for more on hemo/pneumothorax, see the thoracic trauma section
Spontaneous Pneumothorax
Coin test: hold a silver dollar flat against the anterior chest under clavicle in the 3rd ICS, midclavicular line strike with another silver dollar, normally sounds dull
or listen in the supraclavicular fossa while percussing the intrascapular spaces
look for deep sulcus sign on supine film, also anterior cardiac air:
Primary
Tall thin men who smoke
from blebs or bullae
Bleb has only pleura
Bullae have both pleura and lung tissue, they collapse with exhalation because they communicate with bronchial system (seen in emphysema)
Secondary
Most common cause is COPD
pocket shots (in the subclavian vein) by drug abusers
PCP pneumonia in HIV patients especially in those using aerosol pentamidine
Traumatic
Iatrogenic
Needle biopsy by FOB
Thoracentesis
narrow bore NGTs
Barotrauma
from mechanical ventilation
Diagnosis
PA x-ray, may need expiratory film or LLR with horizontal beam to better delineate.
Management
oxygen probably does nothing to benefit absorption (Noninvasive treatment of pneumothorax with oxygen inhalation. Chadha TS. Respiration 44(2):147-52, 1983)
Can be treated with aspiration, safer and more cost effective than chest tube
Minimal pneumothorax (<25%)=4 cm apical or 1 cm lateral on C-XR
Beware of reexpansion pulmonary edema.
1.25% absorbed spontaneously every 24 hours
100% O2 increases this 4-6 fold
Pleurodesis
in the past, sterile tetracycline was used, now doxycycline is a stand-in
Talc can also be used though it causes a greater systemic reaction
Patients who have received pleurodesis will have a much more difficult surgical course if it is needed
Surgery
either formal open or video assisted thoracoscopy (VAT)
PCP pneumothoraces are often very difficult to manage and aggressive therapy should be utilized early
Persistent leak
If leak persists beyond 7 days, suspect bronchopleural fistula
usually requires surgery though pleurodesis may have a role
ACP Guidelines 1999
Primary Pneumo
admit large and place small bore tube with Heimlich or larger bore tube
Thoracoscopy is preferred to pleurodesis
The tube should be placed on water seal not suction to limit reexpansion pulmonary edema
removal should be considered 6-12 hours after evidence of last air leak
Secondary Pneumo
all patients need to be admitted
Place chest tubes in large pneumos, but do not apply suction
do not use Heimlich valves
wait 12-24 hours after air leak
Consider CT scan to search for bullae
Spontaneous Hemothorax
(Curr Opin Pulm Med 2006;12(4):273)
The development of spontaneous hemothorax can result from thoracic malignancies, primary vascular events, coagulopathy, spontaneous pneumothorax and a variety of infectious diseases. SHP is an uncommon but potentially life-threatening clinical situation due to rapid ventilatory collapse and the large volume of concealed blood loss into the pleural cavity. It is one of the causes of patients presenting with unexplained signs of significant hypovolemia.
The source of the bleeding can be a small non-contractile vessel in an area of torn vascular adhesion between the two layers of the pleurae[2,3,6,10**] (Fig. 2), rupture of a vascular bulla or lung parenchyma at the apex of the lungs[2,6,7,10**] (Fig. 3), or the presence of an aberrant vessel that is usually thin-walled and does not contract adequately due to the lack of muscular fibres.[2,3,6,7,10**,11] Interestingly, more recent pathological studies have shown vessel degeneration and sclerosis, as well as intimamedia fibrosis, to be the likely causes of vasoconstriction failure in these aberrant vessels.[2] The bleeding adhesions in SHP are commonly found near the apex and subclavian vessels, and also in the aorta, superior vena cava and pericardium. Normal hemostasis by vasoconstriction and clot formation may be impeded by lung movement, changes in pleural pressure during respiration and the absence of a surrounding tamponade effect. In our experience, the source of bleeding can be identified intra-operatively in 53% of SHP patients; bleeding occurs most commonly from a torn vascular adhesion band from the apical parietal pleura, which accounts for threequarter of cases. In comparison, authors of other series were able to identify a source of bleeding in 50-100% of their cases,[2,6,7,10**] and around half of the identified bleeding was from an aberrant vessel.[6,10**]
If CRIT is >50% of the pt’s blood crit, then it is a hemothorax, not a blood effusion
Chylothorax
hyponatremia, hypocalcemia, and acidosisPseudochylothorax is another type of lipid effusion, but differs from chylothorax in that it is very cholesterol rich and contains no chylomicrons on lipoprotein electrophoresis. The importance for the emergency physician is that this type of effusion is caused by tuberculosis in over 50% of cases [25].
Although controversial, many authorities recommend conservative management as initial therapy for chylothorax. Conservative management involves tube thoracostomy drainage, no oral intake, and total parenteral nutrition. The reason the patient is kept NPO is to decrease lymph flow to allow healing of the defect. Lymph flow is about 14 mL/h in the fasting state and over 100 mL/h after eating [11]. Although ingested fats are the main cause for increasing chyle flow, even fat-free diets and water will increase the flow [26]. Most authorities recommend conservative management for no more than 2 weeks [27]. At this point, surgical management is indicated. Procedures include thoracic duct ligation by open technique or video-assisted thoracoscopic surgery, pleuro-peritoneal shunting, thoracoscopic fibrin glue injection of the defect, and talc pleurodesis [15, 16 and 28]. Some authorities recommend earlier surgery in patients with large chyle leaks and those who already have significant nutritional or metabolic compromise [15 and 29].
Pleural Effusion
Pleural fluid is secreted by the parietal and absorbed by the visceral pleura capillaries. LHF causes effusion by backpressure to absorption, RHF because of increased secretion. Hypoalbuminemia can also give a transudative effusion.
If disease of pleura, then exudative malignancy or inflammatory.
Increased peritoneal fluid can also cause pleural effusion via the lymphatics.
Chest Tube Drainage of Transudative Pleural Effusions Hastens Liberation From Mechanical Ventilation
CHEST March 2011 vol. 139 no. 3 519-523
Spontaneous Hemothorax
(Chest. 2008; 134:1056-1065)
Pleuritis
Pain is from the parietal pleura. Dresslers syndrome-post mi pleuritis c or s effusion
Left Lower Lobe Collapse
Can be from mucus plugging
The lower lobe collapses medially and posteriorly. It is classically taught that LLL collapse produces a triangular shaped opacity behind the heart. On the PA radiograph, there will be a dense, airless triangle of increased opacity at the medial base representing the collapsed lobe. The major fissure – usually not seen on the PA film – separates the airless lower lobe from the rest of the aerated lung and causes the sharply demarcated lateral border of the triangle (black arrow). 
Other findings which support the diagnosis of LLL collapse include displacement of the heart and mediastinal structures to the left. Note the heart border (black arrowheads) has shifted to the left as compared to the previous film. The mediastinal structures have shifted to the left as well. The left hemidiaphragm has become elevated and less clearly seen medially as the left lower lobe collapses against it. (Emedhome.com)
Empyema
exudative or acute phase- fibropurulent or transitional phase-pH <7, low glucose, ldh<1000 organizing chronic phase
Spontaneous Pneumomediastinum
chest x-ray and ct of chest are sufficient. Routine esophogram esophagoscopy are not needed unless ct shows something (Emerg Med J 2010;27:29)
Pneumoperitineum after cpr
Approach to Pneumoperitoneum after CPR. J Trauma 2006 61-6-1552.jpg
