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II. REFERENCE

A pneumothorax (noo-mo-THOR-acks) is a collapsed lung. Pneumothorax occurs when air

leaks into the space between your lungs and chest wall. This air pushes on the outside of your
lung and makes it collapse. In most cases, only a portion of the lung collapses.
A pneumothorax can be caused by a blunt or penetrating chest injury, certain medical
procedures involving your lungs, or damage from underlying lung disease. Or it may occur
for no obvious reason. Symptoms usually include sudden chest pain and shortness of breath.

CAUSES

The lungs normally inflate by increasing the size of the chest cavity, resulting in a negative
(vacuum) pressure in the pleural space (the area within the chest cavity but outside the lungs).
If air enters the pleural space either by a hole in the lung or the chest wall, the pressure in the
pleural space equals the pressure outside the body. Thus, the vacuum is lost and the lung
collapses.
Spontaneous pneumothorax is caused by a rupture of a cyst or a small sac (bleb) on the
surface of the lung. Pneumothorax may also occur following an injury to the chest wall such
as a fractured rib, any penetrating injury (gun shot or stabbing), surgical invasion of the chest,
or may be deliberately induced in order to collapse the lung. A pneumothorax can also
develop as a result of underlying lung diseases, including cystic fibrosis, chronic obstructive
pulmonary disease (COPD), lung cancer, asthma, and infections of the lungs.
Pneumothorax can be caused by:

Chest injuries. Any blunt or penetrating injury to your chest can cause lung collapse.
Some injuries may happen during physical assaults or car crashes, while others may
inadvertently occur during medical procedures that involve the insertion of a needle
into the chest.

Underlying lung diseases. Damaged lung tissue is more likely to collapse. Lung
damage can be caused by many types of underlying diseases, including chronic
obstructive pulmonary disease (COPD), cystic fibrosis and pneumonia.

Ruptured air blisters. Small air blisters (blebs) can develop on the top of your lung.
While not considered to be a disease of the lungs, these blebs sometimes burst
allowing air to leak into the space that surrounds the lungs.

Mechanical ventilation. A severe type of pneumothorax can occur in people who

need mechanical assistance to breathe. The ventilator can create an imbalance of air
pressure within the chest. The lung may collapse completely and the heart may be
squeezed to the point that it can't work properly.

RISK FACTORS
Spontaneous pneumothorax affects about 9,000 persons each year in the U.S. who have no
history of lung disease. This type of pneumothorax is most common in men between the ages

of 20 and 40, particularly in tall, thin men. Smoking has been shown to increase the risk for
spontaneous pneumothorax.
Risk factors for pneumothorax include:

Your sex. In general, men are far more likely to have a pneumothorax than are
women.

Smoking. The risk increases with the length of time and the number of cigarettes
smoked, even without emphysema.

Age. The type of pneumothorax caused by ruptured air blisters is most likely to occur
in people between 20 and 40 years old, especially if the person is a very tall and
underweight man.

Genetics. Certain types of pneumothorax appear to run in families.

Lung disease. Having an underlying lung disease especially chronic obstructive

pulmonary disease (COPD) makes a collapsed lung more likely.

Mechanical ventilation. People who need mechanical ventilation to assist their

breathing are at higher risk of pneumothorax.

A history of pneumothorax. Anyone who has had one pneumothorax is at increased

risk of another, usually within one to two years of the first episode.

SIGNS AND SYMPTOMS

Symptoms of a pneumothorax include chest pain that usually has a sudden onset. The pain is
sharp and may lead to feelings of tightness in the chest. Shortness of breath, rapid heart rate,
rapid breathing, cough, and fatigue are other symptoms of pneumothorax. The skin may
develop a bluish color (termed cyanosis) due to decreases in blood oxygen levels
A small, uncomplicated pneumothorax may quickly heal on its own. When the pneumothorax
is larger, doctors usually insert a flexible tube or needle between your ribs to remove the
excess air.

TEST AND DIAGNOSE

A pneumothorax is generally diagnosed using a chest X-ray. In some cases, computerized
tomography (CT) scan may be needed to provide more detailed images. CT scanners combine
X-ray images taken from many different directions to produce cross-sectional views of
internal structures.

