Pneumothorax
Case Conference March 26th, 2015 49 Year-Old-Man Shortness of breath PMHx Hypertension Social History Single Hyperlipidemia Lives alone MI 2002 Smoked until 5 years ago: 90 pack years COPD Meds Metoprolol 50mg BID Drinks 1-2 bottles of beer per day Occasional marijuana Family History Lisinopril 20mg Father: MI, CVA Simvastatin 20mg Mother: CHF Aspirin 325mg Advair 250/50 BID Albuterol prn Sister: PE HPI Patient developed acute dyspnea while watching football on TV Felt fine earlier in the day Worsened over the course of the afternoon Patient called his sister for help Sister called 911 Vitals by EMS BP 158/90, HR 136, RR 32, 78% on RA Questions? What would you do next? 1. EKG 2. CXR 3. Cardiac US 4. Lung US Physical Exam T 98.5, BP 162/92, HR 144, RR 42, 84% 15LPM Gen: pale, resp distress, can’t speak Respiratory: tachypnea, diminished breath sounds bilaterally, not moving much air; symmetric chest rise ISTAT Lab: 15.1 138 104 4.0 CV: tachycardia, regular; no JVD or peripheral edema ABG: 7.25/68/50 Trop < 0.01 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 Simple Pneumothorax Pressure is still sub-atmospheric No mediastinal shift Tension Pneumothorax Pressure exceeds Patm (esp on expiration) Usually due to a “check valve” Lets air in, but not out Mediastinal shift Open Pneumothorax Chest wall defect allows air in “sucking wound” Mediastinum shifts to normal side and then swings back on expiration Primary Spontaneous Pneumothorax No precipitating event No known lung disease Risk factors: Smoking FHx Marfan Thoracic endometriosis Men>Women Early 20’s 25-50% chance of recurrence MC in the 1st year Risks for recurrence: Female Tall stature in men Low body weight Failure to stop smoking Primary Spontaneous Pneumothorax Presentation Usually occurs at rest Most are in their 20s (rare after 40) Sudden onset pleuritic chest pain and dyspnea Severity of sx correlate with volume of air in pleural space Dyspnea Physical Findings Diminished breath sounds, reduced chest excursion Hyperresonant to percussion Hypoxemia (if tachycardia, or HypoTN à think tension) Hypercapnea is unusual in PSP Secondary Spontaneous Pneumothorax Occurs as a complication of underlying lung disease Most commonly associated: COPD (50-70%) CF Lung Cancer (Primary / METS) Necrotizing pneumonia Bacterial, fungal, PJP, TB Board Pearl: HIV + PTX = PJP Other less common causes: Asthma, ILD, Marfan, RA Presentation Similar to PSP But usually more severe due to less reserve / underlying lung disease Diagnosis CXR White visceral pleural line Convex No pulmonary vessels beyond the pleural edge Look at lung parenchyma (? Underlying lung disease) Sensitivity 28-75% Chest CT Generally not necessary (unless unclear) US Absence of lung sliding Presence of lung point Sensitivity 86-98% It’s How Big?? What Do I Do Now? Primary Spontaneous Pneumothorax Clinically stable AND 1st pneumothorax: < 2-3 cm (b/n lung and chest wall on CXR) Supplemental oxygen (4-6x faster resolution), observation Observe at least 6 hrs and DC if no progression on CXR > 3 cm OR symptomatic with chest pain and/or dyspnea Needle aspiration Clinically unstable OR recurrent OR hemothorax OR failed needle aspiration: Chest tube, consider thoracoscopy If PTX persists and can’t do thoracoscopy, chemical pleurodesis through CT It’s How Big?? What Do I Do Now? 2o Spontaneous Pneumothorax Stable, asympatomatic, or small PTA (<2 cm): oxygen and observe > 2 cm: chest tube (tube thoracostomy) Need to intervene sooner b/c of underlying lung disease Increases risk of persistent air leak and further expansion of pneumothorax Experts recommend that all patients being observed as an inpatient Tension Pneumothorax Immediate needle decompression 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 Oxygen Helps with quick reabsorption (6 fold) Needle Aspiration Place catheter and aspirate air If air return stops Place stopcock & repeat CXR in 4 hrs Ongoing air leak Tube Thoracoscopy Doesn’t work as well for secondary PTX So just do the tube Chest Tube Water seal +/- suction Use suction if PTX fails to resolve Monitor for air leak, lung expansion Clamp chest tube Repeat imaging 24 hours later Remove chest tube if stable Oh Dang, It Didn’t Work! Now What? Persistent Air Leak If there’s still an air leak after 3 days à be more aggressive If patient has at least 90% re-expansion: Attach Heimlich valve to CT VATS Blood patch or chemical pleurodesis If failure of Lung Re-expansion (< 90% reexpanded) VATS Video-Assisted Thoracoscopy (VATS) Stapling or wedge resection of bullae Obliterate pleural space Mechanical abrasion of pleura (gauze) Intra op insufflation of talc Laser abrasion of parietal pleura Oh Dang, It’s Back 25-50% of PSPs will recur Highest risk in first 30 days Risk is higher in SSP - More likely in those with blebs or bullae on high resolution CT Every one with RECURRENCE should undergo intervention to prevent another one VATS pleurodesis Reduced recurrence rate to < 5% (if done with bleb/bullae resection) Chemical pleurodesis via tube thoracostomy or pigtail catheter Reduces recurrence rate to < 25% Thoracotomy (less common, works better, but morbid) Choice depends on expertise of practitioner at each institution Stop smoking! Tension Pneumothorax Presentation Decreasing SaO2, PaO2, ScvO2 Tachycardia Elevated JVP / CVP Hyperresonance, decreased BS Increased IPP causes Further collapse Diaphragmatic depression More likely in vented than awake patients Treat as emergency 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
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