Pleural Diseases PDF

Pleural diseases Rahma Ammar By Dr. Haitham Nabeel - Your Date Here Your Footer Here De,ni.on >I o -20)mL an-make excessive amount of ;uid between pleural layers that impairs the expansion of...

Pleural diseases Rahma Ammar By Dr. Haitham Nabeel - Your Date Here Your Footer Here De,ni.on >I o -20)mL an-make excessive amount of ;uid between pleural layers that impairs the expansion of the lungs -> - Your Date Here Your Footer Here 3  in CHE Pathophysiology of 9 -11 - I & transudate versus only fluid exudate * - Normal: capillary hydrostaBc pressure - (driving ;uid out of capillaries) and capillary oncoBc pressure (keeping ;uid within b - - capillaries) are roughly balanced. - - - - Transudate is extravascular ;uid caused by I hydrostaBc pressure (e.g., S - inflation, - increased capillary & 545 malignany 3 - I in congesBve heart failure) or decreased - - ! * ↳ (e.g., in Permiability - - capillary oncoBc pressure hypoalbuminemia). Transudate is& - - low in protein and cells and therefore tends to be - clear. - - - - - - Exudate is extravascular ;uid caused by - increased capillary permeability (e.g., - secondary to in;ammaBon or malignancy). Exudate isOne i - high in protein and cells and - therefore tends to be yellow or cloudy. - I Your Date Here Your Footer Here 4  E.ology Swiss iteral is 1- & & & - B - X - -- - - - > - - dueto - -embolicene -I -> s 35 --- left sided 5s pleural effusion * - - - - - - - - - - - - - -+ - bilateral hypothyroidism pleural effusion) - - Rf - - - SLE & BA - - - - & dressers. Your Date Here Your Footer Here 5  pleural effusion diagnosis, is not a Clinical features - it's a an underlying disease. sign of 5 -- - - - - - - 1 Symptoms - - PaBents with a small pleural eLusion (< 300 mL) are oPen asymptomaBc. > CharacterisBc symptoms Dyspnea if theres inflamation -> with E. Pleuri.c chest pain &(sharp retrosternal pain) - - - PC 5)I=-j8 Dry, nonproducBve cough =Diss 2 - viscera&penra W -> - - S Symptoms- of the underlying disease $6,1,5 8. 95, (e.g., fever in empyema, cachexia = - 1 in cases of malignancy, symptoms of leP-sided heart failure)- > => - -- Your Date Here Your Footer Here 6  Clinical features Physical exam ,ndings > Appear when more than - 500ml of pleural ;uid accumulates InspecBon and palpaBon - -Dis I --- - Asymmetric expansion and unilateral lagging on the aLected side - -> - Reduced tac.le fremitus due to ;uid in the pleural space resonance - AuscultaBon Faint or absent breath sounds over the area of eLusion - --- - - - Pleural fric.on rub If(squeaking sound of in;amed pleural layers rubbing - Percussion: dullness over the area of eLusion -Is associated with - pleuritis/planning together during inspiraBon and expiraBon) - > stony Your Date Here Your Footer Here 7  Diagnos.cs Chest x-ray > Indica.ons - Standard iniBal imaging modality for detecBng pleural eLusion. - Suppor.ve ,ndings Findings starts to appear aPer 200ml of pleural ;uid accumulates Typically unilateral blunBng of the - -> - costophrenic - angle 5 & fluid Homogeneous density with a meniscus-shaped margin (meniscus sign) > nee - Large eLusionS5. - - Complete opaciZcaBon of the lung = MediasBnal shiP I - > Tracheal deviaBon away from the eCusion (space-occupying lesion) -> Your Date Here Your Footer Here 8  merate LeE-sided pleural eCusion massive lis - S X-ray chest (PA view) -I Extensive opaciZcaBon is visible in the tracke uSiS - - & middle and lower lung Zelds of the leP hemithorax with a meniscus-shaped margin. This is a typical