Difference between revisions of "Iatrogenic pneumothorax"

(Evaluation)
 
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===Causes<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010."  Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>===
 
===Causes<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010."  Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>===
 
*Transthoracic needle aspiration (24%)
 
*Transthoracic needle aspiration (24%)
*Subclavian vessel puncture (22%)
+
*[[central line: subclavian|Subclavian vessel puncture]] (22%)
*Thoracentesis (22%)
+
*[[Thoracentesis]] (22%)
 
*Pleural biopsy (8%)
 
*Pleural biopsy (8%)
*Mechanical ventilation (7%)
+
*[[Mechanical ventilation]] (7%)
  
 
==Clinical Features==
 
==Clinical Features==
 
''Consider in all patients with sudden [[Deterioration After Intubation (DOPE)|deterioration after intubation]]''
 
''Consider in all patients with sudden [[Deterioration After Intubation (DOPE)|deterioration after intubation]]''
 
*Sudden onset pleuritic [[chest pain]]
 
*Sudden onset pleuritic [[chest pain]]
*Tachypnea, hypoxemia, increased work of breathing
+
*[[Tachypnea]], [[hypoxemia]], increased work of breathing
 
*Reduced ipsilateral lung excursion
 
*Reduced ipsilateral lung excursion
*[[Hypotension]]→ tension pneumothorax
+
*[[Hypotension]]→ [[tension pneumothorax]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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===Unstable===
 
===Unstable===
*[[Needle decompresion]] followed by [[chest tube]] insertion
+
*[[Needle decompression]] followed by [[chest tube]] insertion
  
 
===Stable<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010."  Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>===
 
===Stable<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010."  Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>===
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====On Positive Pressure Ventilation====
 
====On Positive Pressure Ventilation====
*[[Needle decompresion]] followed by [[chest tube]] insertion
+
*[[Needle decompression]] followed by [[chest tube]] insertion
  
 
{{Needle aspiration of pneumothorax}}
 
{{Needle aspiration of pneumothorax}}

Latest revision as of 16:09, 12 October 2019

Background

Causes[1]

Clinical Features

Consider in all patients with sudden deterioration after intubation

Differential Diagnosis

Pneumothorax Types

Evaluation

Clinically Stable

Defined as having all of the following:

  • Resp rate < 24
  • Heart rate 60-120 beats per minute
  • Normal BP
  • SaO2 >90% on room air and patient can speak in whole sentences

Workup

Pneumothorax.jpeg
  • CXR
    • Displaced visceral pleural line without lung markings between pleural line and chest wall
    • Upright is best
      • Expiratory films DO NOT improve accuracy[2]
      • Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
    • Supine CXR = deep sulcus sign
  • CT Chest
    • Very sensitive and specific

Lung ultrasound of pneumothorax

  • No lung sliding seen (not specific for pneumothorax)
  • May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
  • Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
    • NO comet tail artifact
    • Bar Code appearance on M-mode (absence of "seashore" waves)

Management

Supplemental oxygen (non-rebreather mask) initially for all

Unstable

Stable[1]

Not on Positive Pressure

  • Observation (majority) vs. aspiration
  • Chest tube if become symptomatic

On Positive Pressure Ventilation

Needle Aspiration of Pneumothorax

  • Use thoracentesis or "pig-tail" kit, if available
  • Place in 2nd IC space in midclavicular line or 4th/5th IC space in anterior axillary line
  • Withdraw air with syringe until no more can be aspirated
    • Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
  • Once no further air can be aspirated:
    • Option 1
      • Place closed stopcock and secure catheter to the chest wall
      • Obtain CXR four hours later
      • If adequate lung expansion has occurred, remove catheter
      • Following another two hours of observation, obtain another CXR
      • If the lung remains expanded, may discharge patient
    • Option 2
      • Leave catheter in place
      • Attached a Heimlich (one-way) valve
      • May discharge with follow-up within two days
  • If 2.5 L of air has been aspirated, and a significant PTX remains, tube thoracostomy is indicated

Adult Chest Tube Sizes

Chest Tube Size Type of Patient Underlying Causes
Small (8-14 Fr)
  • Alveolar-pleural fistulae (small air leak)
  • Iatrogenic air
Medium (20-28 Fr)
  • Bronchial-pleural fistulae (large air leak)
  • Malignant fluid
Large (36-40 Fr)
  • Bleeding (Hemothorax/hemopneumothorax)
  • Thick pus

Disposition

  • See Management section

See Also

External Links

References

  1. 1.0 1.1 "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010." Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF
  2. Eur Respir J. 1996 Mar;9(3):406-9