Pneumothorax

Transcription

Pneumothorax
Case
Conference
March 26th, 2015
49 Year-Old-Man
Shortness of breath
š  PMHx
š  Hypertension
š  Social History
š  Single
š  Hyperlipidemia
š  Lives alone
š  MI 2002
š  Smoked until 5 years ago: 90 pack years
š  COPD
š  Meds
š  Metoprolol 50mg BID
š  Drinks 1-2 bottles of beer per day
š  Occasional marijuana
š  Family History
š  Lisinopril 20mg
š  Father: MI, CVA
š  Simvastatin 20mg
š  Mother: CHF
š  Aspirin 325mg
š  Advair 250/50 BID
š  Albuterol prn
š  Sister: PE
HPI
š  Patient developed acute dyspnea
while watching football on TV
š  Felt fine earlier in the day
š  Worsened over the course of the
afternoon
š  Patient called his sister for help
š  Sister called 911
š  Vitals by EMS
š  BP 158/90, HR 136, RR 32, 78% on RA
Questions?
š  What would you do next?
1.  EKG
2.  CXR
3.  Cardiac US
4.  Lung US
Physical Exam
š  T 98.5, BP 162/92, HR 144, RR 42, 84% 15LPM
š  Gen: pale, resp distress, can’t speak
š  Respiratory: tachypnea, diminished breath
sounds bilaterally, not moving much air;
symmetric chest rise
ISTAT Lab:
15.1
138 104
4.0
š  CV: tachycardia, regular; no JVD or
peripheral edema
ABG: 7.25/68/50
Trop < 0.01
š  Neuro: disoriented, unable to answer
questions
He got Intubated
22
9
1.0
197
Our Patient
Normal
*
v  Hospital Course:
v  Chest tube placed in ED
v  Transferred to ICU
v  Remained intubated several days:
COPD, pneumonia
v  Extubated and chest tube removed
v  Completed course of antibiotics,
steroids
v  Discharged to home on Advair,
added Spiriva
v  One month later, re-admitted with
2nd pneumothorax:
v  Attempted VATS (failed)
v  Underwent thoracotomy with
bleb resection
Pneumothorax
Board Question
67-yo woman has abrupt onset of R pleuritic chest pain and moderate dyspnea. She recently had symptoms
typical of an URI (rhinorrhea, HA, sore throat, and nonproductive cough) and her chest pain and dyspnea
seemed to be triggered by an episode of vigorous coughing. No fevers, chills, purulent sputum, or risk factors
for thromboembolic disease. She smokes.
PMH: COPD
Meds: Salmeterol and albuterol prn
Gen: uncomfortable but no resp distress, speaking full sentences
T 37.0, BP 129/58, HR 78, RR 22, 98% on 2L NC
Pulm: prolonged expiratory phase, no wheezes, breath sounds symmetric, trachea midline
CV: Normal and no murmurs, no edema
EKG: Sinus rhythm
CXR: 1.48cm pneumothorax
What is your next step in addition to hospital admission?
1.  Evaluation for pleurodesis
2.  Needle aspiration
3.  Serial CXR
4.  Tube thoracoscopy
Introduction
š  Simple Pneumothorax
š  Pressure is still sub-atmospheric
š  No mediastinal shift
š  Tension Pneumothorax
š  Pressure exceeds Patm (esp on expiration)
š  Usually due to a “check valve”
š Lets air in, but not out
š  Mediastinal shift
š  Open Pneumothorax
š  Chest wall defect allows air in
š “sucking wound”
š  Mediastinum shifts to normal side and then
swings back on expiration
Primary Spontaneous Pneumothorax
š  No precipitating event
š  No known lung disease
š  Risk factors:
š  Smoking
š  FHx
š  Marfan
š  Thoracic endometriosis
š  Men>Women
š  Early 20’s
š  25-50% chance of recurrence
š  MC in the 1st year
š  Risks for recurrence:
š  Female
š  Tall stature in men
š  Low body weight
š  Failure to stop smoking
Primary Spontaneous Pneumothorax
š  Presentation
š  Usually occurs at rest
š  Most are in their 20s (rare after 40)
š  Sudden onset pleuritic chest pain and dyspnea
š  Severity of sx correlate with volume of air in pleural space
š Dyspnea
š  Physical Findings
š  Diminished breath sounds, reduced chest excursion
š  Hyperresonant to percussion
š  Hypoxemia (if tachycardia, or HypoTN à think tension)
š  Hypercapnea is unusual in PSP
Secondary Spontaneous Pneumothorax
š  Occurs as a complication of
underlying lung disease
š  Most commonly associated:
š  COPD (50-70%)
š  CF
š  Lung Cancer (Primary / METS)
š  Necrotizing pneumonia
š Bacterial, fungal, PJP, TB
Board Pearl: HIV + PTX = PJP
š  Other less common causes:
š  Asthma, ILD, Marfan, RA
š  Presentation
š  Similar to PSP
š  But usually more severe due to less
reserve / underlying lung disease
Diagnosis
š  CXR
š  White visceral pleural line
š  Convex
š  No pulmonary vessels beyond the pleural edge
š  Look at lung parenchyma (? Underlying lung disease)
š  Sensitivity 28-75%
š  Chest CT
š  Generally not necessary (unless unclear)
š  US
š  Absence of lung sliding
š  Presence of lung point
š  Sensitivity 86-98%
It’s How Big?? What Do I Do Now?
