Pneumothorax

Dr. Hytham Nafady

Etiology

Primary spontaneous pneumothorax

• It occurs in young healthy individuals without underlying lung disease.

• It is due to rupture of apical sub-pleural bleb.Predisposing factors:• Smoking.• Tall, thin male.Recurrence:• 50% on the same side.• 10% on the opposite side.

Subpleural bleb

• Pocket of air within the visceral pleura.• < 1 cm & usually apical.

Secondary spontaneous pneumothorax:

Due to underlying lung disease.

• Cavitary lesion.

• Cystic lung disease.

• Emphysematous bullae.

• Pneumatocele.

Traumatic pneumothorax

Accidental trauma:• Blunt trauma: with fracture ribs.• Penetrating trauma: stab wound or gun shot

injury.Iatrogenic trauma:• Positive pressure ventilation:Alveolar rupture interstitial emphysema

pneumothorax.• Interventional procedures:Biopsy, thoraco-centesis, CVP line.

Pathology Pneumothorax

Closed pneumothorax

Openpneumothorax

Tension pneumothorax

Closed pneumothorax

Open pneumothorax

Tension pneumothorax

The pleural tear Is sealed

The pleural tear is open

The pleural tear act as a ball & valve mechanism

The pleural cavity pressure is < the atmospheric pressure

The pleural cavity pressure is = the atmospheric pressure

The pleural cavity pressure is > the atmospheric pressure

C.P

Dyspnea is more common in 2ry spontaneous pneumothorax rather than 1ry spontaneous pneumothorax due to poor pulmonary reserve.

• Dyspnea.

• Pleuritic chest pain.

Radiological manifestations

Pneumothorax

in erect position

Pneumothorax

in supine position

Air in apicolateral pleural space

Air in anteromedial pleural space.

Small pneumothorax

Small pneumothorax

Large pneumothorax

Large pneumothorax

Large pneumothorax with mediastinal shift

Large pneumothorax with mediastinal shift

Tension Pneumothorax

Tension pneumothorax

Tension pneumothorax

Visceral pleural line

DD of visceral pleural lineSkin fold:• Positive mash band (optical edge enhancement).• Extend beyond the chest wall.• Lung markings extend beyond it.

DD of visceral pleural line

Scapular edge

DD of apical radiolucency

Emphysematous bulla:

• Rounded (while pneumothorax is crescentic & tapers toward the lung base).

• Double wall sign on CT is consistent with ruptured bulla causing pneumothorax.

Giant emphysematous bulla

Emphysematous bulla Vs pneumothorax

Emphysematous bulla Vs pneumothorax

Signs of pneumothorax in supine position

Deep costophrenic sulcus

Sharp mediastinal contour

Double diaphragm signsubpulmonic pneumothorax

Lucent cardiophrenic sulcus

Large pneumothorax(without mediastinal shift)

CT can diagnose easily pneumothroax

CT can diagnose easily pneumothroax

U/S in pneumothorax

• Classical belief lung not optimal for U/S.

• Ultrasound found to be more sensitive than CXR in diagnosis of pneumothorax.

U/S signs of pneumothorax

• Loss of lung sliding.

• Loss of comet tails.

• loss of seashore sign (M mode).

• Stratosphere sign or bar code sign(M mode).

Stratosphere or bar code sign

Stratosphere

Bar code

Seashore

Recurrence of spontaneous pneumothorax

• 50% on the same side.

• 15% on the contralateral side.

More common in

• 2ry spontaneous pneumothorax.

Tension pneumothorax • It is life threatening condition.• The pleural pressure is more than the atmospheric

pressure.Radiological manifestations of large pneumothorax • Mediastinal shift, • Flattening of the hemidiaphragm &• Lung collapse.Associated with clinical manifestations of circulatory

collapse (tachycardia, hypotension & sweating).It is more common with • Positive pressure ventilation & • Traumatic pneumothorax.

Tension pneumothorax

Tension pneumothorax complicating lymphangioleimyomatosis

Hydropneumothorax

• Due to rupture of pleural adhesions.• Bronchopleural fistula.

Encysted pneumothorax

• Due to pleural adhesions.

Failure of re-expansion of the collapsed lung

• Due to pleural adhesions.

• Or tracheobronchial injury.

Re-expansion pulmonary edema

• Due to rapid re-expansion of collapsed lung.

Quizzes

Emphysematous bulla

Emphysema & bilateral pneumothorax