TREATMENT
The goal in treating a pneumothorax is to relieve the pressure on your lung, allowing it to reexpand, and to prevent recurrences. The best method for achieving this depends on the
severity of the lung collapse and sometimes on your overall health.
Observation
If only a small portion of your lung is collapsed, your doctor may simply monitor your
condition with a series of chest X-rays until the air is completely absorbed and your lung has

re-expanded. Normally this takes a week or two. Supplemental oxygen can speed the
absorption process.
Needle or chest tube insertion
If a larger area of your lung has collapsed, it's likely that a needle or chest tube will be used to
remove the air. The hollow needle or tube is inserted between the ribs into the air-filled space
that is pressing on the collapsed lung. With the needle, a syringe is attached so that the doctor
can pull out the excess air just like a syringe is used to pull blood from a vein. Chest tubes
are often attached to a suction device that continuously removes air from the chest cavity.
Surgery
If a chest tube doesn't resolve your problem, surgery may be necessary to close the air leak.
In most cases, the surgery can be performed through small incisions, using a tiny fiber-optic
camera and narrow, long-handled surgical tools. The surgeon will look for the leaking bleb
and sew it closed. In some cases, a substance like talc may be blown in through the tube to
irritate the tissues around the lung so that they'll stick together and seal any leaks. Rarely, the
surgeon will have to make a larger incision between the ribs to get better access to multiple or
larger air leaks.

TUBERCULOSIS
TB is a infection disease that caused of mycobacterium tuberculosis. The spots of TB
infection germ are respiratory tracts, absorption tracts and opened injury in skin. Most of TB
infection occur pass through air , by means of droplet inhalation that consist of basil which
come from person who infected. The spreading capacity from a sufferer is depended on the
number of germ that issued from the lung.someone might be infected by TB from the droplet
concentration in the air, and how long they breath that air.
TB is a disease that controlled by imunity response insequenced cell. Efector cells are
macrofag and limfosit ( usually T cell ). They are imunoresponsive cells. This type usually
local, involving macrofag which actived in infection spot by limfosit and its limfokin. The
response is called as hypersensitivity cellular reaction ( slow reaction )

CLASSIFICATION OF TBC BASE ON THE HISTORY

1. Primary TBC
its happen when someone attack primarly by TBC germ. The infection started when
the TBC germ replicated successfully in the lung. Thats cause the inflammation. Limfe
tractus will carry TBC germ into limfe gland around lung hilus and it.s called as primary
complexs.
Time between infection happens until primary complexs form are around 4 6 weeks.
The infection cold be proven by by the occur of tuberculin reaction that changes from
negative into positive. The incubation period is time needed from infected till become
sick, approximated for about 6 month.
2. After Primary TBC
Usually happen after several month or year. After primary infection, for example
because of the descent body defense in consequence infected by HIV or malnutrient
status. The main characteristic for after primary TBC is the broadening lung damage in
occurring cavity or pleural effusion.

Primary Progressive Tuberculosis

Active tuberculosis develops in only 5% to 10% of persons exposed to M tuberculosis. When
a patient progresses to active tuberculosis, early signs and symptoms are often nonspecific.
Manifestations often include progressive fatigue, malaise, weight loss, and a low-grade fever
accompanied by chills and night sweats.22 Wasting, a classic feature of tuberculosis, is due to
the lack of appetite and the altered metabolism associated with the inflammatory and immune
responses. Wasting involves the loss of both fat and lean tissue; the decreased muscle mass
contributes to the fatigue.23 Finger clubbing, a late sign of poor oxygenation, may occur;
however, it does not indicate the extent of disease. 24 A cough eventually develops in most
patients. Although the cough may initially be nonproductive, it advances to a productive
cough of purulent sputum. The sputum may also be streaked with blood. Hemoptysis can be
due to destruction of a patent vessel located in the wall of the cavity, the rupture of a dilated
vessel in a cavity, or the formation of an aspergilloma in an old cavity. The inflamed
parenchyma may cause pleuritic chest pain. Extensive disease may lead to dyspnea or
orthopnea because the increased interstitial volume leads to a decrease in lung diffusion
capacity. Although many patients with active disease have few physical findings, rales may
be detected over involved areas during inspiration, particularly after a cough. Hematologic
studies might reveal anemia, which is the cause of the weakness and fatigue. Leukocytosis