Znding of pleural eLusion. je ; *10, s, Imenisans Sign -- - IIs -heart E - - &- Your Date Here Your Footer Here 9 Diagnos.cs Ultrasound 6 - Indica.ons Quick bedside assessment ⑮ js'; 91 - - Thoracentesis planning - needing is Suppor.ve ,ndings: hypoechoic/anechoic structures in the lower margins of the pleural cavity (costodiaphragmaBc recess) Very sensiBve: can detect ;uid amounts as low- as 20 mL X-ray, - - Pleural ;uid septaBons may be present. zoom Allows for detecBon of pleural thickening and pleural nodules Your Date Here Your Footer Here 10 Pleural eCusion Ultrasound chest (posterior right hemithorax) icegle Anechoic ;uid (green overlay; F) is visible in - 0 the costodiaphragmaBc recess between the - - right hemidiaphragm (D) and atelectaBc lung. L: liver iver Source: AMBOSS Your Date Here Your Footer Here 11  Diagnos.cs 1.I Chest CT malignancy -61,;s effusion 1 - 3 S C A ↳ Indica.ons: gold standard but use is limited due to radiaBon and contrast exposure sative Procedure: chest CT without IV contrast is usually sufcient A With IV contrast: allows for the detecBon of - underlying >>>> -> malignancy (e.g., metastases and/or primary tumor) - CT angiogram: helps to idenBfy vascular pathology (e.g., dissecBon or AVM) Suppor.ve ,ndings Can detect > 3–5 mL of ;uid - Fluid density measurement can help diLerenBate pleural eLusion from empyema and hemothorax Disease-speciZc signs Your Date Here Your Footer Here 12  Diagnos.cs - ⑧I S- - ~ es 1 ojs Diagnos.c thoracentesis - - - - atypical features 9583,1. + - - oiI Analysis of the pleural ;uid (via thoracentesis) is usually required to deZniBvely I - analysis establish the underlying eBology but may not be necessary if there is already a clear - 15 63 diagnosis of an underlying condiBon (e.g., known CHF or connecBve Bssue disease). Si - / Descrip.on II AspiraBon of ;uid from the pleural space for diagnosBc (e.g., transudate vs. exudate) purposes S / Check serum protein, lipid panel, and LDH as well for calculaBon of Light criteria. -I x2* Indica.ons - Any new unilateral eLusion > 1 cm on x-ray in an undiagnosed paBent - - History of malignant tumor with eLusion > 1 cm on x-ray - P L 1 Pneumonia with parapneumonic eLusion > 5 cm on x-ray atypical features - - Heart failure in conjuncBon with atypical Zndings (e.g., pleuriBc chest pain, fever, unilateral eLusion) Suspected transudaBve bilateral eLusions with atypical features (e.g., fever, pleuriBc chest pain, - > eLusions of disparate size) 13 yis;;,,pEj'sIss - ↓'s Pleural Guid analysis The most important criteria are: > _ Appearance. -i Protein content. nee Cellular components (cytology). nee mainte- 00 0 RBC - puhay interation) - Your Date Here lotnoralycyps, Your Footer Here is now Cransualafel 14  Pleural Guid analysis DiCeren.a.ng - ↳ transudates from exudates I - > I - - - - & >0.5 --- - B!30.6 5 -> reeeee ↑ LDH > 2/3 upper limit - -by - - (A) 8D, i I - Your Date Here Your Footer Here 15  e Transudate is usually clear, has a decreased cell count, - - - and has low levels of protein, albumin, - - and LDH.- - - Exudate typically appears cloudy, has an - - increased cell count, and has high levels of - protein, albumin, and LDH. - - Clinical pearl! Your Date Here Your Footer Here 16 DiCeren.al -- diagnosis of transuda.ve eCusion ⑧ 1. Conges.ve Heart failure *A > Most common transudaBve cause 2. Liver cirrhosis - The eLusion is more frequent on the right ascites due to PHT ↳> > fluid escape through diaphragm & 3. Hypoalbuminemia : from pleural abdomen to thorax. (es. right) - b decreased oncoBc pressure (e.g. nephroBc syndrome). - - - PE, I = nee 4. Urinothorax - -> urine inthe chest Urinary obstrucBon or trauma. 