Physiotherapy management in Pneumothorax

Definition:
 Air collects
between the
visceral and parietal
pleura.
 Air in the pleural
space will allow the
lung to more away
from the chest wall
and the lung will
partially deflate.
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Types:
 Spontaneous
 Traumatic
Spontaneous: This can occur at any age but is most common in
young men who are otherwise apparently healthy.
 It may also be associated with emphysema and chronic bronchitis in
men over 50 years of age, or result from other underlying disease or
be associated with mechanical ventilation.
 These spontaneous causes may be summarised as:
 airflow limitation due to asthma or bullous emphysema
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 Positive pressure ventilation, particularly with the use of positive
end-expiratory pressure (PEEP)
 • Infections (e.g. Staphylococcal pneumonia, tuberculosis)
 • Cystic fibrosis
 • Marfan's syndrome
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Traumatic pneumothorax: A traumatic pneumothorax may be
caused by:
 Penetrating injury to the chest (e.g. by stab wound or a bullet)
 Non-penetrating injury to the chest wall (e.g. impact of an RTA
involving the chest)
 During the insertion of an intravenous (e.g. subclavian) line
 During surgery to the chest wall
 During pleural aspiration or biopsy
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 When the chest wall remains intact, the condition is termed a closed
pneumothorax, but if the chest wall is opened following the trauma
the term used is open pneumothorax.
 In the presence of an open wound, the emergency treatment is the
application of a large dressing pad over the chest wall.
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Pathological changes: As air escapes into the pleural cavity and
reduces the subatmospheric pressure the lung collapses.
 The hole in the pleura closes, the air becomes absorbed and the lung
gradually re-expands.
 Sometimes this does not happen and the hole in the pleura becomes
like a valve.
 Air then enters the pleural cavity on inspiration but cannot escape
during expiration.
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 The lung remains collapsed and, as air accumulates in the pleural
cavity and the pressure increases, there is displacement of the heart
together with compression of the other lung and great vessels.
 This is termed a tension pneumothorax and has to be treated as an
emergency by needle aspiration and thereafter by insertion of a drain
connected to an underwater seal.
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Clinical features:
 The onset is often sudden with severe chest pain and progressive
breathlessness. There is diminished chest movement unilaterally,
and an absence of breath sounds often over the apex of the affected
side.
 Other clinical features may be related to the underlying pathology
(e.g. emphysema).
 In a patient with known lung disease a pneumothorax should always
be considered if the patient becomes more breathless for no apparent
reason.
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 Subcutaneous emphysema may develop at the time of the pleural air
leak or following the insertion of an intercostal drain when air may
track into the subcutaneous tissues. Subcutaneous air results in a
crackling sensation on palpation.
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Investigations:
 The chest X-ray
shows absence
of lung
markings and
the edge of the
collapsed lung
can be seen.
This will
confirm the
diagnosis.
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 Inspiratory and expiratory radiographs will help define the visceral
pleura where there is a small pneumothorax.
TREATMENT:
 A small pneumothorax requires no treatment apart from a few days
bedrest until it resolves.
 A large pneumothorax (more than 25% of the pleural space is filled
with air) is treated by needle aspiration or by an intercostal drain
which connects the pleural cavity to a drainage bottle creating an
underwater seal.
 The drain is removed when there are no more bubbles in the
drainage bottle - indicating that the pleural cavity is free of air.
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 Surgery is indicated for a recurrent pneumothorax.
 Pleurodesis comprises the insertion of a powder into the pleural
cavity. This acts as an irritant to the pleural surfaces causing them to
adhere to each other.
 Pleurectomy is the removal of the parietal pleura from the chest wall
leaving a raw surface to which the visceral layer sticks. A hole in the
visceral pleura may have to be stitched.
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Physiotherapy in pneumothorax:
 A patient who has an underwater drainage system requires
expansion breathing exercises to re-expand the lung.
 Also, full-range shoulder movements are necessary to maintain
shoulder, shoulder girdle and thoracic mobility.
 This treatment is generally given 3-4 times daily until the drain is
removed.
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 Following pleurodesis, expansion breathing exercises are essential
to ensure that when the adhesions form between the layers of the
pleura the lung is fully expanded.
 The patient must be taught to practice expansion breathing exercises
so that thoracic mobility is maintained, otherwise there may be
sharp pleuritic pain if the intrapleural adhesions become too
contracted.
 If the lung does not re-expand within 36 hours then a second
operation is required.
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Physiotherapy management in Pneumothorax

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Physiotherapy management in Pneumothorax