Pneumothorax case presentation
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This document presents the case of a 50-year-old male smoker with COPD who presented with acute dyspnea and left chest pain for 3 days. On examination, the patient was dyspneic with decreased breath sounds and chest expansion on the left side. A chest X-ray showed a 41% pneumothorax on the left. A tube thoracostomy was performed and the lung re-expanded. The tube was removed after 2 days and the patient was discharged on medications with instructions to follow up after 1 week.
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Pneumothorax case presentation
- 1. PNEUMOTHORAX CASE PRESENTATION By Dr. Ashish kumar Santosh Medical college and hospital.
- 2. 50 year old male Jameel chronic smoker known case of COPD , shopkeeper by occupation ,married , having 3 childrens, referred to us from medicine dept. on 11/06/18 with c/o acute dyspnea - 3 days acute lt. chest pain - 3 days Dyspnea :was progressive in nature aggravated on cough and not relieved by rest , does not increase on lying down or change in position. No H/o variation in severity of dyspnea with time ie diurnal variation or PND. Lt. chest pain: was sharp and stabbing in nature, acute onset, non radiating , not associated with sweating, vomiting and palpitation. Pain aggravated on deep breathing & coughing ,relieved on lying in left decubitus position .
- 3. Past Hx : He was known case of COPD , on medication DPI- tiotropium, formetrol and budesonide since 2 years. No H/O of tuberculosis or any other respiratory problem in the past other than COPD. No H/o HTN /DM/any surgery / any chest trauma
- 4. Personal Hx : Smoker for past 30 years , 10 sticks per day approx. Smoking index 300, 15 pack year. No H/o Bowel and bladder habits alteration No H/o alcohol intake and other substance abuse Family Hx: No H/o hypertension , diabetes , tuberculosis in family Occupational Hx: provisional store shopkeeper Social Hx: Poor socioeconomic status.
- 5. GENERAL PHYSICAL EXAMINATION Patient was dyspneic, Conscious, oriented to time place and person BP :130/80 mmHg Pulse :118 bpm Respiratory rate : 28/ min SPO2 : 76 % Temp: Afebrile P-I-CY-C-L-E- not present JVP not raised
- 6. INSPECTION Trail’s sign positive trachea shifted to right. Asymmetrical chest, Bulging of the left chest from apex to base anteriorly and posteriorly. Accessory muscles of respiration are hyperactive. Asymmetrical and unequal movement of the chest. Thoraco-adominal movement. Respiration was shallow and rapid @ 28 / min. Pursed lip breathing was present No visible vein, scar ,edema and swelling over chest Apex beat is 3.5 cm right to MCL. Retraction of subcostal margins. Widening of intercostal space not appreciated on inspection.
- 7. INSPECTION Rt chest movements Lt chest movements Supraclavicular Normal Diminished Infra clavicular Normal Diminished mammary Normal Diminished Axillary Normal Diminished Infra-axillary Normal Diminished Supra scapular Normal Diminished Inter-scapular Normal Diminished Infra-scapular Normal Diminished
- 8. PALPATION All inspection finding confirmed by palpation No localized tenderness and raised tem. present. No parasternal heave. Trail’s sign confirmed on palpation, trachea shifted to right side. Bulging present on left chest from apex to base anteriorly and posteriorly Apex impulse shifted 3.5 cm Rt. From MCL. Chest expansion : 2.5 cm
- 9. PALPATION Rt TVF /chest movements & expansion Lt TVF / chest movements & expansion Supraclavicular Normal Diminished Infra clavicular Normal Diminished mammary Normal Diminished Axillary Normal Diminished Infra-axillary Normal Diminished Supra scapular Normal Diminished Inter-scapular Normal Diminished Infra-scapular Normal Diminished
- 10. PERCUSSION Rt Lt Supraclavicular (Kronig’s Isthmus) Resonant Hyper-resonant Direct Clavicular percussion Resonant Hyper-resonant Infra clavicular Resonant Hyper-resonant Mammary Resonant Hyper-resonant Axillary Resonant Hyper-resonant Infra-axillary Resonant Hyper-resonant Supra scapular Resonant Hyper-resonant Inter-scapular Resonant Hyper-resonant Infra-scapular Resonant Hyper-resonant Liver dullness in 6th ICS Traube’s area masked
- 11. PERCUSSION Cardiac dullness could not be appreciated Basal percussion – lower border of left lung resonance was depressed one space below.
