Which Statement Best Describes an Immediate Reaction to Martin

Standing Education Activity

A pneumothorax is a collection of air outside the lung but within the pleural cavity. Information technology occurs when air accumulates between the parietal and visceral pleura inside the breast. The air accumulation can use pressure on the lung and make it collapse. Pneumothoraces tin be even farther classified as unproblematic, tension, or open. A elementary pneumothorax does non shift the mediastinal structures, every bit does a tension pneumothorax. An open pneumothorax also is known every bit a “sucking” chest wound. This activeness examines when this condition should be considered in differential diagnosis and how to evaluate it properly. This activity highlights the role of the interprofessional team in caring for patients with this condition.

Objectives:

• Recall the presence of a pneumothorax.

• Describe the pathophysiology of a tension pneumothorax.

• Summarize the treatment options for pneumothorax.

• Review the importance of improving intendance coordination among interprofessional squad members to improve outcomes for patients afflicted by pneumothorax.

Access costless multiple pick questions on this topic.

Introduction

A pneumothorax is defined every bit a drove of air outside the lung but inside the pleural crenel. It occurs when air accumulates between the parietal and visceral pleurae within the breast. The air aggregating tin can employ pressure on the lung and make it collapse. The caste of collapse determines the clinical presentation of pneumothorax. Air can enter the pleural space by ii mechanisms, either by trauma causing a communication through the chest wall or from the lung past rupture of visceral pleura. In that location are ii types of pneumothorax: traumatic and atraumatic. The two subtypes of atraumatic pneumothorax are master and secondary. A primary spontaneous pneumothorax (PSP) occurs automatically without a known eliciting event, while a secondary spontaneous pneumothorax (SSP) occurs subsequent to an underlying pulmonary affliction. A traumatic pneumothorax can be the result of blunt or penetrating trauma. Pneumothoraces tin exist even further classified as simple, tension, or open up. A simple pneumothorax does not shift the mediastinal structures, as does a tension pneumothorax. Open pneumothorax is an open wound in the chest wall through which air moves in and out.[1][2][iii][4]

Etiology

Risk factors for primary spontaneous pneumothorax

• Smoking

• Tall thin body habitus in an otherwise healthy person

• Pregnancy

• Marfan syndrome

• Familial pneumothorax

Diseases associated with secondary spontaneous  pneumothorax

• COPD

• Asthma

• HIV with pneumocystis pneumonia

• Necrotizing pneumonia

• Tuberculosis

• Sarcoidosis

• Cystic fibrosis

• Bronchogenic carcinoma

• Idiopathic pulmonary fibrosis

• Severe ARDS

• Langerhans cell histiocytosis

• Lymphangioleiomyomatosis

• Collagen vascular affliction

• Inhalational drug use like cocaine or marijuana

• Thoracic endometriosis

Causes of iatrogenic pneumothorax

• Pleural biopsy

• Transbronchial lung biopsy

• Transthoracic pulmonary nodule biopsy

• Cardinal venous catheter insertion

• Tracheostomy

• Intercostal nerve block

• Positive pressure ventilation

Causes of traumatic pneumothorax

• Penetrating or blunt trauma

• Rib fracture

• Diving or flying

Causes of tension pneumothorax

• Penetrating or blunt trauma

• Barotrauma due to positive pressure ventilation

• Percutaneous tracheostomy

• Conversion of spontaneous pneumothorax to tension

• Open pneumothorax when occlusive dressing work equally one mode valve

Causes of pneumomediastinum

• Asthma

• Parturition

• Emesis

• Severe cough

• Traumatic disruption of oropharyngeal or esophageal mucosa

Epidemiology

Main spontaneous pneumothorax more often than not occurs in xx-xxx years of age. The incidence of PSP in the United States is vii per 100,000 men and 1 per 100,000 women per year[5]. The majority of recurrence occurs inside the first year, and incidence ranges widely from 25% to l%. The recurrence rate is highest over the first 30 days.