š  Primary Spontaneous Pneumothorax
š  Clinically stable AND 1st pneumothorax:
š < 2-3 cm (b/n lung and chest wall on CXR)
š Supplemental oxygen (4-6x faster resolution), observation
š Observe at least 6 hrs and DC if no progression on CXR
š > 3 cm OR symptomatic with chest pain and/or dyspnea
š Needle aspiration
š  Clinically unstable OR recurrent OR hemothorax OR failed needle aspiration:
š Chest tube, consider thoracoscopy
š If PTX persists and can’t do thoracoscopy, chemical pleurodesis through CT
It’s How Big?? What Do I Do Now?
š  2o Spontaneous Pneumothorax
š  Stable, asympatomatic, or small PTA (<2 cm): oxygen and observe
š  > 2 cm: chest tube (tube thoracostomy)
š  Need to intervene sooner b/c of underlying lung disease
š Increases risk of persistent air leak and further expansion of pneumothorax
š Experts recommend that all patients being observed as an inpatient
š  Tension Pneumothorax
š  Immediate needle decompression
š Large-bore needle to 2nd intercostal space at mid-clavicular line
Treatment Basics
1.  Oxygen
2.  Cardiopulmonary stabilization
3.  Remove air from the pleural space
š  Oxygen
š  Helps with quick reabsorption (6 fold)
š  Needle Aspiration
š  Place catheter and aspirate air
š  If air return stops
š Place stopcock & repeat CXR in 4 hrs
š  Ongoing air leak
š Tube Thoracoscopy
š  Doesn’t work as well for secondary PTX
š So just do the tube
Chest Tube
š  Water seal +/- suction
š  Use suction if PTX fails to resolve
š  Monitor for air leak, lung expansion
š  Clamp chest tube
š  Repeat imaging 24 hours later
š  Remove chest tube if stable
Oh Dang, It Didn’t Work! Now What?
š  Persistent Air Leak
š  If there’s still an air leak after 3 days à be
more aggressive
š  If patient has at least 90% re-expansion:
š Attach Heimlich valve to CT
š VATS
š Blood patch or chemical pleurodesis
š  If failure of Lung Re-expansion (< 90% reexpanded)
š VATS
Video-Assisted Thoracoscopy (VATS)
š  Stapling or wedge resection of bullae
š  Obliterate pleural space
š  Mechanical abrasion of pleura
(gauze)
š  Intra op insufflation of talc
š  Laser abrasion of parietal pleura
Oh Dang, It’s Back
š  25-50% of PSPs will recur
š  Highest risk in first 30 days
š  Risk is higher in SSP - More likely in those with blebs or bullae on high resolution CT
š  Every one with RECURRENCE should undergo intervention to prevent another one
š  VATS pleurodesis
š Reduced recurrence rate to < 5% (if done with bleb/bullae resection)
š  Chemical pleurodesis via tube thoracostomy or pigtail catheter
š Reduces recurrence rate to < 25%
š  Thoracotomy (less common, works better, but morbid)
š  Choice depends on expertise of practitioner at each institution
š  Stop smoking!
Tension Pneumothorax
š  Presentation
š  Decreasing SaO2, PaO2, ScvO2
š  Tachycardia
š  Elevated JVP / CVP
š  Hyperresonance, decreased BS
š  Increased IPP causes
š  Further collapse
š  Diaphragmatic depression
š  More likely in vented than awake patients
š  Treat as emergency
š  Needle decompression vs chest tube
Chest Drainage Systems
Wall Suction
Air & Fluid from
Patient’s Lung
Atmospheric Vent
Air
Air
Suction Level:
-10 to
-40mm Hg
Air
Typically use
Suction of
-10 to -20mmHg
Suction
Regulation
Water Seal
Collection
Chamber
Don’t be fooled
The New Moe (pneumo)
Pneumothorax
Spontaneous
Primary
Traumatic
Secondary
COPD
CF
Infectious
ILD
Status Asthmaticus
Iatrogenic
Needle Aspiration
Thoracentesis
Central Line
Barotrauma