may also occur because of the large increase in the number of leukocytes, or white blood
cells, in response to the infection.7
PATOGENENCY
The risk factor are :
1. must have infection sorce
2. the number of bacillus as an infection cause must be sufficient
3. the high virulence of TBC bacillus
4. The descent of body defense make the bacillus reproduce
Clinic illustration :
1. The main symptom
Continous cough with/without sputum during 3 weeks or more
2. Additional symptom
- Sputum mixed with blood
- Haemoptoe
- Dyspnea and chest pain
- Weakness
- Night sweat
- Decrease weight
- Feverish fever more than 1 month
DIAGNOSIS
Lung TBC diagnosis can be stood at by BTA finding in sputum inspection microscopicly. The
inspection result tangibled positive if at least 2 from 3 SPS specimen must be positive.
If only 1 specimen which positive, so its needed a further check up, that is chest x-ray photo
or SPS sputum check up repeated.
a. If the x-ray result supports TBC, so the patient is diagnosed as TBC BTA sufferer
positive
b. If the x-ray result unsupports TBC, so the sputum check up repeated
If three sputum specimen are negative, give an extensive spectrum antibiotic during 1-2
weeks. If the condition still bad, do SPS sputum check up repeated.
a. If the SPS result are positive, diagnosed as infection TBC BTA infected
b. If the SPS result are still negative, do thr chest X-ray check up.
If the X-ray result supports TBC, diagnosed as negative BTA patient but the

X-ray positive
If the X-ray result not supports TBC, the patient is not TBC.

MEDICAL TREATMENT
Purpose :
1. Cure the patient
2. Prevent death

3. Prevent relapse
4. Decreasing the level of spreading
Category 1 (2HRZE/4H3R3) :
New patient lung TBC positive BTA
Patient lung TBC negative BTA, X-ray positive who got serious illness
Patient heavy extra lung TBC
Intensive stage consist of Isoniasid(H), Rifampicin(R), Pirazinamid(Z), dan Etambutol(E).
Those medicine are given everyday during two (2) month (2HRZE). Then continued by next
stage, that consists of Isoniasid(H), and Rifampicin(R). Given three times a week during four
month (4H3R3).
Category 2 (2HRZES/HRZE/5H3R3E3) :
Relaps patient
Failure patient
After default patient
Intensive stage are given for three month consists of HRZES during 2 month given
everyday (2HRZES), continued by HRZE during 1 month given every day (HRZE). Then
continued by next stage that consists of HRE during 5 month given 3 times a week.
Category 3 (2HRZES/4H3R3) :
New patient BTA negative and X-ray positive, light ill.
Patient extra light lung, it is TBC limfadenitis, pleuritis eksudativa unilateral, skin
TBC, bone TBC (except backbone), joint TBC and adrenal gland.
Intensive stage consist of HRZ, given everyday during 2 month(2HRZ), continued by sequel
stage that consist of HR during 4 month given 3 times a week(4H3R3). One packet of
Combipac 3rd category contents of 114 daily blister that consist of 60 blister HRZ for the
intensive stage and 54 blister HR for the sequel stage each packed in a small doss and
bounded in a big doss.
Implied OAT (HRZE)
If the end of intensive treatment of new patient BTA positive in 1 st category or patient BTA
positive retreatment by category 2nd, sputum check up result still BTA positive (positive
BTA), given medical implied (HRZE) everyday during 1 month.
COMPLICATION OF TUBERCULOSIS
Without treatment, tuberculosis can be fatal. Untreated active disease typically affects your
lungs, but it can spread to other parts of the body through your bloodstream. Examples
include:
Bones. Spinal pain and joint destruction may result from TB that infects your bones. In
many cases, the ribs are affected.

Brain. Tuberculosis in your brain can cause meningitis, a sometimes fatal swelling of the

membranes that cover your brain and spinal cord.

Liver or kidneys. Your liver and kidneys help filter waste and impurities from your
bloodstream. These functions become impaired if the liver or kidneys are affected by

tuberculosis.
Heart. Tuberculosis can infect the tissues that surround your heart, causing inflammation
and fluid collections that may interfere with your heart's ability to pump effectively. This
condition, called cardiac tamponade, can be fatal.