Secondary spontaneous pneumothorax is more than seen in quondam age patients threescore-65 years. The incidence of SSP is half-dozen.3 and 2 cases for men and women per 100,000 patients, respectively. The male to female person ratio is three:1. COPD has an incidence of 26 pneumothoraces per 100,000 patients.[half dozen] The risk of spontaneous pneumothorax in heavy smokers is 102 times higher than not-smokers.

The leading crusade of iatrogenic pneumothorax is transthoracic needle aspiration (unremarkably for biopsies), and the 2nd leading cause is central venous catheterization. These occur more frequently than spontaneous pneumothorax, and their number is increasing equally intensive care modalities are advancing. The incidence of iatrogenic pneumothorax is 5 per 10,000 admissions in the hospital.

The incidence of tension pneumothorax is difficult to make up one’s mind as i-third of cases in trauma centers have decompressive needle thoracostomies earlier reaching the hospital, and not all of these had tension pneumothorax.

Pneumomediastinum has an incidence of one case per 10,000 admissions in the hospital.

Pathophysiology

The pressure gradient inside the thorax changes with a pneumothorax. Normally the pressure of the pleural space is negative when compared to atmospheric pressure. When the breast wall expands outwards, the lung also expands outwards due to surface tension between parietal and visceral pleurae. Lungs take a tendency to collapse due to elastic recoil. When there is advice betwixt the alveoli and the pleural space, air fills this space changing the gradient, lung collapse unit equilibrium is achieved, or the rupture is sealed. Pneumothorax enlarges, and the lung gets smaller due to this vital chapters, and oxygen fractional pressure level decreases. Clinical presentation of a pneumothorax tin range anywhere from asymptomatic to breast pain and shortness of breath. A tension pneumothorax can crusade severe hypotension (obstructive shock) and even decease. An increase in primal venous force per unit area can result in distended neck veins, hypotension. Patients may have tachypnea, dyspnea, tachycardia, and hypoxia.

Spontaneous pneumothorax in the majority of patients occurs due to the rupture of bullae or blebs. Principal spontaneous pneumothorax is defined as occurring in patients without underlying lung disease just these patients had asymptomatic bullae or blebs on thoracotomy. Primary spontaneous pneumothorax occurs in tall and thin young people due to increased shear forces or more than negative pressure at the apex of the lung. Lung inflammation and oxidative stress are essential to the pathogenesis of primary spontaneous pneumothorax. Current smokers have increased inflammatory cells in modest airways and are at increased risk of pneumothorax.

Secondary spontaneous pneumothorax occurs in the presence of underlying lung affliction, primarily chronic obstructive pulmonary disease; others may include tuberculosis, sarcoidosis, cystic fibrosis, malignancy, idiopathic pulmonary fibrosis, and pneumocystis jiroveci pneumonia.

Iatrogenic pneumothorax occurs due to a complication of a medical or surgical procedure. Thoracentesis is the most common cause.

Traumatic pneumothoraces can effect from edgeless or penetrating trauma, these often create a one-manner valve in the pleural infinite (letting the airflow in but not to flow out) and hence hemodynamic compromise. Tension pneumothorax most commonly occurs in ICU settings, in positive pressure level ventilated patients.

History and Physical

In main spontaneous pneumothorax, the patient is minimally symptomatic as otherwise healthy individuals tolerate physiologic consequences well. The most common symptoms are chest hurting and shortness of breath. The breast pain is pleuritic, precipitous, severe, and radiates to the ipsilateral shoulder. In SSP, dyspnea is more severe because of decreased underlying lung reserve.

The history of pneumothorax in the by is important equally recurrence is seen in fifteen-xl% cases. Recurrence on the contralateral side tin besides occur.

