Diferencia entre revisiones de «Iatrogenic pneumothorax»
(Created page with "==Background== ==Clinical Features== ==Differential Diagnosis== ==Diagnosis== {{Pneumothorax diagnosis}} ==Management== ==Disposition== ==See Also== *Pneumothorax (mai...") |
Sin resumen de edición |
||
| (No se muestran 21 ediciones intermedias de 4 usuarios) | |||
| Línea 1: | Línea 1: | ||
==Background== | ==Background== | ||
===Causes<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010." Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>=== | |||
*Transthoracic needle aspiration (24%) | |||
*[[central line: subclavian|Subclavian vessel puncture]] (22%) | |||
*[[Thoracentesis]] (22%) | |||
*Pleural biopsy (8%) | |||
*[[Mechanical ventilation]] (7%) | |||
==Clinical Features== | ==Clinical Features== | ||
''Consider in all patients with sudden [[Deterioration After Intubation (DOPE)|deterioration after intubation]]'' | |||
*Sudden onset pleuritic [[chest pain]] | |||
*[[Tachypnea]], [[hypoxemia]], increased work of breathing | |||
*Reduced ipsilateral lung excursion | |||
*[[Hypotension]]→ [[tension pneumothorax]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Pneumothorax types}} | |||
== | ==Evaluation== | ||
{{Pneumothorax diagnosis}} | {{Pneumothorax diagnosis}} | ||
{{Lung ultrasound pneumothorax}} | |||
==Management== | ==Management== | ||
''[[Supplemental oxygen]] ([[non-rebreather mask]]) initially for all'' | |||
===Unstable=== | |||
*[[Needle decompression]] followed by [[chest tube]] insertion | |||
===Stable<ref name="BTC">"Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010." Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>=== | |||
====Not on Positive Pressure==== | |||
*Observation (majority) vs. aspiration | |||
*[[Chest tube]] if become symptomatic | |||
====On Positive Pressure Ventilation==== | |||
*[[Needle decompression]] followed by [[chest tube]] insertion | |||
{{Needle aspiration of pneumothorax}} | |||
{{Chest tube size table}} | |||
==Disposition== | ==Disposition== | ||
*See Management section | |||
==See Also== | ==See Also== | ||
*[[Pneumothorax (main)]] | *[[Pneumothorax (main)]] | ||
*[[Deterioration After Intubation (DOPE)]] | |||
==External Links== | ==External Links== | ||
| Línea 19: | Línea 50: | ||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pulmonary]] | |||
Revisión actual - 16:09 12 oct 2019
Background
Causes[1]
- Transthoracic needle aspiration (24%)
- Subclavian vessel puncture (22%)
- Thoracentesis (22%)
- Pleural biopsy (8%)
- Mechanical ventilation (7%)
Clinical Features
Consider in all patients with sudden deterioration after intubation
- Sudden onset pleuritic chest pain
- Tachypnea, hypoxemia, increased work of breathing
- Reduced ipsilateral lung excursion
- Hypotension→ tension pneumothorax
Differential Diagnosis
Pneumothorax Types
Evaluation
Clinically Stable
Defined as having all of the following:
- Resp rate < 24
- Heart rate 60-120 beats per minute
- Normal BP
- SaO2 >90% on room air and patient can speak in whole sentences
Workup
- CXR
- Displaced visceral pleural line without lung markings between pleural line and chest wall
- Upright is best
- Expiratory films DO NOT improve accuracy[2]
- Lateral decubitus films with suspected side up do increase sensitivity. Good approach in pediatrics to avoid CT
- Supine CXR = deep sulcus sign
- CT Chest
- Very sensitive and specific
Lung ultrasound of pneumothorax
- No lung sliding seen (not specific for pneumothorax)
- May also identify "lung point": distinct point where you no longer see lung sliding (pathognomonic)
- Absence of lung sliding WITHOUT lung point could represent apnea or right mainstem intubation
- Evaluate other intercostal spaces because pneumothorax may only be seen in least dependent area of thorax
- NO comet tail artifact
- Bar Code appearance/"Stratosphere" sign on M-mode (absence of "seashore" waves)
- Ultrasound has greater sensitivity than chest x-ray for pneumothorax in trauma patients [3]
Management
Supplemental oxygen (non-rebreather mask) initially for all
Unstable
- Needle decompression followed by chest tube insertion
Stable[1]
Not on Positive Pressure
- Observation (majority) vs. aspiration
- Chest tube if become symptomatic
On Positive Pressure Ventilation
- Needle decompression followed by chest tube insertion
Needle Aspiration of Pneumothorax
- Use thoracentesis or "pig-tail" kit, if available
- Place in 2nd IC space in midclavicular line or 4th/5th IC space in anterior axillary line
- Withdraw air with syringe until no more can be aspirated
- Assume a persistent air leak (failure) if no resistance after 4 liters of air has been aspirated AND the lung has not expanded
- Once no further air can be aspirated:
- Option 1
- Place closed stopcock and secure catheter to the chest wall
- Obtain CXR four hours later
- If adequate lung expansion has occurred, remove catheter
- Following another two hours of observation, obtain another CXR
- If the lung remains expanded, may discharge patient
- Option 2
- Leave catheter in place
- Attached a Heimlich (one-way) valve
- May discharge with follow-up within two days
- Option 1
- If 2.5 L of air has been aspirated, and a significant PTX remains, tube thoracostomy is indicated
- NEJM video on needle aspiration of pneumothorax.
Adult Chest Tube Sizes
| Chest Tube Size | Type of Patient | Underlying Causes |
| Small (8-14 Fr) |
|
|
| Medium (20-28 Fr) |
|
|
| Large (36-40 Fr) |
|
Disposition
- See Management section
See Also
External Links
References
- ↑ 1.0 1.1 "Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010." Thorax 2010;65:ii18-ii31 doi:10.1136/thx.2010.136986 PDF
- ↑ Eur Respir J. 1996 Mar;9(3):406-9
- ↑ Nagarsheth K, Kurek S. Ultrasound detection of pneumothorax compared with chest X-ray and computed tomography scan. Am Surg. 2011 Apr;77(4):480-4. PMID: 21679560.
- ↑ Inaba Et. al J Trauma Acute Care Surg. 2012 Feb;72(2):422-7.
- ↑ Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations.