pleural perfusion

8/14/2019 Pleural perfusion

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PLEURAL EFFUSIONSPLEURAL EFFUSIONS


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Anatomy of pleural membraneAnatomy of pleural membrane

and pleural spaceand pleural space

Pleural membrane consists of parietal

pleura and visceral pleura A space situated between parietal and

visceral pleura is called pleural space

It is normally filled with 5 - 10 milliter

of serous fluid


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Parietal pleura

Receiving its blood supply from thesystemic circulation and containing

sensory nerve ending

Anatomy of pleural membrane

and pleural space


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Visceral pleura

Receiving its blood supply from the low

pressure pulmonary circulation and

containing no sensory nerve fibers


and pleural space


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Pleural space

A potential space that is situated

between parietal and visceral pleura

and normally filled with 5-10 ml of

serous fluid,which serves as a coupling

system


and pleural space


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EtiologyEtiology

from the capillaries in theparietal pleura,

from interstitial spaces of the lung

via the visceral pleura,

from theperitoneal cavity through

small holes in the diaphragm.
http://wikidoc.org/index.php/Capillarieshttp://wikidoc.org/index.php/Pleural_cavityhttp://wikidoc.org/index.php/Pleural_cavityhttp://wikidoc.org/index.php/Peritoneal_cavityhttp://wikidoc.org/index.php/Diaphragm_%28anatomy%29http://wikidoc.org/index.php/Diaphragm_%28anatomy%29http://wikidoc.org/index.php/Peritoneal_cavityhttp://wikidoc.org/index.php/Pleural_cavityhttp://wikidoc.org/index.php/Pleural_cavityhttp://wikidoc.org/index.php/Capillaries


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EtiologyEtiology

This fluid is normally removed bylymphatics in the visceral pleura, whichhave the capacity to absorb 20 times morefluid than is normally formed.

When this capacity is overwhelmed,either through excess formation (from theinterstitial spaces of the lung, the parietal

pleura, or the peritoneal cavity )ordecreased lymphatic absorption, a pleuraleffusion develops.
http://wikidoc.org/index.php/Lymphaticshttp://wikidoc.org/index.php/Lymphatics


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Mechanism of formation-resorptionMechanism of formation-resorption

of pleural fluidof pleural fluid

Parietal Visceralpleura pleura

Hydrostaticpressure(30)

Permeabilityof systemic

circulation(34)

Pressure of pleuralspace (5)

Permeability of pleural

fluid (8)

11

34

34-(5+8+11)=105+8+30-34=9


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The mechanisms that lead to accumulationThe mechanisms that lead to accumulation

of pleural fluidof pleural fluid

l. Increased hydrostatic pressure in microvascular

circulation(congestive heart failure)

2. Decreased oncotic pressure in microvascularcirculation(severe hypoalbuminemia )

3. Decreased pressure in the pleural space (complete lung collapse)


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The mechanisms that lead to accumulation ofThe mechanisms that lead to accumulation of

pleural fluidpleural fluid

4.Increased permeability of themicrovascular circulation(pneumonia)

5. Impaired lymphatic drainage from thepleural space (malignant effusion)

6. Movement of fluid from peritoneal space( ascites )


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Increased Fluid EntryIncreased Fluid Entry

Decreased pleural pressure

i.e. Significant atalectasis,

reduces pressures around nearbyvessels.

Decreased plasma oncotic pressure

Hypoalbuminemia alone notusually enough but can lowerthreshold for other factors


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Increased Fluid EntryIncreased Fluid Entry

Increased permeability

Increase in fluid conductance or

protein permeability

Increased microvascular pressure

Usually increased venous outflowpressure. Arterial pressures usuallynot transmitted due to capillaryresistance. Thought to be lung

interstitial fluid when hydrostaticpressure.


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Decreased Fluid ExitDecreased Fluid Exit

Reflects a reduction in lymphatic function.

Much of how is speculative.

There are intrinsic and extrinsic factors.


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Intrinsic

Prevent ability of lymphatic vessels to

transport fluid- products of inflammation,

endocrine problems (hypothyroidism),

direct injury (chemotherapy, radiotherapy),

infiltration with cancer.


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Extrinsic

Limitation of respiratory motion (diaphragm

paralysis, lung collapse), compression oflymphatics (pleural fibrosis, pleural granulomas),

blockage (pleural malignancy), increased systemic

venous pressure (only acutely because chronically

lymphatics can adapt), decreased liquidavailability (ie after pneumothorax liquid contacts

fewer lymphatic openings)


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Two kinds of pleural effusionsTwo kinds of pleural effusions

Transudates and exudatesTransudates and exudates

A transudative pleural effusion occurs

when systemic factors that influence the

formation and absorption of pleural

fluid are altered.

