TENSION PNEUMOTHORAX

DR.MALAV SHAH
CASE : MR P M

 47 YRS OLD MALE

 MORBIDLY OBESE @ 115 KG
 SUBACUTE ONSET BREATHLESSNESS OVER
FEW DAYS AND FEVER
 ADMITTED TO ICU FOR SEVERE HYPOXEMIA
DR C M
 Chest X ray s/o bilateral airspace shadows –
ARDS (SEVERE)
 INTUBATED AND VENTILATED.
 Invasive hemodynamic monitoring started
WHAT SHOULD BE INITIAL VENTILATOR
SETTINGS?
 MODE : CONTROL : VOLUME
 FIO2 @PaO2 - 55-80 mmhg
 RATE : 20 / MIN
 TV : 6 ML/KG : 700- 800 ml/kg
 Target : to keep plateau pressure below 30-35
mmhg.
 PLATEAU PRESSURE WAS MAINTAINED
AROUND 30-34 mmhg overnight.
Next morning ..

 SINCE EARLY MORNING SLIGHT DROP IN BP,

SAO2 AND INCREASES IN PLATEAU AND PEAK
PRESSURE : worsening ARDS?
 PEEP increased further..
 Sudden drop in blood pressure and SaO2
 CHEST X RAY DONE IN THE MORNING
How my
Mechanical
Ventilation
is Responsible
for
Pneumothorax ?
Back to basics ..

 The purpose of mechanical ventilation is to rest

the respiratory muscles while providing
adequate gas exchange.

 Despite the clear benefits , many patients

eventually die after the initiation of mechanical
ventilation, even though their arterial blood
gases may have normalized.
 In 1967, the term“respirator lung” was coined
to describe the diffuse alveolar infiltrates and
hyaline membranes that were found on
postmortem examination of patients who had
undergone mechanical ventilation.
VILI

 The constellation of pulmonary consequences

of mechanical ventilation has been termed
ventilator-induced lung injury (VILI).
 PRESSURES IN THE LUNG

 When air flow is zero (e.g., at end inspiration),

the principal force maintaining inflation is the
trans pulmonary pressure (alveolar pressure
minus pleural).
 lung volume and transpulmonary pressure are
inextricably linked.
P TP

 TRANSPULMONARY

PRESSURE

= ALVEOLAR PRESSURE –

PLEURAL PRESSURE.
Key factor ?

 Regional lung overdistention is a key factor in

generating ventilator-induced lung injury.
 Limiting inflation pressure during mechanical
ventilation is used as a surrogate strategy to
limit overdistention.
 Alveolar pressure is relatively easy to estimate
clinically as the airway pressure during a period
of zero flow.
 In a patient undergoing mechanical ventilation
who is not making spontaneous breathing
efforts, the airway pressure that is measured
during a period when air flow is stopped at end
inspiration is called the plateau pressure.
 Unfortunately, pleural pressure — the other
variable needed to calculate transpulmonary
pressure - is more complicated.
 it can be estimated in the broader clinical
setting only by measurement of esophageal
pressure.
 Therefore, the plateau pressure is the most
common variable used in a clinical setting to
indicate lung overdistention.
 If the patient is not making respiratory efforts,
the plateau pressure represents the pressure
that is distending the lungs plus the chest wall.
VILI: ventilation at high (absolute) lung
volumes
 leads to alveolar rupture, air leaks, and gross
barotrauma (e.g., pneumothorax,
pneumomediastinum, and subcutaneous
emphysema.
 The term barotrauma can be misleading,
because the critical variable leading to the air
leaks is regional lung overdistention, not high
airway pressure per se.
Dreyfuss et al

 …showed that volume (i.e., lung stretching), not

airway pressure, was the most important factor
in determining injury, a finding that led them to
coin the term “volutrauma.”
 More subtle injury that is manifested as
pulmonary edema can occur as a result of lung
overdistention.
Ventilation at low volumes ?

 Ventilation that occurs at low (absolute) lung

volumes can also cause injury through multiple
mechanisms, including repetitive opening and
closing of airways and lung units,
-Atelectotrauma
 Amplified in lungs in which there are marked
heterogeneities in ventilation.
 VILI

Barotrauma and Atelectrauma

Volutrauma and biotrauma
 Bio trauma
 Moderate degrees of stress and strain
related to the cyclic opening and closing of
alveoli - release of inflammatory mediators
and noxious proteinases.
Back to our pt. : MR P M

 TIDAL VOLUME : 6 ml/kg ACTUAL BODY

WEIGHT
Back to our pt. : MR P M

 TIDAL VOLUME : 6 ml/kg IDEAL BODY WEIGHT

 NOW WHAT ?
Tension Pneumothorax
 When the pleural
pressure is positive
throughout respiratory
cycle
 “Ball-valve
mechanism”
 Injury to pleura creates
a tissue flap that
opens on inspiration
and closes on
expiration
Radiological manifestations
Pneumothorax Pneumothorax
in erect position in supine position
Air in apicolateral pleural Air in anteromedial pleural
space space.
A MISSED CALL ?

 Unfortunately, it is difficult to make a

radiographic diagnosis of a pneumothorax
on portable x-ray films taken in the ICU
setting.
 X-ray Upright-air in Apex
 X-ray In ICU; supine , semi supine
 In addition, concurrent lung disease may
lead to different distributions of free air in
the pleural space than in patients with
relatively normal lungs.
Distribution of air

3%
11% anterio-medial

38% subpulmonic

apicolateral
22%
posterio-medial

others

26%
harp
mall
nsion
arge
ceral
lucency
ophrenic
rect
diaphragm
collapse
diaphragm
pine
phrenic
tinal
lucency
shift
mothorax
mothorax
nal
ral
in width)
contour
line
ulcus
lcus

Pneumothorax
Signs of pneumothorax in
supine position
Deep costophrenic sulcus
Sharp mediastinal contour
Double diaphragm sign
subpulmonic pneumothorax
Lucent cardiophrenic sulcus
Large pneumothorax
(without mediastinal shift)
Tension pneumothorax
Tension pneumothorax
U/S signs of pneumothorax

 Loss of lung sliding.

 Loss of comet tails.
 loss of seashore sign (M mode).
 Stratosphere sign or bar code sign(M mode).
LOSS OF LUNG SLIDING AND LOSS OF
COMET TAIL
Stratosphere or bar code sign
CT Thorax
Tension pneumothorax : Treatment

 life-threatening.
 The immediate treatment is NEEDLE
DECOMPRESSION followed by tube
thoracostomy, or the insertion of a chest
tube.
 The chest tube is left in place until the lung
leak seals on its own.
Thoracostomy (Chest tube)
Prognosis

 Patients with procedure-related pneumothorax

had a lower risk of mortality.
 Patients who had tension pneumothorax and
concurrent septic shock had a higher risk of
mortality.
 pneumothorax due to barotrauma, tension
pneumothorax, and concurrent septic shock
were significantly and independently
associated with death.
TAKE HOME MESSAGE

 KEEP A TAB ON LUNG VOLUMES WITH RESPECT

TO IBW …ALONG WITH PRESSURES.
 LEARN NEW STETHOSCOPE IN ICU : USG
PROBE.