Spontaneous pneumothorax: Difference between revisions
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==Management== | ==Management== | ||
=== | ===Initial Management=== | ||
*Observation alone | *Observation alone | ||
*Observation + oxygen, | *Observation + oxygen, | ||
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**Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated | **Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated | ||
**Underwater seal drainage is adequate (suction only necessary if persistent air leak) | **Underwater seal drainage is adequate (suction only necessary if persistent air leak) | ||
===Stable, First Episode=== | |||
*Small AND asymptomatic(≤2 to 3 cm between the lung and chest wall on a chest radiograph) | |||
**Supplemental oxygen and observed | |||
*Large OR symptomatic (>3 cm rim of air on chest radiograph) | |||
**Aspiration | |||
***If fail aspiration, chest tube and thoracoscopy^ | |||
===Stable, Recurrent OR Hemopneumothorax=== | |||
*Chest tube + thoracoscopy^ | |||
===Unstable=== | |||
*[[Needle decompresion]] followed by [[chest tube]] insertion | |||
^if thoracoscopy is not readily available, chemical pleurodesis through the chest tube | |||
====Primary Spontaneous Pneumothorax==== | ====Primary Spontaneous Pneumothorax==== | ||
Revision as of 12:37, 13 May 2015
Background
- Primary Pneumothorax
- Spontaneous ptx in pt w/o underlying pulm disease
- Secondary Pneumothorax
- Spontaneous ptx in pt w/ underlying pulm disease
- Worse prognosis
Causes
- Smoking
- COPD
- Asthma
- Cystic fibrosis
- Necrotizing pneumonia
- Lung abscess
- PCP PNA
- TB
- Neoplasm
- Interstitial lung disease
- Connective tissue disease
- Pulmonary infarct
Clinical Features
- Sudden onset pleuritic chest pain evolving to dull constant ache over days
- Most often occurs at rest, not during exertion
- Tachypnea, hypoxemia, increased work of breathing
- Reduced ipsilateral lung excursion
- Hypotension -> tension pneumothorax
Differential Diagnosis
Pneumothorax Types
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Diagnosis
- CXR
- Displaced visceral pleural line w/o lung markings between pleural line and chest wall
- Air fluid level with Pleural Effusion = ptx
- Supine CXR view shows deep sulcus sign
- CT Chest
- Very sensitive and specific
- Ultrasound: Lungs
- NO comet tail artifact
- No sliding lung sign
- Bar Code (instead of waves on the beach) appearance on M-mode
Size
- Small: <3cm apex to cupola (chest wall)
- Large: >3cm lung apex to cupola (chest wall)
Management
Initial Management
- Observation alone
- Observation + oxygen,
- Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
- Needle or catheter aspiration
- Needle/catheter aspiration is as effective as chest tube for small ptxs
- Place in 2nd IC space in midclavicular line or 4th/5th IC space in ant axillary line
- If lung fails to expand can try 2nd aspiration attempt, Heimlich valve, or chest tube
- Needle/catheter aspiration is as effective as chest tube for small ptxs
- Tube thoracostomy
- Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated
- Underwater seal drainage is adequate (suction only necessary if persistent air leak)
Stable, First Episode
- Small AND asymptomatic(≤2 to 3 cm between the lung and chest wall on a chest radiograph)
- Supplemental oxygen and observed
- Large OR symptomatic (>3 cm rim of air on chest radiograph)
- Aspiration
- If fail aspiration, chest tube and thoracoscopy^
- Aspiration
Stable, Recurrent OR Hemopneumothorax
- Chest tube + thoracoscopy^
Unstable
- Needle decompresion followed by chest tube insertion
^if thoracoscopy is not readily available, chemical pleurodesis through the chest tube
Primary Spontaneous Pneumothorax
- Small size, clinically stable
- Option 1: Observe for 6hr; d/c if no sx and have pt return in 24hr for recheck
- Option 2: Small-size catheter (<14F) or needle aspiration with immediate catheter removal
- Then observe for 6h; d/c if no sx and have pt return in 24hr for recheck
- Option 3: Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
- Large size or bilateral
- Mod-size chest tube (16-22) and admit; large-size chest tube (24-36) if hemothorax
Secondary Pneumothorax
- Small size, clinically stable
- Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
- Observation alone associated with some mortality
- Large size or bilateral
- Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax
Disposition
Special Instructions
Flying
- Patients can consider flying 1 week after resolution of pneumothorax [1]