The leading causes of transudativepleural effusions in the United States

are left ventricular failure and cirrhosis.


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Clinical HistoryClinical History

Dyspnea: most common symptom; effusionusually at least 500mL; underlying disease may

also contribute

Chest pain: sharp or stabbing; worse withdeep inspiration; diminishes with increase in

size of effusion; signifies pleural irritation

Other signs and symptoms dependent onunderlying disease process (TB: sweats,

weight loss, hemoptysis)


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Physical ExamPhysical Exam

Decreased breath sounds

Dullness to percussion

Decreased tactile fremitus

Egophony

Pleural friction rub


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Usually not present until >300mL of pleural fluid

Egophony: Egophony is the Greek word for"Voice of the Goat". This sound is the "EEEEE" to

"AAAAA" conversion that a person will make

when being asked to say "EEEEE" while the

auscultator listens to the lungs which is heard by

the auscultator as "AAAAA" through the

stethoscope. .


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Friction rub: visceral and parietal pleurae become

inflamed and roughened. The inflamed

membranes will stick together. As the therapistauscultates the chest wall, the rubbing together of

the inflamed membranes will cause the patient to

experience pain and stop breathing - a maneuver

called splinting. The pain is caused by the stickingtogether of the membranes and the pulling apart of

those membranes with continued breathing.


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DiagnosisDiagnosis

Pleural effusion is usually diagnosed on the

basis of the history of your family and

physical exam, and confirmed by chestx-ray.

Chest films acquired in the lateral decubitus

position (with the patient lying on theirside) are more sensitive, and can pick up as

little as 50 ml of fluid.
http://wikidoc.org/index.php/X-rayhttp://wikidoc.org/index.php/X-ray


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At least 300 ml of fluid must be present beforeupright chest films can pick up signs of pleuraleffusion (e.g., blunted costophrenic angles).

Once accumulated fluid is more than 500 ml, thereare usually detectable clinical signs in the patient,such as decreased movement of the chest on theaffected side, dullness to percussion over the fluid,diminished breath sounds on the affected side,decreased vocal fremitus and resonance, pleuralfriction rub, and egophony.
http://wikidoc.org/index.php/Costophrenic_anglehttp://wikidoc.org/index.php/Fremitushttp://wikidoc.org/index.php/Egophonyhttp://wikidoc.org/index.php/Egophonyhttp://wikidoc.org/index.php/Fremitushttp://wikidoc.org/index.php/Costophrenic_anglehttp://wikidoc.org/index.php/Costophrenic_angle


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XX


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UltrasoundUltrasound

Ultrasound

Aids in identification of loculated effusions

Aids in differentiation of fluid from fibrosis

Aids in identification of thoracentesis site

Available at bedside


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CT ScanCT Scan

Aids in differentiation of

Lung consolidation vs. Pleural effusionCystic vs. Solid lesionsPeripheral lung abscess vs. Loculated emypema

Aids in identification of

Necrotic areasPleural thickening, nodules, massesExtent of tumor


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thoracentesisthoracentesis..

Once a pleural effusion is diagnosed, the

cause must be determined. Pleural fluid is

drawn out of the pleural space in a processcalled thoracentesis. A needle is inserted

through the back of the chest wall into the

pleural space.
http://wikidoc.org/index.php/Thoracentesishttp://wikidoc.org/index.php/Thoracentesishttp://wikidoc.org/index.php/Thoracentesishttp://wikidoc.org/index.php/Thoracentesishttp://wikidoc.org/index.php/Thoracentesis


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thoracentesisthoracentesis..

Only symptomatic pleural effusions or

effusions larger than 50% of hemithorax

require thoracentesis or chest tube drainage.Most resolve spontaneously.
http://wikidoc.org/index.php/Thoracentesishttp://wikidoc.org/index.php/Thoracentesishttp://wikidoc.org/index.php/Thoracentesis


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thoracocentesis

T ki d f l l ff iT ki d f l l ff i


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Two kinds of pleural effusionsTwo kinds of pleural effusions

Transudates and exudatesTransudates and exudates

Transudate Exudate Cause non-inflammatory flammatory,tumor

Apperance light yellow yellow, purulent

Specific gravity 1.018

Coagulability unable able

Revalta test negative positive

Protein content 30g/L

P. To serum Pre < 0.5 > 0.5

LDH < 200 I U/ L > 200 I U / L

P. To s < 0.6 > 0.6

Cell count < 10010 6/ L > 50010 6 / L

Differential cell Lymphocyte Different


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Transudative and exudativeTransudative and exudative

pleural effusionspleural effusionsdistinguished by measuring the lactate

dehydrogenase (LDH) and protein levels in

the pleural fluid. Exudative pleuraleffusions meet at least one of the following

criteria, whereas transudative pleural

effusions meet none:


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Light's criteriaLight's criteria

Previously criteria proposed by Light for an

exudative effusion are met if at least one of

the following exists (Light's criteria) 1. pleural fluid protein/serum protein >0.5

2. pleural fluid LDH/serum LDH >0.6

3. pleural fluid LDH more than two-thirdsnormal upper limit for serum


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The above criteria misidentify ~25% of transudatesas exudates. If one or more of the exudativecriteria are met and the patient is clinically thought

to have a condition producing a transudativeeffusion, the difference between the protein levelsin the serum and the pleural fluid should bemeasured. If this gradient is greater than 31 g/L

(3.1 g/dL), the exudative categorization by theabove criteria can be ignored because almost allsuch patients have a transudative pleural effusion.


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If a patient has an exudative pleural

effusion, the following tests on the pleural

fluid should be obtained: description of thefluid, glucose level, differential cell count,

microbiologic studies, and cytology


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Glucose is decreased with cancer, bacterial

infections, orrheumatoid pleuritis. If cancer

is suspected, the pleural fluid is sent forcytology. If cytology is negative, and

cancer is still suspected, either a

thoracoscopy, or needle biopsy of the pleuramay be performed.
http://wikidoc.org/index.php/Rheumatoid_pleuritishttp://wikidoc.org/index.php/Thoracoscopyhttp://wikidoc.org/index.php/Thoracoscopyhttp://wikidoc.org/index.php/Rheumatoid_pleuritishttp://wikidoc.org/index.php/Rheumatoid_pleuritis


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Effusion Due to Heart FailureEffusion Due to Heart Failure

The most common cause of pleural effusion

is left ventricular failure. The effusionoccurs because the increased amounts of

fluid in the lung interstitial spaces exit in

part across the visceral pleura. Thisoverwhelms the capacity of the lymphatics

in the parietal pleura to remove fluid.


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A diagnostic thoracentesis should be

performed if the effusions are not bilateral

and comparable in size, if the patient isfebrile, or if the patient has pleuritic chest

pain, to verify that the patient has a

transudative effusion. Otherwise the patientis best treated with diuretics.


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Parapneumonic EffusionParapneumonic Effusion

associated with bacterial pneumonia, lung

abscess, or bronchiectasis and are probably

the most common cause of exudativepleural effusion in the United States.

Empyema refers to a grossly purulent

effusion.


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Factors indicating the likely need for a procedure

more invasive than a thoracentesis (in increasing

order of importance) include: loculated pleural fluid

pleural fluid pH < 7.20

pleural fluid glucose < 3.3 mmol/L (


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Effusion Secondary to MalignancyEffusion Secondary to Malignancy

lung carcinoma, breast carcinoma, and

lymphoma.

The pleural fluid is an exudate, and itsglucose level may be reduced if the tumor

burden in the pleural space is high.

The diagnosis is usually made via cytologyof the pleural fluid.


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Tuberculous PleuritisTuberculous Pleuritis

usually associated with primary TB and arethought to be due primarily to ahypersensitivity reaction to tuberculousprotein in the pleural spacePatients with tuberculous pleuritis present

with fever, weight loss, dyspnea, and/orpleuritic chest pain. The pleural fluid is an exudate with

predominantly small lymphocytes. Thediagnosis is established by demonstrating

high levels of TB markers in the pleural fluid


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HemothoraxHemothorax

Most hemothoraces are the result of trauma;

other causes include rupture of a blood

vessel or tumor.Most patients with hemothorax should be

treated with tube thoracostomy


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PneumothoraxPneumothorax

Pneumothorax is the presence of gas in the

pleural space.


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..Introductory remarks

Pneumothorax, like chest wall injury, is a common

sequel of blunt thoracic injury.

Because the intrapleural pressure is normally

negative during inspiration, any communication

with atmospheric pressure cause accumulation o

air in the pleural space.

The communications can occur through rather thechest wall or the lung. According to this,

pneumothorax was divided into three types.


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Category Closed pneumothorax

Open pneumothorax Tension pneumothorax


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PathophysiologyPathophysiology


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Size of PneumothoraxSize of PneumothoraxRhea and associates :

A = Maximal apical interpleural distance

B = Interpleural distance at midpoint ofupper half of lung

C = Interpleural distance at midpoint of

lower half of lung

Average interpleural distance = A+B+C/3

Small (40%) .


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Introductory RemarksIntroductory Remarks

As the lung collapsed, the hole on its surface decreases in

size and ultimately closes.

