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1.( Pneumothorax):
(tension pneumothorax)

 : i.: (crepitus) ii.X: : 24-48 ()

Spontaneous Primary pneumothorax Secondary pneumothorax Airway and pulmonary disease (COPD, asthma) Interstitial disease (Pulmonary fibrosis) Infection ( TB..) Neoplastic Catamenial ( Endometriosis) Iatrogenic Post-Traumatic

Surgical indication for primary spontaneous pneumothorax

Early complication
Prolonged air leakage Non re-expansion of the lung Bilaterality Hemothorax Tension Complete pneumothorax

Potential hazard
Occupational hazard Absence of medical facilities in isolated areas Associated single bulla Psychological

Second Episode
Ipsilateral recurrence Contralateral recurrence after a first pneumothorax

Spontaneous Pneumothorax
-Definition & Factors

Definition
Accumulation of intrapleural air as the result of a break in either the visceral or parietal pleura

Factors determining gas reabsorption

Diffusion properties of the gases Pressure gradients Area of contact Permeability of pleural surface

Spontaneous Pneumothorax
-Clinical investigation Signs and symptoms
Sudden onset chest pain Shortness of breathing Cough

Diagnosis
CXR Auscultation

Differential diagnosis
Skin fold Giant bulla

Treatment Options for Pneumothorax

Observation Needle aspiration Percutaneous catheter to drainage
Water seal Pleur-evac type Heimlich valve

Tube thoracostomy
Water seal Pleur-evac type Heimlich valve

Tube thoracostomy with instillation of pleural irritant Video-assisted thoracoscopic surgery Thoracotomy

Indications for Surgical Intervention

Second episode Persistent air leakage for greater than 7-10 days First episode with unexpanded, trapped lung History of contralateral pneumothorax Bilateral pneumothorax Occupational risk (driver, airplane pilot, living ina
remote area)

Large bulla Large undrained hemothorax First episode in a patient with one lung First episode in a patient with severely compromised pulmonary function

Recurrence of Primary Spontaneous Pneumothorax

Therapy

Recurrence (%)
30 20-50 20-30 25 7 2

Expectant Aspiration Chest tube drainage Pleurodesis (tetracycline) Pleurodesis (talc) Surgery

Complication of Pneumothorax
Tension pneumothorax Re-expansion pulmonary edema Persistent air leak Hemothorax (less than 5%) Pneumomediastinum

Removal of Chest Tube

Indications
No fluctuation in the fluid column of the tube (complete lung reexpansion or tube occlusion) Daily fluid drainage <100ml in 24 hours Air leakage has stopped

Proper timing (controversy)

Spontaneous pneumothorax after tube thoracostomy
removal tube within 6 hours of reexpansion--25% collapse

 Tube Thoracostomy

( Chest Intubation)

Indication of Chest Intubation

Drain pleural fluid or air promote lung expansion 1. Pneumothorax 2. Hydrothorax 3. Hemothorax 4. Chylothorax 5. Pyothorax 6. Post-thoracotomy etc.

Apparatus of Chest Tube Drainage

1. Underwater sealed bottle: Separate from atmosphere 2. Collecting bottle: Decrease resistance of drainage 3. Negative pressure suction: Promote lung expansion

Procedure of Chest Intubation

1. Local anesthesia, confirm location 2. Skin incision at selected area 3. Dissect into pleural cavity thru a subcutaneous tunnel 4. Deloculate in pleural cavity 5. Insert tube posteriorly and laterally 6. Close incision wound, fixed the tube 7. Connect tube to underwater sealed bottle (or with negative pressure suction)

Attention In Chest Tube Insertion

Attention 1. Thru thoracostomy wound palpate the underlying structure diaphragm) 2. Avoid trocar intubation (except injury emergency) 3. Keep tube in good direction erosion 4. Avoid intubation thru posterior chest wall 5. Avoid to suture & close thoracostomy wound too loose or too tight Prevent occurrence Underlying organ injury (supra-or infraLung or other organ

Chest pain, great vessel Pain, unable in supine Air leakage Skin necrosis, pain

Attention in Massive Subcutaneous (Mediastinal) Emphysema

1. Keep airway patent (even endotracheal tube) 2. CXR 3. Insert chest tube in pneumothorax or suspicious side 4. Connect tube to negative pressure suction immediately 5. Close thoracostomy wd slightly loose 6. Insert another tube if no improvement 7. Low O2 nasocannula 8. Determine the cause & treat underlying disease 9. Remove tube after complete subsidence

When to Remove Chest Tube ?

Criteria: 1. No air leakage 2. Drained fluid < 50 c.c./day 3. Clear serosanguineous color of fluid 4. Full expansion of lung in CXR Clear sterile fluid remove directly Turbid, infected fluid withdraw progressively open drain

Attention in Chest Tube Care (I)

Attention Fix chest tube firmly Dont clamp tube during transportation in presence of air leakage Dont use negative pressure suction after pneumonectomy Dont apply negative suction immediately after intubation for cases with large volume or long duration of pneumothorax, hydropyothorax Prevent occurrence
Tube moving & contamination Tension pneumothorax

Abrupt mediastinal shift, venous return decrease, death Reexpansion pulmonary edeme

Attention in Chest Tube Care (II)

Attention Prevent occurrence

Dont lift up tube above

thoracostomy wound Use collecting bottle and elevate the connecting tube between 2 bottles in big residual pleural

Back flow contamination

Back flow contamination Lung collapse

space or massive air leakage

Attention in Thoracotomy with Lung Resection (I)

Attention occurrence Suture ligated or close pulmonary vessel with stapler Make adequate length in bronchial stump Cover bronchial stump with fistula surrounding tissue, especially in pneumonectomy Pre-operative anti-TB or anti-fungal drug (at least 2 wks) for suspicious TB or fungal diseases Prevent Slip out, bleeding Stump broken Bronchopleural

Disease flare up