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The Chest: Pneumothorax, Hemothorax, Effusions, & Empyema Bradley J. Phillips, M.D. Burn-Trauma-ICU Adults & Pediatrics Pneumothorax definition, classification, & management Pneumothorax (1) collection of air within the pleural space • transforms the potential space into a real one • may lead to various degrees of respiratory compromise • with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario • impairs respiratory function • decreases venous return to the right-side of the heart Pneumothorax (2) • General Management – First: evacuate the air – Second: address the underlying source – Third: promote pleural symphysis Pneumothorax (3) Classification System • Spontaneous Pneumothorax – Primary – Secondary • Traumatic Pneumothorax – Pulmonary source – Tracheobronchial source – Esophageal source Pneumothorax (4) • Primary Spontaneous Ptx – a disease of younger individuals (15 - 35 yrs of age) – males > females – tall, slim body habitus – cigarette smoking implicated – usual cause: parenchymal blebs • apex of the upper lobe • superior segment of the lower lobe Pneumothorax (5) • Primary Spontaneous Ptx: “in most instances, the treatment of a first-occurrence consists of hospitalization, tube-thoracostomy to closed drainage, lung-re-expansion against the chest wall, and control of any persistent air-leak” [Graeber „98] Pneumothorax (6) when do you operate on a primary spontaneous pneumothorax ? Pneumothorax (7) • Secondary Ptx: due to underlying pulmonary disease – COPD / Asthma / Cystic Fibrosis – Immunocompromised Infections • Tb & Cocci • PCP (becoming more common) – Treatment: Closed Thoracostomy • Water-seal • Heimlich-Flutter Valve • V.A.T.S. Pneumothorax (8) Traumatic Ptx • Parenchymal Injury vs. Tracheobronchial vs. Esophageal – Blunt or Penetrating – Iatrogenic • central lines / thoracentesis / biopsy • endotracheal tube placement (esp. dual-lumen tubes !) • endoscopy / dilational techniques – Barotrauma • Ventilation / blast injury / Boerhave‟s syndrome – Operative Pneumothorax (9) • The Tension Ptx – “path of least resistance” – life-threatening emergency…how do you treat a tension ptx ?? • The Open Ptx: sucking-chest wound – intrinsic lung compliance creates complete collapse – 3-sided dressing – thoracostomy away from the traumatic wound Pneumothorax (10) • Treatment Options – Observation: Inpatient vs. Outpatient – Thoracostomy Drainage • 3rd Interspace / 5th Interspace • Negative Suction / Water-seal – V.A.T.S. (becoming the “standard”) – Muscle-sparing Thoracotomy – Posterolateral & Anterolateral Thoracotomy Pneumothorax (11) Questions ? Pneumothorax (12) Questions…well, I have some - 1. What is the best diagnostic study ? 2. What is the role of “100 % Oxygen” & “Conservative-mgmt” ? 3. How would YOU treat a small Ptx (1 cm) in acute trauma ? 4. What is the predicted recurrence rate for a spontaneous Ptx ? 5. What is a “deep sulcus sign” ? Pleural Effusions what are they ? where do they come from ? & how do you treat them ? Definition the accumulation of excess fluid within the pleural space in response to injury, inflammation, or both may represent a local response to disease or may just be a manifestation of a systemic illness Pathogenesis of Effusions Rate of Fluid Rate of Fluid Accumulation Removal 1. Altered Pleural Membrane Permeability 2. Decreased Intravascular Oncotic Pressure 3. Increased Capillary Hydrostatic Pressure 4. Lymphatic Obstruction 5. Abnormal Sites of Entry Clinical Manifestations • Pain • Cough • Dyspnea • Dullness to Percussion • Diminished or Absent Vocal Resonance • Diminished or Absent Tactile Vocal Fremitus • Friction Rub Clinical: A Few Points Large Effusions that prevent contact between the Visceral & Parietal Pleura during respiration are seldom associated with pleuritic chest pain. • Tumors involving the parietal pleura generally produce constant dull pain (Remember Ben Daly, M.D.) • Large effusions interfere with expansion of the lung and produce dyspnea, shortness of breath, and atelectasis Radiologic Assessment (1) • Chest X-Ray: PA & Lateral-Decub blunting of either costophrenic angle is indicative of the accumulation of between 250 - 500 ml of fluid • Lateral-Decubitus films (that allow fluid to shift to the dependent portion of the thoracic cavity) help differentiate fluid from pleural thickening & fibrosis • Sub-Pulmonic Effusion: accumulation of fluid between the lung & the diaphragm which gives the false impression of an elevated hemi- diaphragm Radiologic Assessment (2) • Ultrasound: Helpful in Confirming the Presence of a Small Pleural Effusion & Identifying Loculations • C.T. : Extremely Sensitive !! • also helps to view the underlying lung (which may be obscured by pleural disease) • can distinguish between Lung Abscess & Empyema Pleural Fluid Analysis Thoracentesis = Pneumothorax Pleural Fluid Analysis Thoracentesis: Transudate vs. Exudate 1. Gross Appearance 2. Cell Count & Differential 3. Gm Stain, C & S 4. Cytology 5. LDH 6. Protein 