Spontaneous Pneumothorax

Spontaneous Pneumothorax, Empyema Thoraces
SPONTANEOUS
PNEUMOTHORAX
Definition
Types
CLINICAL PRESENTATION
Management (THE INDICATION FOR
SURGICAL INTERVENTION)
It is presence
of air in the
pleural cavity
due to
rupture of
visceral
pleura
without
an external
traumatic or
iatrogenic
cause.
Primary:
Secondary:
1. presents with sharp
pleuritic pain and
breathlessness.
2. Bleeding and tension
pneumothorax can occur.
3. They are usually self-
limiting; careful observation is
wiser than
too-ready resort to a chest
drain.
4. if the patient is not in
respiratory distress or hypoxic,
there is no urgency.
5. Tension pneumothorax
should be immediately
relieved by inserting a cannula
into the hemithorax in to
second intercostal space.
An intercostal tube inserted in 5th intercostal
space mid axillary line in the triangle of safety
and connected to an underwater seal is central
to the management of chest disease.
Current recommendations from the British
Thoracic Society are that in cases of :
1. persistent air leak following drain
insertion
2. failure of the lung to re-expand,
an early (3–5 days) thoracic surgical opinion
should be sought.
OTHER INDICATIONS FOR SURGICAL
INTERVENTION FOR PNEUMOTHORAX
1. Second ipsilateral pneumothorax
2. First contralateral pneumothorax
3. Bilateral spontaneous pneumothorax
4. Spontaneous haemothorax
5. Professions at risk (e.g. pilots, divers)
6. Pregnancy
It is due to
leaks from
small blebs,
vesicles or
bullae, which
may become
pedunculated,
• typically at
the apex of
the upper
lobe or on
the upper
border of
the lower
or middle
lobes.
• Commonly
seen in
young
people.
This occurs
when the
visceral
pleura leaks
as part of an
underlying
lung disease;
including:
tuberculosis,
emphysema,
any
degenerative
or cavitating
lung disease
and necrosing
tumours.
• As such it
tends to
occur in
older
patients.

PROCEDURES FOR
DEFINITIVE
MANAGEMENT
PLEURECTOMY AND PLEURODESIS
Surgery for pneumothorax can be performed by video-assisted thoracoscopic surgery (vats) or as an open procedure
(thoracotomy).
The object of the exercise is three-fold:
1. To deal with any leaks from the lung;
2. To search for and obliterate any blebs and bullae (bullectomy);
3. To make the visceral pleura adherent to the parietal pleura so that any subsequent leaks are contained and the lung cannot
completely collapse.
Pleural adhesion is achieved in one of three ways:
1. pleurectomy: systematically strip the parietal pleura from the chest wall.
2. pleural abrasion: a scourer is used to scrape off the slick surface of the parietal pleura.
3. chemical pleurodesis: usually talc is used and is insufflated into the chest cavity.

EMPYEMA THORACIS
Definition
Causes
CLINICAL PRESENTATION
DIAGNOSIS
presence
of pus in
pleural
space.
Conditions that
predispose to
empyema formation:
1. Pulmonary
infection
2. Aspiration of
pleural effusion
3. Trauma
4. Extrapulmonary
sources
5. Bone infections
THREE PHASES OF EMPYEMA
THORACIS(below)
THE PATIENT'S HISTORY MAY REVEAL
THE FOLLOWING FINDINGS:
• Recent diagnosis and treatment
of pneumonia
• Recent history of penetrating
chest trauma or diaphragmatic
injury (should raise clinical
suspicion for empyema) [9]
• Cough productive of bloody
sputum that frequently has
offensive odour .
• Fever
• Shortness of breath
• Anorexia, weight loss
• Night sweats
• Pleuritic chest pain
When a pleural effusion is present, a diagnostic
thoracentesis may be performed and analyzed.
• The following findings are suggestive of an
empyema.
• grossly purulent pleural fluid
• Ph level less than 7.2
• WBC count greater than 50,000 cells/µl
(or polymorphonuclear leukocyte count of
1,000 iu/dl)
• Glucose level less than 60 mg/dl
• Lactate dehydrogenase level greater than
1,000 iu/ml
• Positive pleural fluid culture

EMPYEMA THORACIS CAUSES
Pulmonary infection
Aspiration of pleural
effusion
Trauma
Extrapulmonary sources
Bone infections
1. Unresolved pneumonia
2. Bronchiectasis
3. Tuberculosis
4. Fungal infections
5. Lung abscess
Any aetiology
1. Penetrating injury
2. Surgery
3. Oesophageal
perforation
Subphrenic abscess
Osteomyelitis of ribs or
vertebrae
PHASES OF EMPYEMA THORACIS and its management
THE EXUDATIVE PHASE
FIBRINOPURULENT PHASE
THE ORGANISING PHASE
Definition
• there is protein-rich (>30 g/l)
effusion.
• If this becomes infected with
the organisms from the lung
(typically streptococcus milleri
and haemophilus influenza in
children), the scene is set for
empyema.
the fluid thickens
CAUSES the lung to be trapped by a
thick peel or ‘cortex’
+
at this stage, antibiotics may be
all that is required. aspiration or
drainage to dryness in addition
is preferred.
drainage at this stage is prudent as
antibiotics alone are unlikely to be
curative.
for which surgical management may
be required
Management
Antibiotics & chest tube drainage
Video assisted thoracoscopic
debridement, chest tube drainage
and antibiotics
Decortication may be required. The
fibrous cortex or peel from the
entrapped underlying lung is
removed so that the lung can
expand to obliterate the pleural
space.