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

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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

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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

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Spontaneous Pneumothorax-Clinical investigation

• Signs and symptoms
• Sudden onset chest pain
• Shortness of breathing
• Cough
• Diagnosis
• CXR
• Auscultation
• Differential diagnosis
• Skin fold
• Giant bulla

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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

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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

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Recurrence of Primary Spontaneous Pneumothorax

• Therapy Recurrence ()
• Expectant 30
• Aspiration 20-50
• Chest tube drainage 20-30
• Pleurodesis (tetracycline) 25
• Pleurodesis (talc) 7
• Surgery 2

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Complication of Pneumothorax

• Tension pneumothorax
• Re-expansion pulmonary edema
• Persistent air leak
• Hemothorax (less than 5)
• Pneumomediastinum

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Removal of Chest Tube

• Indications
• No fluctuation in the fluid column of the tube
  (complete lung reexpansion or tube occlusion)
• Daily fluid drainage lt100ml in 24 hours
• Air leakage has stopped
• Proper timing (controversy)
• Spontaneous pneumothorax after tube thoracostomy
• removal tube within 6 hours of reexpansion--25
  collapse

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• Tube Thoracostomy
• ( Chest Intubation)

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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.

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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

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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)

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Attention In Chest Tube Insertion

• Attention Prevent
  occurrence
• 1. Thru thoracostomy wound Underlying organ
  injury
• palpate the underlying structure (supra-or
  infra-diaphragm)
• 2. Avoid trocar intubation (except Lung or other
  organ injury
• emergency)
• 3. Keep tube in good direction Chest pain, great
  vessel erosion
• 4. Avoid intubation thru posterior Pain, unable
  in supine
• chest wall
• 5. Avoid to suture close Air leakage
• thoracostomy wound too loose Skin necrosis,
  pain
• or too tight

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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

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When to Remove Chest Tube ?

• Criteria
• 1. No air leakage
• 2. Drained fluid lt 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

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Attention in Chest Tube Care (I)

• Attention Prevent occurrence
• Fix chest tube firmly Tube moving contamination
• Dont clamp tube during Tension pneumothorax
• transportation in presence of
• air leakage
• Dont use negative pressure suction Abrupt
  mediastinal shift,
• after pneumonectomy venous return decrease,
  death
• Dont apply negative suction Reexpansion
  pulmonary edeme immediately after intubation for
• cases with large volume or long
• duration of pneumothorax, hydro-
• pyothorax

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Attention in Chest Tube Care (II)

• Attention Prevent occurrence
• Dont lift up tube above Back flow contamination
• thoracostomy wound
• Use collecting bottle and elevate Back flow
  contamination
• the connecting tube between 2 Lung collapse
• bottles in big residual pleural
• space or massive air leakage

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Attention in Thoracotomy with Lung Resection (I)

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