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PNEUMOTHORAX
NURFARAHANI
CLASSIFICATION
Spontaneous pneumothorax has no
antecedent traumatic or iatrogenic cause
Can be divided into 2 types:
Where there is no underlying lung
secondary disesase
Eg: COPD and pneumonia
Primary pneumothorax
A primary spontaneous pneumothorax is one which
occurs in a patient with no known underlying lung
disease. Tall and thin people are more likely to
develop a primary spontaneous pneumothorax.
There may be a familial component, and there are
well associations:
Marfan syndrome
Ehlers-Danlos syndrome
alpha-1 antitrypsin deficiency
homocystinuria
Secondary pneumothorax
When the underlying lung is abnormal, a pneumothorax is referred to as secondary
spontaneous. There are many pulmonary diseases which predispose to pneumothorax
including:
cystic lung disease
emphysema, asthma
pneumocystis jiroveci pneumonia (PJP)
honeycombing: end stage interstitial lung disease
lymphangiomyomatosis (LAM)
Langerhans cell histiocytosis (LCH)
due to apical lung changes from ankylosing spondylitis
cystic fibrosis
parenchymal necrosis
lung abscess, necrotic pneumonia, septic emboli, fungal disease, tuberculosis
cavitating neoplasm, metastatic osteogenic sarcoma
radiation necrosis
other
catamenial pneumothorax: recurrent spontaneous pneumothorax during menstruation, associated
with endometriosis of pleura
rarely pleuroparenchymal fibroelastosis
Catamenial pneumothorax
Occur in conjunction of menstruation
Caused primarily by endometriosis of pleura
Occur in woman aged 30-40 yrs old
Begins 1-3 day after menses onset
Pathophysiology:
Endometrial tissue attaches within the thoracic cavity, forming
chocolate-like cysts
The mechanism through which endometrial tissue reaches the
thorax remains unclear.
The cysts can release blood; the endometrial cyst "menstruates" in
the lung. Air can move in by an unknown mechanism. The blood and
air cause the lung to collapse (i.e. catamenial hemopneumothorax)
CLINICAL FEATURE
Chest pain (sharp and pleuretic)
Dyspnea
Tachycardia
Tachpnoea
The diagnosis of
pneumothorax is
established by
demonstrating the outer
margin of the visceral
pleura (and lung), known as
the pleural line, separated
from the parietal pleura
(and chest wall) by a lucent
gas space devoid of
pulmonary vessels.
The presence of a deep
costophrenic angle on a
supine film may be the only
sign of pneumothorax; this
has been termed the deep
sulcus sign. The supine
radiograph is of particular
importance in trauma or
critically ill patients.
The most common
radiographic
manifestations of
tension
pneumothorax are
mediastinal shift,
diaphragmatic
depression, and rib
cage expansion.
Bullae vs pneumothorax
Bullae is the air-filled space in the lung parenchyma
due to destruction of alveolar tissue, distal to terminal
bronchiole
Bullae may be mistaken from loculated pneumothorax
The pleural line caused by pneumothorax is usually
bowed at its centers towards lateral chest wall but
inner margins of bullae is generally concave rather
than convex
DD by comparison with previous xray, or CT scanning
USG
A portable ultrasound machine with a high-
frequency (5-10 MHz) linear probe is typically
used.
Examination should begin with the patient in a
supine position and at the most superior
portion of the chest, which should correspond
to the least gravitationally dependent area of
the thorax. This is usually in the third or fourth
intercostal space in the mid-clavicular line.
The ribs are identified; these will appear
hyperechoic, and their acoustic shadows will
appear as hypoechoic rays extending from the
ribs. The interspace between the 2 ribs is used
as a fixed anatomic landmark during the
examination. Next, the pleural line is
identified; this is a hyperechoic line found at
the inferior border of the space between the 2
ribs.
The presence of a pneumothorax is
characterized by the following findings:
Absence of pleural sliding
Absence of comet tail
Absence of pleural sliding