5. Peritoneal dialysis - 6. Atelectasis - Your Date Here Your Footer Here 17 DiCeren.al diagnosis of - transuda.ve eCusion hypothyroidism & 7. Myxedema - - also can be exudaBve - 0 8. “Meigs' syndrome” - > The triad of benign Zbroma or other ovarian tumors with ascites - - - - - and large pleural eLusions. - - Usually on the right side. = also can be exudaBve - 9. Sarcoidosis -> also can be exudaBve - Your Date Here Your Footer Here 18 DiCeren.al diagnosis of- - exuda.ve eCusion A- Infec.ve and inGammatory causes & Parapneumonic eLusion - - Tuberculous eLusion infection & inflammation - - upper abdominal abscess -> -en PancreaBBs and pancreaBc pseudocysts -> left sided - - Esophageal rupture & high levels of - salivary amylase B- NON INFECTIOUS CAUSES - Malignancyone ofthecommon effusion causes of # Rheumatoid arthriBs. -> + disease -> - - Systemic lupus erythematosus. - - Uremia - Asbestosis - Drug-induced & Your Date Here Your Footer Here 19 Narrowing the diCeren.al diagnosis of exuda.ve eCusions Associated condi.ons Pleural Guid parameter  Parapneumonic eLusion - WBC count > 10,000 cells/mm3  PancreaBBs - -  Pulmonary embolism - Cell count and diCeren.al ->  Collagen vascular disease - Acute infecBon Paranemonic > / Neutrophils > 50% of - - - Pulmonary infarct I = > -I - total leukocytes ° - Primary or chronic tuberculous Lymphocytes > 50% of - - - infecBon total leukocytes - - Malignant eLusion - Chylothorax Hemothorax - RBC count > 5,000 cells/μL A - - Malignant eLusion (i.e., - s - bleeding-> -> tumor) new S vessels Pulmonary embolism/infarct - I Hematocrit > 0.5 ×&peripheral hematocritB 2 Hemothorax - - sem PCV 45 e ! I ( = -I PCV ofPC 25 = 2 "188 20 / -  Narrowing the diCeren.al diagnosis of exuda.ve eCusions Associated condi.ons Pleural Guid parameter - S & E Complicated parapneumonic - PH of PE -> serum PH I I eLusion - / Empyema - Malignant eLusion pH < 7.2 Esophageal perforaBon - Collagen vascular disease acdie 18 i * invection Cemp yewal - Malignant eLusion - Parapneumonic eLusion - - Empyema -> is3 - Rheumatoid pleurisy Ja- Glucose < 60 mg/dl - > Tuberculous pleurisy - Esophageal rupture - Lupus pleuriBs - Parapneumonic eLusion - Posi.ve Gram stain or culture -> Empyema infecti - - - & 21 Narrowing the diCeren.al diagnosis of exuda.ve eCusions Associated condi.ons Pleural Guid parameter  Tuberculous eLusion AD Adenosine deaminase0 > 50 mcg/L Ter - - Posi.ve AFB smear microscopy - aid fast baciliti Malignant eLusion Abnormal cytology # - PancreaBBs (left) > Amylase > 200 mcg/dL - - Malignant eLusion Esophageal perforaBon-> A Salivary anylase - Ruptured ectopic pregnancy Collagen vascular diseases RA Posi.ve rheumatoid factor, ANA > est - Chylothorax - Triglycerides > 110 mg/dL - Chylothorax Cloudy, milky - Parapneumonic eLusion Purulent - Empyema - Jinfection - Appearance Hemothorax - Bloody - Malignant eLusion - Pulmonary embolism/infarct - 22 Treatment Stabilize pa/ents with respiratory distress. = - Provide supplemental oxygen Consider urgent therapeu6c thoracentesis for pa6ents with: Signs of increased work of breathing Hypoxemic respiratory failure Hypercapnic respiratory failure Hemodynamic compromise secondary to the e?usion Iden/fy and treat the underlying condi/on. > Consider elec6ve therapeu/c thoracentesis. - * & - Consider specialized procedures and/or surgical therapy aCer specialty