Pneumothorax (main): Difference between revisions
No edit summary
Line 8: Line 8:


===Causes===
===Causes===
#COPD/Asthma
#Smoking
#COPD
#Asthma
#Cystic fibrosis
#Cystic fibrosis
#Necrotizing pneumonia
#Necrotizing pneumonia
#Lung abscess
#Lung abscess
#PCP
#PCP PNA
#TB
#TB
#Neoplasm
#Neoplasm
Line 21: Line 23:
===Diagnosis===
===Diagnosis===
====Presentation====
====Presentation====
*Sudden onset of pleuritic chest pain evolving to dull constant ache over days
*Sudden onset pleuritic chest pain evolving to dull constant ache over days
*Most often occurs at rest, not during exertion
*Most often occurs at rest, not during exertion
====Physical Exam====
====Physical Exam====
*Tachypnea
*Hypoxemia
*Increased work of breathing
*Reduced ipsilateral lung excursion
*Reduced ipsilateral lung excursion
*Hyperresonance
*Hyperresonance
*Tachypnea
*Hypoxia
*Increased work of breathing
*Hypotension -> tension pneumothorax
*Hypotension -> tension pneumothorax
====Imaging====
====Imaging====
Line 35: Line 37:
**No sliding lung sign
**No sliding lung sign
**Bar Code (instead of waves on the beach) appearance on M-mode
**Bar Code (instead of waves on the beach) appearance on M-mode
*CXR*
*CXR
*Displaced visceral pleural line
**Displaced visceral pleural line w/o lung markings between pleural line and chest wall
*Size
**Air fluid level with [[Pleural Effusion]] = ptx
**Large >3cm apex to cupola
**Supine CXR view shows deep sulcus sign
**Small <3cm apex to cupola
*Air fluid level with [[Pleural Effusion]] = ptx
*Deep sulcus sign
*CT Chest
*CT Chest
**Very sensitive and specific
**Very sensitive and specific
*Size
***Large >3cm lung apex to cupola (chest wall)
***Small <3cm apex to cupola (chest wall)


===Treatment===
===Treatment Options===
Important features are:
*Oxygen, observation, needle or catheter aspiration, tube thoracostomy
#Stability of the patient
**Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
##2001 ACP Guidelines for stability:
**Needle/catheter aspiration is as effective as chest tube for small ptxs
###RR<24, O2 Sat >90%, HR between 60-120, nl BP
*Important considerations are:
###Can speak in full sentences
#Stability
###Age <50yo
##RR<24, O2 Sat >90%, HR between 60-120, nl BP
#Size of pneumothorax
##Can speak in full sentences
##Absence of hemothorax
#Size of ptx
#Primary or secondary pneumothorax
#Primary or secondary pneumothorax
#Time course unimportant
 
====Primary Spontaneous Pneumothorax====
====Primary Spontaneous Pneumothorax====
#Clinically stable and small pneumothorax
#Small size, clinically stable
##Observe in ED at least 6hr
##Observe for 6hr, d/c if no sx and have pt return in 24hr for recheck OR
##Repeat CXR shows stable or smaller pneumothorax then no chest tube required
##Small-size catheter (<14F) aspiration with immediate catheter removal
##May DC home with f/u in 12-24 hr
###Then observe for 6h, d/c if no sx and have pt return in 24hr for recheck
##If no f/u or unreliable admit, high-flow O2
##Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
##If ptx enlarges then place chest tube
#Large size or bilateral
#Clincally stable & large pneumothorax
##Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax
##Place [[Chest Tube]] and admit
 
#If pt refuses admission:
##14Fr catheter to Heimlich valve
##12 hour f/u
====Secondary Spontaneous Pneumothorax====
====Secondary Spontaneous Pneumothorax====
#Clincally stable and small pneumothorax
#Small size, clinically stable
##[[Chest Tube]]
##Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
##Observation alone associated with some mortality
##Observation alone associated with some mortality
##Admit
#Large size or bilateral
##Do not simply aspirate or ED observe
##Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax
#Clincically stable and large pneumothorax
##[[Chest Tube]]
##Admit


==Tension Pneumothorax==
==Tension Pneumothorax==
*Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest
===Diagnosis===
===Diagnosis===
*Diminished or absent breath sounds
*Diminished or absent breath sounds
Line 86: Line 85:
**Late sign
**Late sign
===Treatment===
===Treatment===
*Immediate needle decompression if unstable (clinical = decreased BS or US findings)
*Immediate needle decompression if unstable
**Wait for CXR confirmation if stable
**Wait for CXR confirmation if stable
**14ga IV in midclavicular line just above the rib at the second intercostal space
**14ga IV in midclavicular line just above the rib at the second intercostal space