7. Glucose, Amylase Transudate straw-colored, clear, odorless fluid with a WBC less than 1000 / ul • Pleural Membranes are Intact • Secondary to Altered Starling Forces • Low in Protein & other Large Molecules CHF, Cirrhosis, Nephrotic Syndrome Hypoalbuminemia, Constrictive Pericarditis, SVC Obstruction, PE Exudate • Characterized by Increased Protein & LDH [Pleural Fluid vs. Serum Levels] • Secondary to Disruption of Pleural Membrane or Obstruction of Lymphatic Drainage Parapneumonic, Infections, Malignancy, Vasculitic Disease, GI Disease, TB, PE Criteria for “Exudative Effusion” criteria value 1. Pleural Protein : Serum Protein > 0.5 2. Pleural LDH : Serum LDH > 0.6 3. Pleural LDH > 200 only need 1 critical value to establish the diagnosis of exudate a bloody pleural effusion occurring in a patient without a history of trauma or pulmonary infarction is Indicative of Neoplasm in 90 % of cases! Because a RBC count as low as 5000 - 10,000 /ul, can cause a pleural effusion to turn red, the finding of blood-tinged fluid per se has little diagnostic value (usually from needle trauma) A True Hemothorax is when the Pleural Fluid Hct exceeds 50 % of the Peripheral Blood Hct ! Treatment • Transudative Effusion: focus on the systemic cause • Exudative Effusion: dependent on the exact sub-type • Consider Chest Thoracostomy • Gross Pus / Empyema • pH < 7.2 • Hemothorax • Complicated Parapneumonic Processes • Malignant Effusions…but remember the role of pleurodesis! although pleural disease itself is rarely fatal, it may be a significant cause of patient morbidity appropriate treatment may produce dramatic symptomatic relief ! Pleural Effusions Questions ? Hemothorax “ the collection of blood between the visceral and parietal pleura…” Hemothorax (1) • Causes of a Spontaneous Hemothorax – Pulmonary: bullous emphysema, PE, infarction, Tb, AVM‟s – Pleural: torn adhesions, endometriosis – Neoplastic: primary, metastatic (melanoma) – Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation – Thoracic Pathology: ruptured aorta, dissection – Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum Hemothorax (2) The Pathophysiologic Process • the accumulation of pleural blood forms a stable clot • overall ventilation & oxygenation becomes impaired • mechanical compression of the lung parenchyma • mediastinal shift • flattening of the hemidiaphragm Hemothorax (3) The Pathophysiologic Process • over time, the clot is partially-absorbed, leaving behind loculated fluid and fibrinous septations • macro-fibrin deposition begins to provide a structural framework • this “peel” slowly contracts to entrap the underlying lung Hemothorax (5) Goal of Treatment to remove the pleural blood and allow for complete lung re-expansion Hemothorax (4) • General Management Options – thoracentesis: bedside / ultrasound-guided / C.T.-guided – thoracostomy drainage: the mainstay – thorascopic surgery: less than 2 wks. & use a 30-degree scope – thoracotomy: massive hemothorax / instability / chronic hemothorax – local fibrinolytic therapy: urokinase (1000 IU/ml) in 150cc solution Hemothorax (6) • Often, there is an accompanying pneumothorax – Dual Chest Tube Management • Superior-Apical: Ptx • Diaphragmatic-posterior: Htx • Consider targeted-drainage into a loculated collection – All tubes to negative suction with protective water-seal – Prophylactic antibiotics may be indicated while the tubes are in (controversial!!) – Chest tubes removed: 100 -150 cc‟s / day Hemothorax (6) Undrained hemothorax increases the risk of empyema & fibrothorax • Large collections should be drained slowly to minimize the development of re-expansion-pulmonary-edema [“R.E.E.P.”] (stop after 2 liters…wait 6-8 hrs, then drain out another 1-2 liters, etc) • Computed tomography is the diagnostic of choice Hemothorax Questions ? Hemothorax Questions…well, I have some – 1. When do YOU operate on a “Traumatic Hemothorax” ? 2. What options exist in trying to drain a hemothorax (chest tube placement) ? 3. What are the reported complications of chest tube placement ? What is an Empyema ? Empyema Thoracis An Accumulation of Pus in the Pleural Cavity • 1-2 % incidence in the pediatric population • Up to 18 % in immunocompromised adults • General Management – Appropriate Antibiotic Coverage – Thoracostomy Drainage – Streptokinase / Urokinase – Surgical Intervention - Decortication The Stages of Empyema • Stage I - “Exudative” • sterile pleural fluid develops secondary to inflammation without fusion of the pleura • Stage II - “Fibrinopurulent” • a fibrinous peel develops on both pleural surfaces limiting lung expansion • Stage III - “Organizing” • in-growth of capillaries & fibroblasts into the fibrinous peel Empyema: A Pediatric Review # of 500 Cases # of Positive Cultures Staph 0 aureus Strep pneumo Staph aureus # of Positive Cultures # of Cases Strep pneumo Empyema... Questions ? “don’t let it happen !!!” The Chest: Pneumothorax, Hemothorax, Effusions, & Empyema Any Questions…?
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