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Pneumothorax and Pulmonary Embolism VineshHiraniLearningobjectives • Pneumothorax (PTX) and pulmonaryembolism (PE) • Whatisit? • Riskfactors • Signsandsymptoms • Investigations • Management/treatmentWhatisaPTX? • Buildup of air in pleural cavity • Leads to increase pressure on lungs • Developmentof‘one-wayvalve’ (medicalemergency)rax • Buildup of pressure can also be from: • Blood→ haemothorax • Fluid→ hydrothoraxTypesofPTXandriskfactors • Spontaneous vs.traumatic • Primary vs.secondarySpontaneousPTX • PrimaryPTXi.e.nolung diseasepresent • Typical picture • Male, tall,thin andyoung (20-40 year old) • Smoking • Ifsomeone has smoked >20 pack years, they are likely to have some evidence of lung disease • SecondaryPTX i.e.lungdiseasepresent • COPD –most commoncause (60-70%) • Pneumonia • Acute asthma • Fibrotic lung disease e.g. CF, lung fibrosis • Marfans syndrome • IatrogenicTraumaticPTX • Iatrogenic i.e.procedurally induced • Subclaviancentral venousline • Biopsy • Non-iatrogenic trauma • RTC • Falls • Assaulti.e. stabbingsSignsandsymptoms • Symptoms • Acute,ipsilateralpleuriticchestpain • SoB • Minimal inyoungpatients • Moresevereinsecondary PTXi.e. thosewith lungdiseasesSignsandsymptoms • Unilateral is key • Reducedchestexpansion • Hyper-resonantpercussion • Reduced/quietbreathsounds • IncreasedHR(tachycardia) • IncreasedRR (tachypnoea)Investigations-CXR • Key investigation → CXR • Loss of lung markings • Tip– look from hilar rather than lung edges • Make sure not to miss apices of lungs • Airmay rise totop • Large PTX = >2cm • SmallPTX = <2cm • (Other investigations – bloods and ABG)CXR–whichsideisthePTX?Management • Needleaspiration nd • 16-18G (large bore) cannula in 2 intercostal space, midclavicular line • Chestdrain • Triangle of safety → 5 intercostal space, midaxillary line • Bubbling –means air is escaping from pleural space (continuous? none?) • Swinging –fluidmoving with breath sounds (sign of correct placement) • Trauma vs. Seldingers technique • Contraindications • High INR • Low platelets • Pleural adhesions • Pulmonary bullaeT ensionPTX • Medical emergency • Signs • Haemodynamically unstable • Trachealdeviation • Investigations • Clinicaldiagnosis • Mediastinalshiftto contralateralside • Treatment • Emergencyneedledecompression→ immediatechestdraininsertionManagementWhathappensafterPTX? • Repeat CXR after few weeks to assess for resolution • Potentialforpulmonary oedema72 hoursafterlargePTX • Smoking cessation • Flying • 6 weeksposttreatmentOR 1 weekpostnormalCXR • Diving • Permanently avoided • (Some exceptionssurgically)Questionssofar?WhatisaPE? • Thrombus stuck in pulmonary circulation • Typicallythrombus from pelvis or legs • Rarer origins of thrombus: • Rightventricularthrombus(post-MI) • Septicemboli (rightsidedendocarditis–IVDU?)Virchowstriad • Diagram of Virchows triad • Venousstasis • Vascularendothelialinjury • HypercoaguabilityRiskfactors • Reducedmobility • Hospital admission –VTE prophylaxis • Long haul flights • Occupation – vehicle drivers –taxi, bus, HGV etc. • Recent surgery • Abdomen/pelvis • Hipor knee • Leg fracture • Malignancy • Pregnancyorpostpartum(6weeks) • Hormonaltherapiesi.e. HRTor contraceptivepill • Previoushistory ofVTESignsandsymptoms • 'Triad’of symptoms • SoB • Pleuriticchestpain • Haemoptysis • But only 10% present with triad seen above • Dizziness • SyncopeSignsandsymptoms • High RR (tachypnoea) • High HR (tachycardia) • Cyanosis • Pyrexia • Hypotension • Auscultation - pleuralrub or pleural effusion • Peripheral signs of DVT – unilateral,red, hot swellingof legsMassivePEsignsandsymptoms • Severe hypotension (<90 systolicor <60 diastolic) • Raised JVP • Sideofrightheartstrainduetobackpressure2-LevelWellsscore2-LevelWellsscore • Ifscored more than 4 → CTPA • Positive→treatment • Negative→ proximalleg USS • Ifscored more than 1 → D-dimer • Positive→CTPA • (Canstartanticoagulantswhilstawaiting scan) • Negative→ consideralternatediagnosisPERC • Pulmonary embolism rule-out criteria • Ifscoring any of these, PE cannot be ruled out • Over 50yo • HR> 100bpm, O2 <95% (air) • Unilateralleg swelling • Haemoptysis • Recentsurgeryortrauma • Hormoneuse • PriorPE/DVTInvestigations-CTPA • CT pulmonary angiogram – 1 line imaging (usually) • Contraindications • Allergy to contrast • Renal failure • PregnancyCasecourtesyofJeremyJones,Radiopaedia.org,rID: 6120VQscan • Ventilation/perfusion scan • Measurescirculationofairinlungsbyisotopesvs.bloodcirculation • Preferred choice in pregnancy • Adv -lowerradiationdosetobreasttissue(moresensitiveduring pregnancy) • Disadv-higherradiationvs.CTPAD-dimer • Formed when fibrin cross-links in clots are broken down • High sensitivity butlow specificity: • Cancer • Pregnancy • Recentsurgery • Recenttrauma • Severeinfectionorinflammatory disease • LiverdiseaseOtherinvestigations • Bloods • FBC • U&E • Clottingfactors– INR,PT,PTT • ABG • Respiratory alkalosis • Tachypnoea→poorgasexchange→pHincrease→alkalosis • Type1 respiratoryfailure • Lowoxygen • NormalCO2 • ECG • Normalor sinustachycardia • Signs ofrightventricularstrain(invertedTwave inV1-4) • Rare butclassical S1Q3T3Management • Oxygenifhypoxic • Analgesia • Antiemetics • Anticoagulation–typically DOACs (apixabanorrivaroxaban) • Provoked= 3 months(thenreview) • Unprovoked= 6months • Recurrentor malignancy=indefinite • LMWH(enoxaparin,tinzaparin,dalteparin) • IfDOACscontraindicated • Pregnancy,APSor malignancy • Thrombolysis(IV alteplase)→ massivePE (haemodynamically unstablee.g. saddlePE) • (NB.chestcompressions60-90 minutes) Thank you! Any questions? Next session on lung cancer Monday 4th March at 7PM Vinesh.Hirani@student.manchester.ac.uk