consulta6on. Your Date Here Your Footer Here 23 Treatment Therapeu/c thoracentesis The goal of a therapeu6c thoracentesis is to remove Juid (especially > in exudate because of increased risk of infec6on). Removal of 400–500 mL of Juid is usually suScient to relieve symptoms (e.g., dyspnea). - Indica/ons Large e?usion with dyspnea and/or cardiac decompensa6on Complicated parapneumonic e?usions - - Your Date Here Your Footer Here 24 Treatment -1g - S -- ity & Tube thoracostomy nee Indica/ons Pleural e?usion in combina6on with signiUcant cardiac and/ or respiratory decompensa6on For recurrent pleural e?usion or urgent drainage of infected I => and/or loculated e?usions - Drainage of high-viscosity Juid that is likely to clog -Is S - -- Empyema -> Il Hemothorax & Your Date Here Your Footer Here 25  Subtypes and variants Your Date Here Your Footer Here Parapneumonic e>usion De@ni/on Accumula6on of exuda6ve Juid in the pleural cavity in => > - > > response to pneumonia => i's * Uncomplicated:⑧ - - without direct bacterial invasion - Complicated: extension of bacterial - - infec6on into the pleural space Clinical features -I Fever, chills - Cough - Chest discomfort (chest pain) Your Date Here Your Footer Here 27 Parapneumonic e>usion Diagnos/cs - Imaging: associated - pneumonia Pleural -- Buid analysis Exuda6ve e?usion -> light's criteria - Cloudy or purulent appearance - => j' WBC count > 10,000 cells/μL I leukocytosis interlion => -> Posi6ve Gram stain/cultureO (bacterinsi for complicated parapneumonic e?usion - mea o n ns Pleural Buid criteria for- > -> - complicated parapneumonic e>usion pH < 7.2 S - ↑ LDH > Glucose < 60 mg/dL (< 3.3 mmol/L) > Your Date Here Your Footer Here 28 Parapneumonic e>usion Treatment - All pa6ents: systemic an/bio/c treatment - Early an6bio6c treatment can prevent progression to -> - complicated e?usion and empyema. - - Pa6ents with complicated parapneumonic - e?usions: therapeu/c thoracentesis - >it & I I Your Date Here Your Footer Here 29 Empyema De@ni/on pus ! fluid s Accumula6on of pus in the pleural cavity E/ology - Classi@ca/on Most common: pneumonia - - Stage I (exuda6ve): accumula6on of Juid and pusone - Less common -> => Infected hemothorax &-Stage II (Ubrinopurulent): aggrega6on - & - Ruptured lung abscess of Ubrin deposits that- form septa6ons and - -> - - - -> - - - I & Esophageal tear Pleural I pockets I - - - - cavity Thoracic trauma Stage III (organizing): forma6on of thick Ubrous -> - - peel on pleural surface that Clinical features Fever, chills - restricts lung movement ( · Cough Chest discomfort Your Date Here Your Footer Here 30  Empyema Diagnos/cs CXR: will typically show opacity with one or more of the following characteris6cs Meniscus sign # -" - Len6cular shape -infection Di?use consolida6on of adjacent lung - Ultrasound: heterogeneous Juid collec6on - Chest CT Dis6nc6ve appearance of- - empyema Juid Pleural Buid analysis L Exuda6ve e?usion - Pus Grossly purulent appearance S - Posi6ve Gram stain and bacterial culture => - pH < 7.2 > Low glucose (< 30–60 mg/dL) - - - - Your Date Here Your Footer Here 31  - I - * ⑳ Loculated pleural - collec/on X-ray chest (a: PA view: b: lateral view) of a pa6ent with a history of intravenous drug use and empyema. A loculated collec6on (red overlay) in the posterolateral lower leC hemithorax has a biconvex shape compa6ble with a loca6on C↓ within the pleural space. A meniscus and thickened major Ussure from pleural Juid SisE (blue lines) are addi6onally seen (blue lines), ⑧ meniscus sign consolidatio pus along with areas of lung consolida6on (green - 2s - overlay) and atelectasis (red lines). - ibrous, septa s S Dis yem Your Date Here Your Footer Here 32 Treatment of pleural empyema ine - Empiric an/bio/c therapy for pleural infec/on >@° - -> All pa6ents should receive empiric an6bio6cs adjusted to their needs, local resistance pajerns, and ins6tu6onal guidelines. Your Date Here Your Footer Here 33  - > Treatment of pleural empyema - - S S - - & De@ni/ve treatment I Thoracocenthesis - ' empyemal); ⑳ Stage I ·o>Is (thick) Chest tube (thoracostomy)& - to remove empyema Juid - - Consider intrapleural administra6on of Ubrinoly6c agents. - - : & Stage II or mixed stage II/III - - tissue First-line: chest tube drainage -- Second-line: VATS debridement& if chest-tube drainage is ine?ec6ve - assessed thoracoscopic surgery deo sis's ⑧ Stage III chest I VATS debridement I Pleurectomy and lung decor6ca6on via open thoracotomy & 9 # 15 -eus. - Your Date Here Your Footer Here 34 Malignant pleural e>usion I De@ni/on: accumula6on of exuda6ve Juid and=> - malignant cells in the pleural cavity. 51ss; s malignentII i - - => Pathophysiology: cancer-related barrier dysfunc6on of I - - - the capillary walls → increased permea6on of plasma protein, blood cells, and- - -- - tumor cells E/ology > lang et Caused by either direct invasion of the pleural space or = distant metastases breast Most common: lung cancer, breast => - cancer Less common: mesothelioma, lymphoma, and pleural metastases > - > - - Your Date Here Your Footer Here 35  Malignant pleural e>usion Clinical: symptoms of underlying malignancy (e.g., cons6tu6onal symptoms, cachexia, I hemoptysis) - - - - - Diagnos/cs Imaging: associated underlying malignancy - - - Pleural Buid analysis Cell-rich exuda6ve e?usion Right) ---- Cloudy or straw-colored appearance - -> Abnormal cytology E Pronounced nucleoli - Cells with mul6ple nuclei - Numerous Ugures of mitosis - - pH < 7.2 b - Glucose < 60 mg/dL > Amylase > 200 mcg/dL - LDH usually high (> 0.45 x normal serum LDH) - - If hemorrhagic: bloody appearance, RBC count > 5,000 cells/μL - = - > Laboratory studies: posi6ve tumor markers -> - - - 36 Malignant pleural e>usion - Treatment - Asymptoma6c: suppor6ve care - Symptoma6c - Therapeu6c thoracentesis - _ Indwelling pleural catheter - iflarge & recurrent Chemical pleurodesis Treatment of underlying malignancy as needed Y * - - Your Date Here Your Footer Here 37 Tuberculous e>usion I Tuberculous e?usion is > common in our country (endemic area). - – It develops due to one of the following causes: reactionary ‫ انما فدشي تفاعلي‬infection ‫ وسوت‬pleural space ‫مو نتيجة انه البكتريا راحت لل‬ 1) Primary TB infec6on. - ‫يعني اذا سحبته مرح تلگي بي البكتريا انما بحالة ادا هي سوته حتلكيها‬ 2) Subpleural focus of Mycobacterium tuberculosis ruptures into the - pleural space. - Notes: ↑ – Presence of an „adenosine deaminase‟ in the Juid correlate with tuberculosis. - - - – Pleural biopsy are posi6ve in 50 to 80% of cases (casea6ng granuloma on - - - - > histopathology) > & 0 Your Date Here Your Footer Here 38  HEMOTHORAX RBC - - ) Frank blood in the pleural space is usually the result of - trauma, hematologic disorders, pulmonary - - - infarc/on, pleural malignancies or rupture of the => = > most one severe aorta. - Your Date Here Your Footer Here 39  ⑧ Chylothorax De@ni/on ↳ Accumula6on of- - Olympha6c Juid from the thoracic > duct (chyle) in the pleural cavity = - E/ology in surgery Trauma (including