- 12. Auscultation Rt. breath sound /vocal resonance Lt. breath sound /vocal resonance Supraclavicular NVBS / Normal Diminished Infra clavicular NVBS / Normal Diminished Mammary Rhonchi + / Normal Diminished Axillary Rhonchi + / Normal Diminished Infra-axillary Rhonchi + / Normal Diminished Supra scapular NVBS / Normal Diminished Inter-scapular Rhonchi + / Normal Diminished Infra-scapular Rhonchi + / Normal Diminished Scratch sign : positive on left side Coin test : positive on left side
- 14. H L
- 15. PNEUMOTHORAX CALCULATION Light index pneumothorax %= L3 H3 X 100 L is collapsed lung = 6.7 cm H is diameter of hemithorax = 8cm 1- Pneumothorax %=(1- 300/512) x 100 = (1-.58) X 100 =41%
- 16. WHAT WE DID ? Tube Thoracostomy. 24 Fr Malecot catheter was inserted after taking consent, under all aseptic conditions in left 5th intercostal space, under local anaesthesia & connected to under water seal drainage bag. Post Procedure Chest X-Ray showed expansion of lung.
- 17. 11/06/18
- 18. • After lung has Re expanded, There was no bubbling through water-sealed bag that indicates there was no air leak. • Tube was clamped at night and patient was monitored for the symptoms and patient had no discomfort. • Xray was repeated with clamped tube on the next morning. • The ICD was removed after confirming the expansion of lung clinically and radiologically. • Post ICD removal X-ray showed expansion of left lung.
- 19. 13/06/18
- 20. POST EXTUBATION Post extubation we evaluated the patient. dyspnea improved. No discomfort till evening BP was 130/70 Spo2 93% RR- 18/min .
- 21. DISCHARGED On Xray Lung re-expansion Confirmed Patient vitals was stable o Patient discharged and advised 1. Antibiotics – Tab. Amoxclav 625 bd, Tab. Metrogyl 400 tds for 7 days. 2. Bronchodilators- DPI. Formeterol and Budesonide 3. DPI Salbutamol 4. Breathing exercises- 5. Advised to Avoid straining, heavy weight lifting 6. Review after 1 week
- 22. REVIEWED AFTER 1 WEEK Patient had no fresh complaints Vitals stable On Xray re expansion confirmed.
- 23. Thank you
- 25. pneumothorax Spontaneous Primary Secondary Traumatic Non Iatrogenic (trauma) Iatrogenic Pneumothorax Undrlying disease COPD,T.B, etc No under lying dz i.e rupture of subpleural bleb
- 26. CLASSIFICATION 1. Spontaneous # Primary - No evidence of overt lung disease - occurs in males aged 15-30 - air escapes from the lung into the pleural space through rupture of a small emphysematous bulla or pleural bleb - smoking, tall stature & the presence of apical subpleural blebs are additional risk factors
- 27. #SECONDARY - underlying lung disease - occurs mainly in males above 55 yrs - most commonly COPD & TB - also seen in asthma, lung abscess, pul infarcts, bronchogenic carcinoma, all forms of fibrotic & cystic lung disease
- 28. 2.TRAUMATIC iatrogenic ( from thoracic surgery or biopsy) chest wall injury ( blunt trauma , stab injury)
- 29. TYPES OF PNEUMOTHORAX 1. Closed spontaneous pneumothorax 2. Open spontaneous pneumothorax 3. Tension pneumothorax
- 32. CLOSED TYPE Communication b/n airway and the pleural space seals off as the lung deflates Mean pleural pressure remains negative Spontaneous reabsorption of air & re-expansion of lung occur over a few days or weeks Infection uncommon
- 33. OPEN TYPE Communication b/n pleura & bronchus doesn’t seals off (Bronchopleural fistula) Intra pleural pressure = atm. Pressure Collapsed lung, no re expansion Transmission of infection from the airways into the pleural space through fistula common (empyema)
- 34. TENSION TYPE Communication b/n the airway & the pleural space acts as a one-way valve allowing air to enter the pleural space during inspiration but not to escape on expiration. Large amt of air accumulates progressively in the pleural space Intrapleural pressure increases above atm pressure
- 35. Pressure causes mediastinal shift towards the opposite side with compression of the opposite lung & impairment of systemic venous return causing cardiovascular compromise.
- 36. INVESTIGATIONS Chest x ray Shows : increased radiolucency, with absence of bronchovascular markings extent of mediastinal shift. pleural fluid,if present . underlying pulmonary disease .
- 38. TRAUMATIC PNEUMOTHORAX Supplemental oxygen or aspiration done. Tube thoracostomy , if not improves. If hemo pneumothorax is present, 1 chest tube should be placed in the superior part to evacuate air, other should be placed in the inferior part to remove blood.
- 39. INDICATIONS OF TUBE THORACOSTOMY 1. Pneumothorax 2. Malignant pleural effusion 3. Empyema 4. Hemopneumothorax 5. Post operative i.e thoracotomy , cardiac surgery.
- 40. COMPLICATION OF TUBE THORACOSTOMY 1. Hemothorax 2. Perforaton of visceral organ 3. Pleural infection 4. Sub cutaneous emphysema 5. Re-Expansion pulmonary edema.