On examination, the following findings are noted

• Respiratory discomfort

• Increased respiratory rate

• Asymmetrical lung expansion

• Decreased tactile fremitus

• Hyperresonant percussion note

• Decreased intensity of breath sounds or absent breath sounds

In tension pneumothorax following boosted findings are seen

• Tachycardia more than 134 beats per infinitesimal

• Hypotension

• Jugular venous distension

• Cyanosis

• Respiratory failure

• Cardiac arrest

Some traumatic pneumothoraces are associated with subcutaneous emphysema. Pneumothorax may be difficult to diagnose from a physical exam, especially in a noisy trauma bay. However, it is essential to make the diagnosis of tension pneumothorax on a concrete test.

Evaluation

Chest radiography, ultrasonography, or CT tin be used for diagnosis, although diagnosis from a breast 10-ray is more mutual. Radiographic findings of 2.5 cm air space are equivalent to a 30% pneumothorax. Occult pneumothoraces may be diagnosed by CT only are usually clinically insignificant. The extended focused abdominal sonography for trauma (E-FAST) test has been a more contempo diagnostic tool for pneumothorax. The diagnosis of ultrasound is usually made by the absenteeism of lung sliding, the absence of a comet-tails artifact, and the presence of a lung point. Unfortunately, this diagnostic method is very operator dependent and sensitivity, and specificity can vary. In skilled hands, ultrasonography has up to a 94% sensitivity and 100% specificity (better than chest x-ray). If a patient is hemodynamically unstable with suspected tension pneumothorax, intervention is not withheld to await imaging. Needle decompression tin can be performed if the patient is hemodynamically unstable with a convincing history and concrete examination, indicating tension pneumothorax.[vii][8][9][10][eleven]

Treatment / Management

Management depends on the clinical scenario.

For patients who have associated symptoms and are showing signs of instability, needle decompression is the treatment of a pneumothorax. This normally is performed with a 14- to 16-gauge and 4.5 cm in length angiocatheter, just superior to the rib in the second intercostal infinite in the midclavicular line. Afterward needle decompression or for stable pneumothoraces, the treatment is the insertion of a thoracostomy tube. This usually is placed above the rib in the fifth intercostal space anterior to the midaxillary line. The size of the thoracostomy tube ordinarily ranges depending on the patient’south height and weight and whether there is an associated hemothorax.

Open up “sucking” breast wounds are treated initially with a three-sided occlusive dressing. Further treatment may require tube thoracostomy and/or breast wall defect repair.

An asymptomatic pocket-size master spontaneous pneumothorax (depth less than 2cm) patient is usually discharged with follow up in outpatient after 2-4 weeks. If the patient is symptomatic or depth/size is more than 2cm needle aspiration is done, after aspiration, if the patient improves and residue depth is less than 2cm then the patient is discharged otherwise tube thoracostomy is done.

In secondary spontaneous pneumothorax, if size/depth of pneumothorax is less than 1cm and no dyspnea so the patient is admitted, loftier flow oxygen is given and observation is done for 24 hours. If size/ depth is between 1-2cm, needle aspiration is done, then the balance size of pneumothorax is seen, if the depth afterwards the needle aspiration is less than 1cm direction is done with oxygen inhalation and observation and in example of more than 2cm, tube thoracostomy is done. In case of depth more than 2cm or breathlessness, tube thoracostomy is washed.

Air can reabsorb from the pleural infinite at a rate of i.5%/day. Using supplemental oxygen can increment this reabsorption charge per unit. Past increasing the fraction of inspired oxygen concentration, the nitrogen of atmospheric air is displaced irresolute the pressure gradient betwixt the air in the pleural space and the capillaries. Pneumothorax on chest radiography approximately 25% or larger usually needs treatment with needle aspiration if symptomatic and if it fails then tube thoracostomy is done.