iatrogenic) most cause of chylothorax common - - -> Malignancy (e.g.,- - lymphoma, bronchogenic carcinoma) > Congenital lympha6c anomalies (e.g., lymphangiectasis) - the - dilation of lymphatic vessels Your Date Here Your Footer Here 40 Chylothorax Clinical: Chest pain is rare. Diagnos/cs - Chest CT: underlying malignancy or thoracic injury - #> - Pleural Buid analysis Cloudy,- - milky Juid with high concentra6ons of lipids - (triglycerides, cholesterol, chylomicrons, and fat-soluble vitamins) Exuda6ve e?usion - - Total cholesterol usually < 200 mg/dL S PI - Triglyceride concentra6on > 110 mg/dL &ps -> LDH usually low - - Glucose level similar to the plasma glucose level Lymphocyte predominance Your Date Here Your Footer Here 41  Pneumothorax Your Date Here Your Footer Here  De@ni/on Pneumothorax: a collec6on of air within the pleural space between6595 - I & -b-1 *S E b 1 the lung (visceral pleura) and the chest wall (parietal pleura) that can lead to par6al S - 39;.. or complete pulmonary collapse. May be classiUed as: - - -> - Spontaneous pneumothorax -DsI / - = - ↳ - Primary spontaneous pneumothorax: occurs in pa6ents without clinically apparent underlying - - lung disease - Secondary spontaneous pneumothorax: occurs as a complica/on of underlying lung disease - Trauma/c pneumothorax: a type of pneumothorax caused by a trauma (e.g., I # penetra6ng injury, iatrogenic trauma) > - Tension pneumothorax: a life-threatening variant of pneumothorax characterized - - by progressively increasing pressure within the chest and cardiorespiratory - - t compromise - simple Your Date Here Your Footer Here 43 Epidemiology Primary spontaneous pneumothorax - Sex: ♂ or > ♀ (∼ 6:1) Peak incidence: 16–25 years -- Secondary spontaneous pneumothorax - Sex: ♂ o>♀ I (∼ 3:1) Peak incidence: 60–65 years - Your Date Here Your Footer Here 44 E"ology Primary (idiopathic or simple pneumothorax) - - - - Caused by ruptured subpleural apical blebs - Risk factors Family history Male sex => > - Young age > -> Asthenic body habitus (slim, tall stature) (e.g., in Marfan syndrome) - => - > - Smoking (90% of cases): up to 20-fold increase in risk (risk increases = with the cumulaHve number of cigareJes smoked) HomocysHnuria Your Date Here Your Footer Here 45 E"ology Secondary (pneumothorax as a complicaHon of - - underlying lung disease) - COPD (smoking) → rupture of bullae in emphysema => => InfecHons ⑤ Pulmonary tuberculosis ↳ PneumocysHs pneumonia → alveoliHs, rupture of a cavity - - CysHc Rbrosis → bronchiectasis with obstrucHve emphysema and - bleb or cyst rupture Marfan syndrome - Malignancy - Your Date Here Your Footer Here 46 E"ology Trauma"c pneumothorax " Blunt trauma (e.g., motor vehicle accident in which the - - thorax hits the steering wheel or rib fracture occurs) PenetraHng injury (e.g., gunshot, stab wound) - ° Iatrogenic pneumothorax: mechanical venHlaHon with - high PEEP (barotrauma), thoracocentesis, central venous catheter placement, bronchoscopy, lung biopsy - Your Date Here Your Footer Here 47  E"ological classi?ca"on of pneumothorax & 1. Spontaneous pneumothorax: The - - - - - - accumulaHon of air within the pleural space - without an external precipitaHng event. - - – Primary spontaneous pneumothorax:- no 0 - - I - known underlying lung disease (e.g., rupture of - - a previously asymptomaHc subpleural apical - bleb). - – Secondary spontaneous pneumothorax: A - complicaHon of known, underlying lung disease -, -- & Planne-- - - - (e.g., emphysema, PneumocysHs pneumonia). Space S & - & 2. TraumaHc pneumothorax: The accumulaHon - - of air within the pleural space; secondary to - chest trauma. - I 3. Iatrogenic pneumothorax: The accumulaHon = - of air within the pleural space; secondary to an - iatrogenic intervenHon (e.g., thoracocentesis, - - O pleural/lung biopsy). - Your Date Here Your Footer Here 48 Pathophysiology Increased intrapleural pressure → alveolar collapse → - - decreased V/Q raHo and increased right-to- - = - leb shunHng. - Your Date Here Your Footer Here 49 Pathophysiology Spontaneous pneumothorax: rupture of blebs and bullae → air " - moves into pleural space with increasing posiHve - - pressure → ipsilateral lung is compressed and collapses - - Trauma"c pneumothorax # Closed pneumothorax: air enters through a hole in the lung (e.g., - - following blunt trauma) - Open pneumothorax: air enters through a lesion in the chest wall (e.g., - - following penetraHng trauma) - Air enters the pleural space on inspiraHon and leaks to the exterior on - expiraHon. Air shibs between the lungs - Your Date Here Your Footer Here 50  &I - chest wall - - chestsis's 35- - - Open and closed pneumothorax - - Open pneumothorax: The entry of air into the pleural cavity through an unsealed defect in the thoracic wall (e.g., following penetraHng trauma). Closed pneumothorax: The entry of air into the pleural cavity through a breach in the visceral pleura (e.g., ruptured pulmonary bulla). 2 a &S. S - -" - Your Date Here Your Footer Here 51 Pathophysiology Tension pneumothorax > Disrupted visceral pleura, parietal pleura, or tracheobronchial tree - - - One-way valve mechanism, in which air enters the pleural space on - inspiraHon- - but cannot exit - Progressive accumulaHon of air in the pleural space and increasing - posiHve pressure within the chest - Collapse of ipsilateral lung; compression of contralateral lung, - trachea, heart, and superior vena cava; angulaHon of inferior vena cava Impaired respiratory funcHon, reduced venous return to the heart - Reduced cardiac output - Hypoxia and hemodynamic instability - - Your Date Here Your Footer Here 52 Tension > pneumothorax A tension pneumothorax develops secondary - to one-way valve mechanism, which is - - caused by an injury to the lung parenchyma - or chest wall and allows air to enter the I trachen pleural space during inspiraHon (valve open) - 20- - but not escape during expiraHon (valve d , - E closed). Progressive accumulaHon of air - - - -h 20 within the pleural space causes an ipsilateral Ilapsa * increase in intrapleural pressure, leading to - heart ipsilateral lung collapse and mediasHnal shib - - to the contralateral side. The mediasHnal Pressure on - shib compresses the vena cavae, trachea, - l great veining and the contralateral lung, leading to - & s ↓ Preload CO b -;53,96? +.5 wing hemodynamic instability and hypoxia. (distended meck veins) : Isdefects; ↳ ses$1 - - & -> - - - Your Date Here Your Footer Here 53 Clinical features - I PaHents range from being asymptomaHc to having #>> - ° features of hemodynamic compromise. - a -I Sudden, severe, and/or stabbing, ipsilateral - - - ⑰ pleuriHc chest pain and dyspnea reduced chestexpansion - - ipsilaterally Reduced or absent breath sounds, I - 4 hyperresonant percussion, decreased fremitus on - - - I - the ipsilateral side - Subcutaneous emphysema in open raumatic Premothorax Your Date Here Your Footer Here 54  Clinical features Addi"onal ?ndings in tension pneumothorax - - Severe acute respiratory distress: cyanosis, restlessness, - - diaphoresis - Si - Caffected) # Reduced chest expansion on the ipsilateral side Plevral - - -R I Distended neck veins and hemodynamic instability - effusion - (tachycardia, hypotension, pulsus paradoxus) - - - - - > - Secondary injuries may be present (e.g., open or closed - after t wounds). - rua Your Date Here Your Footer Here 55 Diagnos"cs General principles - The diagnosis of pneumothorax is usually conRrmed by- chest x- > - I ray. Ultrasound is becoming an increasingly accepted modality for = - idenHfying pneumothorax and is part of the eFAST. CT can provide informaHon about the underlying cause - - (e.g., bullae in spontaneous pneumothorax). - - Tension pneumothorax is primarily a clinical diagnosis and - prolonged diagnosHc studies should be avoided in favor - - of ini"a"ng immediate treatment. en Your Date Here Your Footer Here 56  life threatening In cases of tension pneumothorax, immediate decompression is a - priority and should& - not be delayed by imaging. I Cau"on! Your Date Here Your Footer Here 57 Chest x-ray Indica"ons:& > ° all paHents suspected of having pneumothorax - Procedure: Upright PA chest x-ray in inspiraHon is the - - modality of choice. Suppor"ve ?ndings of pneumothorax Ipsilateral pleural line with reduced/absent lung markings (i.e., - increased transparency) Abrupt change in radiolucency -> due to the loss of intrathoracic volue - Hemidiaphragm elevaHon on the ipsilateral side collaps - - * -e If pulmonary disease is present: airway or parenchymal lesions -> Your Date Here Your Footer Here 58  S Se -S - - I 3g LeI pneumothorax - Chest x-ray (PA view) There is a loss of bronchovascular markings - sniftget I⑳ E 8air (green overlay) in the upper leb hemithorax - - with mediasHnal shib to the right. The leb - I, I - hemidiaphragm (green line) is elevated due collap - se - - to the loss of leb intrathoracic volume. - These Rndings are characterisHc of a leb pneumothorax hemed elevation Your Date Here Your Footer Here 59  Chest x-ray Suppor"ve ?ndings of tension pneumothorax - - Ipsilateral diaphragmaHc eaJening/inversion and [ widened intercostal spaces > = > - MediasHnal shib toward the contralateral side E Tracheal devia"on toward the contralateral side - -> Your Date Here Your Footer Here 60  X lung tissue, Tension - pneumothorax Chest x-ray (PA view) There is a loss of lung markings on the right S > side and almost complete right lung collapse ⑦ (red shaded area). There is also a contralateral shib of the azygoesophageal - recess (red line) and a slight leb shib of the mediasHnal border (green line) and the A ⑭ - - Capse trachea (white broken line). 5 - - These Rndings indicate a tension pneumothorax with a mediasHnal shib. - at & ening Your Date Here Your Footer Here 61 Treatment All pa"ents Assess paHent stability - Provide respiratory support and treat dyspnea. I Evaluate the type and size of pneumothorax. - Unstable or high-risk pa"ents: e.g., with tension pneumothorax, bilateral pneumothorax, or who - - - require mechanical venHlaHon - - Immediate #> chest decompression-> needle Treat obstrucHve shock if present. wlysth intercostal space dayllaryline. a - Stable spontaneous pneumothorax management: depends on the risk of progression and recurrence = Low-risk: conservaHve management - - Higher risk: chest - -- tube placement - Trauma"c pneumothorax management - Most paHents require chest tube placement.-high risks, - Follow the ABCDE approach to trauma to assess for addiHonal injuries. - Your Date Here Your Footer Here 62