pneumothorax case presentaion

1. PNEUMOTHORAX CASE
PRESENTATION
By Dr. Ashish kumar
Santosh Medical college and hospital.

2.  50 year old male Jameel chronic smoker known case of COPD ,
shopkeeper by occupation ,married , having 3 childrens, referred
to us from medicine dept. on 11/06/18 with c/o
 acute dyspnea - 3 days
 acute lt. chest pain - 3 days
 Dyspnea :was progressive in nature
 aggravated on cough and not relieved by rest ,
 does not increase on lying down or change in position.
 No H/o variation in severity of dyspnea with time ie diurnal variation or PND.
 Lt. chest pain: was sharp and stabbing in nature,
 acute onset, non radiating , not associated with sweating, vomiting and
palpitation.
 Pain aggravated on deep breathing & coughing ,relieved on lying in left
decubitus position .

3.  Past Hx :
 He was known case of COPD , on medication DPI- tiotropium,
formetrol and budesonide since 2 years.
 No H/O of tuberculosis or any other respiratory problem in the
past other than COPD.
 No H/o HTN /DM/any surgery / any chest trauma

4.  Personal Hx :
 Smoker for past 30 years , 10 sticks per day approx.
 Smoking index 300,
 15 pack year.
 No H/o Bowel and bladder habits alteration
 No H/o alcohol intake and other substance abuse
 Family Hx:
 No H/o hypertension , diabetes , tuberculosis in family
 Occupational Hx:
 provisional store shopkeeper
 Social Hx: Poor socioeconomic status.

5. GENERAL PHYSICAL EXAMINATION
 Patient was dyspneic, Conscious, oriented to time place and
person
 BP :130/80 mmHg
 Pulse :118 bpm
 Respiratory rate : 28/ min
 SPO2 : 76 %
 Temp: Afebrile
 P-I-CY-C-L-E- not present
 JVP not raised

6. INSPECTION
 Trail’s sign positive trachea shifted to right.
 Asymmetrical chest, Bulging of the left chest from apex to
base anteriorly and posteriorly.
 Accessory muscles of respiration are hyperactive.
 Asymmetrical and unequal movement of the chest.
 Thoraco-adominal movement.
 Respiration was shallow and rapid @ 28 / min.
 Pursed lip breathing was present
 No visible vein, scar ,edema and swelling over chest
 Apex beat is 3.5 cm right to MCL.
 Retraction of subcostal margins.
 Widening of intercostal space not appreciated on inspection.

7. INSPECTION Rt chest movements Lt chest movements
Supraclavicular Normal Diminished
Infra clavicular Normal Diminished
mammary Normal Diminished
Axillary Normal Diminished
Infra-axillary Normal Diminished
Supra scapular Normal Diminished
Inter-scapular Normal Diminished
Infra-scapular Normal Diminished

8. PALPATION
 All inspection finding confirmed by palpation
 No localized tenderness and raised tem. present.
 No parasternal heave.
 Trail’s sign confirmed on palpation, trachea shifted
to right side.
 Bulging present on left chest from apex to base
anteriorly and posteriorly
 Apex impulse shifted 3.5 cm Rt. From MCL.
 Chest expansion : 2.5 cm

9. PALPATION Rt TVF /chest
movements &
expansion
Lt TVF / chest movements
& expansion
Supraclavicular Normal Diminished
Infra clavicular Normal Diminished
mammary Normal Diminished
Axillary Normal Diminished
Infra-axillary Normal Diminished
Supra scapular Normal Diminished
Inter-scapular Normal Diminished
Infra-scapular Normal Diminished

10. PERCUSSION Rt Lt
Supraclavicular
(Kronig’s Isthmus)
Resonant Hyper-resonant
Direct Clavicular
percussion
Resonant Hyper-resonant
Infra clavicular Resonant Hyper-resonant
Mammary Resonant Hyper-resonant
Axillary Resonant Hyper-resonant
Infra-axillary Resonant Hyper-resonant
Supra scapular Resonant Hyper-resonant
Inter-scapular Resonant Hyper-resonant
Infra-scapular Resonant Hyper-resonant
Liver dullness in 6th ICS Traube’s area masked

11. PERCUSSION
 Cardiac dullness could not be appreciated
 Basal percussion – lower border of left lung
resonance was depressed one space below.

12. Auscultation
Rt. breath sound /vocal
resonance
Lt. breath sound
/vocal resonance
Supraclavicular NVBS / Normal Diminished
Infra clavicular NVBS / Normal Diminished
Mammary Rhonchi + / Normal Diminished
Axillary Rhonchi + / Normal Diminished
Infra-axillary Rhonchi + / Normal Diminished
Supra scapular NVBS / Normal Diminished
Inter-scapular Rhonchi + / Normal Diminished
Infra-scapular Rhonchi + / Normal Diminished
Scratch sign : positive on left side
Coin test : positive on left side

14. H
L

15. PNEUMOTHORAX CALCULATION
 Light index
pneumothorax %= L3
H3
X 100
L is collapsed lung = 6.7 cm
H is diameter of hemithorax = 8cm
1-
Pneumothorax %=(1- 300/512) x 100
= (1-.58) X 100
=41%

16. WHAT WE DID ?
 Tube Thoracostomy.
 24 Fr Malecot catheter was inserted after taking
consent, under all aseptic conditions in left 5th
intercostal space, under local anaesthesia &
connected to under water seal drainage bag.
 Post Procedure Chest X-Ray showed expansion of
lung.