Indications for surgical intervention(VATS vs. thoracotomy)

• Continuous air leak for longer than vii days

• Bilateral pneumothoraces

• The get-go episode in loftier-hazard profession patient, i.east., Divers, pilots

• Recurrent ipsilateral pneumothorax

• Contralateral pneumothorax

• Patients who have AIDS

Patients who undergo a video-assisted thoracic surgery (VATS) get pleurodesis to occlude pleural infinite. Mechanical pleurodesis with bleb/bullectomy decreases the recurrence rate of pneumothorax to <v%. Options for mechanical pleurodesis include stripping of the parietal pleura versus using an abrasive “scratchpad” or dry out gauze. A chemical pleurodesis is an option in patients who may not tolerate mechanical pleurodesis. Options for chemical pleurodesis include talc, tetracycline, doxycycline, or minocycline, which are all irritants to the pleural lining.

Differential Diagnosis

Differential diagnoses of pneumothorax include:

• Aspiration, bacterial or viral pneumonia

• Acute aortic dissection

• Myocardial infarction

• Pulmonary embolism

• Astute pericarditis

• Esophageal spasm

• Esophageal rupture

• Rib fracture

• Diaphragmatic injuries

Prognosis

PSP is usually benign and mostly resolves on its own without whatever major intervention. Recurrence can occur upwards to iii years period. Recurrence charge per unit in the following five years is 30% for PSP and 43% for SSP. The risk of recurrence increases with each subsequent pneumothorax; information technology is 30% with outset, 40% after a send, and more than than 50% after the third recurrence. PSP is not considered a major health threat, but deaths take been reported. SSPs are more than lethal depending upon underlying lung disease and the size of the pneumothorax. Patients with COPD and HIV take high mortality later on pneumothorax. The mortality of SSP is 10%. Mortality of tension pneumothorax is high if appropriate measures are not taken.

Complications

• Respiratory failure or arrest

• Cardiac arrest

• Pyopneumothorax

• Empyema

• Rexpansion pulmonary edema

• Pneumopericardium

• Pneumoperitoneum

• Pneumohemothorax

• Bronchopulmonary fistula

• Damage to the neurovascular bundle during tube thoracostomy

• Pain and skin infection at the site of tube thoracostomy

Consultations

• Interventional radiologist

• Thoracic surgeon

• Pulmonology consultant

Deterrence and Patient Education

Patients with pneumothorax should exist educated that they should not travel past air or to remote areas until after the consummate resolution of pneumothorax. Patients with loftier-take chances occupations like scuba divers and pilots should be brash that they should not dive or fly until definitive surgical direction of their pneumothorax is done.

All patients are brash to end smoking. They should be assessed for their will to quit smoking; they should be educated and provided pharmacotherapy if they decided to quit.

Pearls and Other Issues

Do non let a breast radiograph or CT scan delay treatment with needle decompression or thoracostomy tube if the patient is clinically unstable, i.east., tension pneumothorax.

Worsening subcutaneous emphysema tin be associated with malposition of a chest tube and repositioning with a new breast tube is recommended. A chest tube should never be reinserted as this can increase the patient’southward risk for empyema.

An untreated pneumothorax is a contraindication for flying or scuba diving. If air transport is required, then a thoracostomy tube should exist placed before transport.

If in that location is a persistent or recurrent pneumothorax despite treatment with thoracostomy tube, these patients need specialty consultations for a possible video-assisted thoracoscopic surgery (VATS) with or without pleurodesis or thoracotomy.

If the patient is discharged from the hospital after a resolved pneumothorax, recommendations should exist made for no flight or scuba diving for a minimum of two weeks. Patients with a known history of spontaneous pneumothorax should not be medically cleared for occupations involving flying or scuba diving.

Enhancing Healthcare Team Outcomes

The management of a pneumothorax is oft done by the emergency department md. In some cases, the disorder may be managed by the ICU staff and the thoracic surgeon. The care of patients who take a chest tube is washed by the nurse. All nurses who manage patients with a breast tube should know how a chest bleed functions. Patients need to be examined every shift and the patency of the chest tube is of import. Patients with small pneumothorax can be observed if they have no symptoms. If discharged the patient should be seen within 24 hours.

Review Questions

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