0521779407-17 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:57
1188 Pneumothorax■Chest tube-for primary spontaneous ptx that failed aspiration, recur-
rent primary spontaneous ptx, or secondary spontaneous ptx.
➣Insert into 2nd intercostal space anteriorly or directly into locu-
lated air under CT or fluoroscopic guidance
➣Place initially to waterseal
➣If air leak >24 hours, connect to 20 cm H 2 O wall suction
➣24 hours after resolution (no air leak, nl CXR), place tube to
waterseal; repeat expiratory CXR in 3–6 hours
➣If no recurrence, clamp tube for 12–24 hours under close obser-
vation to look for slow air leaks
➣If ptx recurs, return to suction; if no recurrence, remove tube.
➣Side effects-pain, pleural infections, reexpansion pulmonary
edema
➣Contraindications – unclear anatomy (ptx vs bulla); obtain chest
CT
■Pleurodesis – recurrent primary spontaneous or secondary sponta-
neous ptx associated with respiratory compromise.
➣Sclerosing agents: talc, tetracycline, minocycline, bleomycin, do-
xycycline
Side effects – pain, fever, ARDS
Contraindications –
absolute: allergy to chemical sclerosing agent, trapped or
unexpanded lung
relative: likelihood of future lung transplant; young patient
with emphysema – treat these patients with VATS with sta-
pling of blebs and abrasion of apical pleura
➣Multiple sclerosing strategies:
Instillation via chest tube
Surgical thoracoscopy, thoracotomy -for air leaks >7 days,
failed chemical pleurodesis, recurrent ptx; blebs/bullae are
resected; pleurodesis via partial pleurectomy, physical abra-
sion of pleural surfaces or installation of sclerosing agents
Side effects- fevers, wound infection, air leaks, pneumonia,
risks of general anesthesia. Thoracoscopic procedures require
longer OR time, greater treatment failures, but require less
anesthesia, lesser post-op lung function abnormalities, and
less wound pain
Contraindications for thoracoscopic surgery:
inability to tolerate one lung ventilation, extensive
adhesion in thoracic cavity, complex anatomical
variation, small thoracic cavity