Revision as of 03:50, 24 July 2011

Spontaneous Pneumothorax

Background

  • Primary Pneumothorax
    • Spontaneous ptx in pt w/o underlying pulm disease
  • Secondary Pneumothorax
    • Spontaneous ptx in pt w/ underlying pulm disease
    • Worse prognosis

Causes

  1. Smoking
  2. COPD
  3. Asthma
  4. Cystic fibrosis
  5. Necrotizing pneumonia
  6. Lung abscess
  7. PCP PNA
  8. TB
  9. Neoplasm
  10. Interstitial lung disease
  11. Connective tissue disease
  12. Pulmonary infarct

Diagnosis

Presentation

  • Sudden onset pleuritic chest pain evolving to dull constant ache over days
  • Most often occurs at rest, not during exertion

Physical Exam

  • Tachypnea
  • Hypoxemia
  • Increased work of breathing
  • Reduced ipsilateral lung excursion
  • Hyperresonance
  • Hypotension -> tension pneumothorax

Imaging

  • Ultrasound
    • NO comet tail artifact
    • No sliding lung sign
    • Bar Code (instead of waves on the beach) appearance on M-mode
  • CXR
    • Displaced visceral pleural line w/o lung markings between pleural line and chest wall
    • Air fluid level with Pleural Effusion = ptx
    • Supine CXR view shows deep sulcus sign
  • CT Chest
    • Very sensitive and specific
  • Size
      • Large >3cm lung apex to cupola (chest wall)
      • Small <3cm apex to cupola (chest wall)

Treatment Options

  • Oxygen, observation, needle or catheter aspiration, tube thoracostomy
    • Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
    • Needle/catheter aspiration is as effective as chest tube for small ptxs
  • Important considerations are:
  1. Stability
    1. RR<24, O2 Sat >90%, HR between 60-120, nl BP
    2. Can speak in full sentences
    3. Absence of hemothorax
  2. Size of ptx
  3. Primary or secondary pneumothorax

Primary Spontaneous Pneumothorax

  1. Small size, clinically stable
    1. Observe for 6hr, d/c if no sx and have pt return in 24hr for recheck OR
    2. Small-size catheter (<14F) aspiration with immediate catheter removal
      1. Then observe for 6h, d/c if no sx and have pt return in 24hr for recheck
    3. Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
  2. Large size or bilateral
    1. Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax

Secondary Spontaneous Pneumothorax

  1. Small size, clinically stable
    1. Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
    2. Observation alone associated with some mortality
  2. Large size or bilateral
    1. Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax

Tension Pneumothorax

  • Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Diagnosis

  • Diminished or absent breath sounds
  • Hypotension or e/o hypoperfusion
  • Distended neck veins
    • May not occur if pt is hypovolemic
  • Tracheal deviation
    • Late sign

Treatment

  • Immediate needle decompression if unstable
    • Wait for CXR confirmation if stable
    • 14ga IV in midclavicular line just above the rib at the second intercostal space
  • Always followed by Chest Tube placement

Traumatic Pneumothorax

Background

  • Present in 25% of pts w/ chest trauma
  • Rib fx and penetrating trauma most common causes
  • Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied

Types

  • Can be open, closed, or occult
    • Open
      • Communication between pleural space and atmospheric pressure (sucking chest wound)
    • Occult
      • PPV can convert an occult ptx to a tension ptx

Diagnosis

  • Ptx after a stab wound may be delayed for up to 6 hr
    • If pt decompensates obtain repeat imaging
  • CXR
    • Upright is best (esp expiratory film)
      • Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
      • No lung markings distal to white line
    • Supine
      • Look for deep sulcus sign
  • US
    • Absence of lung sliding; absence of seashore (M-mode)

Treatment

  • Tension ptx
    • Immediate needle thoracostomy
  • Open ptx
    • Cover wound with three-sided dressing
      • Make sure to avoid complete occlusion (may convert injury to a tension ptx)
  • Tube thoracostomy indicated if:
    • Pt cannot be observed closely
    • Pt requires intubation
    • Pt will be transported by air or over a long distance
  • Observation alone ok if:
    • Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
    • Occult ptx (seen only on CT) unless pt requires mechanical ventilation

See Also

Chest Tube

Thoracic Trauma

Hemothorax

Source

  • Tintinalli
  • Roberts and Hedges Clinical Procedures in Emergency Medicine
  • Rosen's
  • American College of Chest Physicians Consensus Statement
Retrieved from "https://www.wikem.org/w/index.php?title=Pneumothorax_(main)&oldid=4840"