17. 11/06/18

18. • After lung has Re expanded, There was no bubbling
through water-sealed bag that indicates there was no air
leak.
• Tube was clamped at night and patient was monitored for
the symptoms and patient had no discomfort.
• Xray was repeated with clamped tube on the next
morning.
• The ICD was removed after confirming the expansion of
lung clinically and radiologically.
• Post ICD removal X-ray showed expansion of left lung.

19. 13/06/18

20. POST EXTUBATION
 Post extubation we evaluated the patient.
dyspnea improved.
No discomfort till evening
BP was 130/70
Spo2 93%
RR- 18/min
.

21. DISCHARGED
 On Xray Lung re-expansion Confirmed
 Patient vitals was stable
o Patient discharged and advised
1. Antibiotics – Tab. Amoxclav 625 bd, Tab.
Metrogyl 400 tds for 7 days.
2. Bronchodilators- DPI. Formeterol and Budesonide
3. DPI Salbutamol
4. Breathing exercises-
5. Advised to Avoid straining, heavy weight
lifting
6. Review after 1 week

22. REVIEWED AFTER 1 WEEK
 Patient had no fresh complaints
 Vitals stable
 On Xray re expansion confirmed.

23. Thank you

25. pneumothorax
Spontaneous
Primary
Secondary
Traumatic
Non Iatrogenic
(trauma)
Iatrogenic
Pneumothorax
Undrlying disease
COPD,T.B, etc
No under lying dz
i.e rupture of
subpleural bleb

26. CLASSIFICATION
1. Spontaneous
# Primary
- No evidence of overt lung disease
- occurs in males aged 15-30
- air escapes from the lung into the pleural
space through rupture of a small emphysematous
bulla or pleural bleb
- smoking, tall stature & the presence of apical subpleural
blebs are additional risk factors

27. #SECONDARY
- underlying lung disease
- occurs mainly in males above 55 yrs
- most commonly COPD & TB
- also seen in asthma, lung abscess, pul infarcts,
bronchogenic carcinoma, all forms of fibrotic &
cystic lung disease

28. 2.TRAUMATIC
 iatrogenic ( from thoracic surgery or biopsy)
 chest wall injury ( blunt trauma , stab injury)

29. TYPES OF PNEUMOTHORAX
1. Closed spontaneous pneumothorax
2. Open spontaneous pneumothorax
3. Tension pneumothorax

32. CLOSED TYPE
 Communication b/n airway and the pleural space seals off
as the lung deflates
 Mean pleural pressure remains negative
 Spontaneous reabsorption of air & re-expansion of lung
occur over a few days or weeks
 Infection uncommon

33. OPEN TYPE
 Communication b/n pleura & bronchus doesn’t
seals off (Bronchopleural fistula)
 Intra pleural pressure = atm. Pressure
 Collapsed lung, no re expansion
 Transmission of infection from the airways into
the pleural space through fistula common
(empyema)

34. TENSION TYPE
 Communication b/n the airway & the pleural
space acts as a one-way valve allowing air
to enter the pleural space during inspiration
but not to escape on expiration.
 Large amt of air accumulates progressively in the
pleural space
 Intrapleural pressure increases above atm
pressure

35.  Pressure causes mediastinal shift towards the
opposite side with compression of the
opposite lung & impairment of systemic
venous return causing cardiovascular
compromise.

36. INVESTIGATIONS
Chest x ray
Shows : increased radiolucency, with absence of
bronchovascular markings
 extent of mediastinal shift.
 pleural fluid,if present .
 underlying pulmonary disease .

37. Management of pneumothorax

38. TRAUMATIC PNEUMOTHORAX
 Supplemental oxygen or aspiration done.
 Tube thoracostomy , if not improves.
 If hemo pneumothorax is present, 1 chest
tube should be placed in the superior part to
evacuate air, other should be placed in the
inferior part to remove blood.

39. INDICATIONS OF TUBE THORACOSTOMY
1. Pneumothorax
2. Malignant pleural effusion
3. Empyema
4. Hemopneumothorax
5. Post operative i.e thoracotomy , cardiac surgery.

40. COMPLICATION OF TUBE THORACOSTOMY
1. Hemothorax
2. Perforaton of visceral organ
3. Pleural infection
4. Sub cutaneous emphysema
5. Re-Expansion pulmonary edema.