4/13/2016 Physiology Review Pressure Relationships: Intrapulmonary Pressure ~ within the alveoli, rises & falls with phase of breathing, equalizes itself with the atmospheric pressure outside of the body. 1 Intrapleural Pressure ~ within the pleural cavity, always about 4mm Hg less than the pressure inside the alveoli, therefore it is negative relative to both the intrapulmonary & atmospheric pressures. 1 Transpulmonary Pressure ~ difference between the intrapulmonary & intrapleural pressures. This is the force that keeps the airspace of the lungs open, preventing atelectasis , or collapsed lung. 1 Anatomical Review Pneumothorax Respiratory Tract: Presence of air in the pleural space. 2 2 Trachea Bronchi Bronchioles Alveoli Alveolar sacs 1 Classified as spontaneous or traumatic. Spontaneous ~ occurs without preceding trauma or obvious Each lung is suspended in its own cause. 2 cavity inside the pleural cavity and is Primary ~ otherwise healthy person without underlying connected to the mediastinum. 1 lung disease. 2 The pleura covers the entire external Secondary ~ complication of underlying lung disease, surface of each lung, secreting fluid that most commonly COPD. 2 allows the lungs to glide with the thorax Traumatic ~ occur as result of direct or indirect trauma to the during respiration. 1 chest. 2 Anatomical Review Pneumothorax Term first described in 1803. 3 1st modern description of PTX occurring in healthy people (PSP) in 1932. 3 Significant global health problem ~ 7.4/100k cases per year reported in men in US, 37/100k in UK. Less than half that in women. 4 Risk factors ~ Family Hx, Marfan, homocystinuria, thoracic endometriosis, & smoking. 4 4 studies that included 505 patients, smoking habit associated with 7 x higher risk of PSP in light smokers than non, & 21 x in moderate smokers, & 102 x in heavy smokers (>pack/day). 4 No evidence of relationship between onset of PTX & physical activity, onset just as likely to occur during sedentary activity. 3 1 4/13/2016 Case Report Case Report DOI: 22 September 2015 21 yo, AA male. Tuesday practice of bye week. 5’10”, 200 lb. Full pads but “Thud” type drill. Previous Sx, core muscle Period and drill changed the next play. Initially continued play for a few minutes release/repair 2012. with no mention of distress. No known underlying lung Began coughing. conditions. C/O “just feeling weird” & “Funny feeling in throat”. Redshirt Junior Running Back. Began squatting & bending over trying to alleviate symptoms. “10% ‘er” No C/O loss of breath or difficulty breathing at that time. Case Report Case Report DOI: 22 September 2015 Not permitted to RTP. Tuesday practice of bye week. Removed to ATR. Full pads but “Thud” type drill. All vitals WNL. Began c/o pain in the R side of back and first c/o abnormality with respiration approx 30-40 minutes post injury. Lung exam auscultation now absent of breathing sounds on the R. Fluro-scan of chest positive for absence of lung markings over R lung. Transported to ER. Case Report Case Report ER Treatment CXR positive for large R side PTX. 4 2 4/13/2016 Case Report Case Report ER Treatment 09.24 No change. CXR positive for large R side PTX. ER Thoracostomy ~ placement of small bore 09.25 Diagnosis of air leak “pig tail” chest tube. & PTX increase. 09.26 Larger bore chest tube placement under fluoroscopy. Case Report Case Report ER Treatment 09.27 No change. CXR positive for large R side PTX. 09.28 Air leak return due to likely un-viewable ER Thoracostomy ~ placement of small bore pulmonary bleb ~ a blister like air pocket that 2 “pig tail” chest tube. forms on the surface of the lung. Post tube placement ~ B/L breath sounds equal, CXR Blebs are found at lung apices at confirmed good tube placement, expanded lung fields thoracoscopy & CT scan in 90% of PSP 3 B/L. cases. Admitted to room for observation & kept on suction. 09.29 Lung remained completely expanded, though leak remained. 09.30 Fever present. PTX enlarged. CT basilar atelectasis & possible bleb at apex. Case Report Case Report Monitored next day 09.23 09.30 OR for VATS procedure, apical bleb Noted elevated creatinine levels, but no treatment required. stapling, & pleurodesis . CXR & CT No evidence of bleb on lung, but determined likely cause of air leak at apex was bleb. Post procedure, no lung leak. 10.01 no air leak present on or off of suction. 3 4/13/2016 Case Report Case Report th 10.02 No air leak, placed back on water 02.2016 Participated in 4 Quarter seal. program for 2 weeks with no restrictions. 10.03 plan to discharge when drainage of fluid stops. DNP spring practice. 10.04 120cc / 24 hours. 10.05 <10cc / 24 hours. 2016 ? Chest tube removed CXR remained stable post CT removal. 10.06 discharged with orders of no weight lifting for 1 week, initiate light aerobic activity as tolerated. 14 nights in hospital ~ 18 lbs. lighter. Case Report References 10.15 F/U with pulmonologist. 1. Marieb, Elaine N., (1998). Human Anatomy & Physiology (4 th ed.). Menlo Park, CA: The Benjamin/Cummings Publishing Company, Inc. 2. Murray, John, et al., (2005). Murray & Nadel’s Textbook of Respiratory Medicine (4 th ed.). Philadelphia, PA: Elsevier Saunders, Inc. 3. MacDuff, Andrew, et al., “Management of Spontaneous Pneumothorax: British Thoracic Society Pleural Disease Guideline 2010.” Thorax: An International Peer-Reviewed Journal for Health Professionals in all Aspects of Respiratory Medicine. Vol. 65, Issue Supplement 2 (2010). Web. 8 February 2016. 4. Light, Richard. “Primary Spontaneous Pneumothorax in Adults.” Up to Date. 2015: Wolters Kluwer. Web. 8 February 2016. 5. Campo, MD, Carlos E. Personal Interview & Diagnostic Imaging Review. 8 February 2016. Case Report 10.22 initiated cardio work. Jogging boxes, ladder work, jump rope, battle ropes, etc. 10.26 cleared to participate in non-contact practice with goal of continued conditioning and RTP. D/C practice & DNP remainder of 2015. 4.