management preference, or poor prognosis) à Doxy and Talc >> Bleo

5. Chest CT Scan: no consensus, may be useful for PTX recurrence, persistent air leak, and potential surgical management

6. PLEURODESIS:

#Medical pleurodesis ใน CVT ไม่แนะนำให้ทำ เนื่องจาก success rate ต่ำ

ถ้ามา surgical หลังทำ medical pleurodesis แล้วมันจะยาก คือมันเยินไปแล้ว

คือหายแล้วก็ D/C ไป หากมี recurrent มาให้ส่งมาทำ surgical pleurodesis ดีกว่า

1. Doxyycline:

                                                              i.      mechanism by low pH of solution à pleuritis à adhesions

                                                            ii.      better results when combined with thoracoscopy

                                                          iii.      500mg in 100cc NS and 20cc of 1% lidocaine into pleural space à clamp CT for 8° à change positions à unclamp and let to sxn for 48° or until drainage <150cc/24°

2. Talc:

                                                              i.      finely powdered Mg silicate – 50 grams

                                                            ii.      effective pleural irritant

                                                          iii.      SE = fever, pain, fibrothorax, restricted PFTs, talc embolism, Mesothelioma (secondary to contaminants particularly asbestos)

                                                          iv.      96 pts with first PTX: recurrence in 5 yrs: aspir=36%, tetra=13%, talc=8%

7. OPERATIVE INDICATIONS: second episode, persistent air leak, unexpanded “trapped lung”, history of contra-lateral PTX, bilateral PTX, Occupational risk: diver, pilot, live in remote area, large bulla, tension PTX, large undrained hemothorax

8. RISK OF RECURRENCE:                       
1. simple aspiration or CT = 25-50% in 2 yrs     
2. after second episode = 50-75%
3. 2030 pts: overall recurrence = 26% and surgery = 16%

9. SPECIAL SETTINGS:
1. AIDS: recurrent PCP
2. Cystic Fibrosis: caution against pleurodesis as may make transplant more difficult
3. Catanemial:     within 48-72° of menses

                                                              i.      air tracking from open cervix into peritoneal cavity thru diaphragm into pleura?

                                                            ii.      deposits of thoracic implants of endometrium that break down during menses that allow escape of air?

                                                          iii.      elevated PgF2 causing bronchoconstriction, hyperexpansion, and distal alveolar rupture?

10. COMPLICATIONS:
1. Tension PTX: 
2. Reexpansion Pulmonary Edema:

                                                              i.      via increase in capillary permeability

                                                            ii.      risks include rapidity of expansion, chronicity of collapse, loss of surfactant, pulm artery pressure changes

3. Persistent Air Leak:
4. Hemothorax:  <5%

                                                              i.      tearing of pleura resulting in hemorrhage

                                                            ii.      most will tamponade the bleeding point when reexpanded

                                                          iii.      if continues may need exploration

5. Pneumomediastinum:   <1%

                                                              i.      often seen after activity with pleuritic chest pain and subcutaneous air in neck and chest

                                                            ii.      hammans crunch = apex of the heart

                                                          iii.      must R/O perforated esophagus or injury to major airway

                                                          iv.      usually innocuous

6. Barotrauma:

                                                              i.      on positive pressure vent and underlying disease

                                                            ii.      may see interstitial, subcutaneous emphysema, pneumomediastinum, pneumopericardium, pneumoperitoneum – may be harbingers of future PTX

http://sinaipulmonary.org/wp-content/uploads/2010/09/Pneumothorax.doc