• transforms the potential space into a real one

• may lead to various degrees of respiratory compromise

• with progression, the intrapleural pressure may exceed atmospheric pressure creating a tension-scenario

• • impairs respiratory function

  • decreases venous return to the right-side of the heart

General Management:

• First - evacuate the air

• Second - address the underlying source

• Third - promote pleural symphysis

Classification System

1. Spontaneous Pneumothorax

3. Primary

4. Secondary

• Causes of a Spontaneous Hemothorax

• • Pulmonary: bullous emphysema, PE, infarction, Tb, AVM's

  • Pleural: torn adhesions, endometriosis

  • Neoplastic: primary, metastatic (melanoma)

  • Blood Dyscrasias: thrombocytopenia, hemophilia, anticoagulation

  • Thoracic Pathology: ruptured aorta, dissection

  • Abdominal Pathology: pancreatic pseudocyst, hemoperitoneum

• The Pathophysiologic Process

• • the accumulation of pleural blood forms a stable clot

  • overall ventilation & oxygenation becomes impaired

  • • mechanical compression of the lung parenchyma

    • mediastinal shift

    • flattening of the hemidiaphragm

• • over time, the clot is partially-absorbed, leaving behind loculated fluid and fibrinous septations

  • macro-fibrin deposition begins to provide a structural framework

  • this “peel” slowly contracts to entrap the underlying lung

• Goal of Treatment: to remove the pleural blood and allow for complete lung re-expansion

• • General Management Options

  • • thoracentesis: bedside / ultrasound-guided / C.T.-guided

    • thoracostomy drainage: the mainstay

    • thorascopic surgery: less than 2 wks. & use a 30-degree scope

    • thoracotomy: massive hemothorax / instability / chronic hemothorax

    • local fibrinolytic therapy: urokinase (1000 IU/ml) in 150 solution

• • Often, there is an accompanying pneumothorax

  • • Dual Chest Tube Management

    • • Superior-Apical: Ptx

      • Diaphragmatic-posterior: Htx

      • Consider targeted-drainage into a loculated collection

  • • All tubes to negative suction with protective water-seal

    • Prophylactic antibiotics are indicated while the tubes are in

    • Chest tubes removed: 100 -150 cc's/day

• Large collections should be drained slowly to minimize the development of re-expansion-pulmonary-edema [“R.E.E.P.”]

• Computed tomography is the diagnostic procedure of choice

• altered pleural membrane permeability

• decreased intravascular oncotic pressure

• increased pleural capillary hydrostatic pressure

• lymphatic obstruction

• abnormal sites of entry

• Pain and breathlessness

• Dullness to percussion

• Diminished or absent breath sounds

• Decreased or absent vocal resonance

• Decreased or absent tactile vocal fremitus

• Egophony at level of meniscus

• Confirm by Radiographic Imaging

• Posteroanterior chest radiograph

• Lateral decubitus chest radiographs

• Ultrasound (loculations)

• CT Scan

Once presence is confirmed radiographically, then perform Thoracentesis to differentiate: Transudate vs. Exudate

• Cell count and differential

• Gram stain, culture and sensitivity

• Cytology

• Protein, LDH

• Other-glucose, amylase, afb

• fluid-to-serum ratio of total protein > 0.5

• fluid-to-serum ratio of LDH > 0.6

• fluid LDH concentration > 2/3 upper limit of normal for serum LDH

• Increased capillary hydrostatic pressure

• Reduced colloid osmotic pressure

• Heart failure (usually presents as a bilateral effusion)

• Hepatic cirrhosis (usually is Right-sided)

• Nephrotic Syndrome (due to hypoalbuminemia)

• Ascites (usually is Right-sided)

• Constrictive pericardial disease

• SVC obstruction

• Pulmonary Embolism

• Disruption of pleural membrane

• Obstruction of lymphatic drainage

• Infections (parapneumonic, t.b.)

• Malignant disorders (primary or metatstatic disease)

• Vasculitic disease (R.A., S.L.E.)

• Gastrointestinal disease (pancreatitis, esophageal rupture, hepatic abscess)

• Pulmonary Embolism

Treatment depends on the underlying pathophysiologic process

If exudative, usually thoracostomy tube drainage.
THE GOAL is to prevent an empyema or a “trapped lung”

1-2 % incidence in the pediatric population
Up to 18 % in immunocompromised adults
General Management

• Appropriate Antibiotic Coverage

• Thoracostomy Drainage

• Streptokinase / Urokinase

• Surgical Intervention - Decortication

Stage I - “Exudative”

• sterile pleural fluid develops secondary to inflammation without fusion of the pleura

Stage II - “Fibrinopurulent”

• a fibrinous peel develops on both pleural surfaces limiting lung expansion

Stage III - “Organizing”

• in-growth of capillaries & fibroblasts into the fibrinous peel

• (aggressive drainage...early VATS)