Spontaneous Pneumothorax, Empyema Thoraces SPONTANEOUS PNEUMOTHORAX Definition Types It is presence of air in the pleural cavity due to rupture of visceral pleura without an external traumatic or iatrogenic cause. Primary: Secondary: 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. CLINICAL PRESENTATION Management (THE INDICATION FOR SURGICAL INTERVENTION) 1. presents with sharp pleuritic pain and breathlessness. 2. Bleeding and tension pneumothorax can occur. 3. They are usually selflimiting; 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 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 presence of pus in pleural space. Causes Conditions that predispose to empyema formation: 1. Pulmonary infection 2. Aspiration of pleural effusion 3. Trauma 4. Extrapulmonary sources 5. Bone infections CLINICAL PRESENTATION 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 DIAGNOSIS 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 Pulmonary infection Aspiration of pleural effusion 1. 2. 3. 4. 5. Any aetiology Unresolved pneumonia Bronchiectasis Tuberculosis Fungal infections Lung abscess Definition + Management EMPYEMA THORACIS CAUSES Trauma Extrapulmonary sources 1. Penetrating injury 2. Surgery 3. Oesophageal perforation Subphrenic abscess PHASES OF EMPYEMA THORACIS and its management THE EXUDATIVE PHASE FIBRINOPURULENT PHASE • there is protein-rich (>30 g/l) the fluid thickens 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. at this stage, antibiotics may be drainage at this stage is prudent as all that is required. aspiration or antibiotics alone are unlikely to be drainage to dryness in addition curative. is preferred. Antibiotics & chest tube drainage Video assisted thoracoscopic debridement, chest tube drainage and antibiotics Bone infections Osteomyelitis of ribs or vertebrae THE ORGANISING PHASE CAUSES the lung to be trapped by a thick peel or ‘cortex’ for which surgical management may be required 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.