When the patient inspires, the hole in the lung surface

reopens as the lung expands, but with expiration the holeagain closes. As pressure in the pleural space increase, the

hole in the pulmonary surface is less and less likely to

open with inspirating effort.

In most cases, when the lung collapses to the point atwhich intrapleural air no longer accumulates with

inspiration, the pneumothorax is stable.


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Clinical FeaturesClinical Features

In slight pneumothorax (lung collapses is less

than 30%), both circulation and respiration are

little impaired, and most patients have no

symptoms.

As the pressure in the ipsilateral pleural cavity

increases (lung collapses is more than 30%), the

patients have the symptoms of chest distress,short of breath, chest pain.


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Clinical featuresClinical features

Physical examination shows that trachea is

pushed toward the other side (normal side),

decreased or diminished breath sound.

The X-ray examination indicates that the lung is

collapsed and air accumulated in the pleural

space, sometimes with little pleural effusion.


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TreatmentTreatment


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TreatmentTreatment

1. Slight (5 to 10%) pneumothorax can be treated

conservatively. The rapid reabsorption of the

air should be verified radiologically. (About 1-2 weeks)

2. Moderate (10 to 30%) pneumothorax often can

be evacuated through needle puncture, but, ifrecurrence occur, it should be drained through

an intercostals tube.


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TreatmentTreatment

Complete pneumothorax quickly can

become compressive.

Intercostals tube drainage is indicated. In the same times, patients with chest

tube placed for trauma should

routinelyreceive antibiotics to prevent infection.


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0pen0pen pneumothoraxpneumothorax


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The incidence of open pneumothorax in peacetime is low while in wartime generallyhigher but varies to some extent according to

the weapons used.Open pneumothorax is usually produced by a

stab or gunshot wound, or by some other sharpobject.

Open or communicating pneumothorax isreferred to as a sucking wound.

The pleural cavity communicates directly with

the atmosphere.


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Open pneumothorax mdiastinal flutter is a form o

internal paradoxical motion where the

mediastinum swings to one side or the other

according to the phase of respiration.

During inspiration, air is more easily aspirated

through the wound than through the glottis, and

the mediastinum is attracted towards the particallyinflated healthy lung; this increases the

pneumothorax.


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During expiration, on the other hand, air escapes

more quickly through the wound than through the

glottis consequently, the mediastinum shifts in

the other direction.

The repercussions of mediastinal flutter are often

aggravated both by the increased dead space

created by rebreathing and by the cyclical torsionof the vascular pedicles.

Symptom and examination.


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DURING INSPIRATION--air enters more easily through the wound than through the glottis

--pulmonary collapse increase

--air passes from the collapsed to the intact lung

--the mediastinum sways towards the intact lung


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ManagementManagement


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Open pneumothorax should be closed with sterile

dressing and then drained.

Drainage must be immediate andeffective;otherwise the patients condition will

deteriorate soon after the chest wall is closed.

The patient must be in full expiration at the

moment the wound is occluded.


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M


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It can be minimized by:

1) removing the occlusive dressing from

time to time and asking the patient tocough loudly or by

2) covering the wound with a valve made

from a colostomy bag with an open

corner. Immediate underwater seal or

suction drainage is indicated in every

case .

M t


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The patient should then be intubated and,if necessary, ventilated with positive

pressure.

When the patients were sent to thehospital, progressive management is thatventilation and blood transfusion toantishock.

The thoracic wound should then bedebrided and explored, and all foreign

bodies and clots moved from the pleuralcavity.


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It may be necessary to enlarge the wound to give

access to intrathoracic injuries found during

routine exploration .

The pleural cavity should be cleaned thoroughly

and topically effective antibiotics applied before

closure. It should be use antibiotics to prevent

infection;Asking the patient to cough and sputum and move

early.


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Tension pneumothoraxTension pneumothorax


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In tension pneumothorax, air continues to

accumulate in the pleural space with each

inspiratory effort.

The fact that the hole opens with

inspiration and closes with expiration

produces a valve-like mechanism that

causes the pneumothorax to increase in sizewith each respiratory cycle and produces a

tension pneumothorax.


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PathophysiologyPathophysiology This pathophysiology is easily and

quickly reversed with decompression

of the pneumothorax Some of the

physical findings associated with

tension pneumothorax are the same asthose seen with any pneumothorax,

but may be more pronounced.

There are no breath sounds on the

injured side, and subcutaneous airmay develops in face, neck and chest.


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The trachea may be deviated away from the side

of the injury.

Shock may also be present and, because there isinterference with venous retun to the right atrium,

neck veins may be distended.

Immediate pleural drainage is mandatory in all

case of tension pneumothorax ;sometimes it mustbe performed even before X-ray .


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If the necessary equipment is unavailable,

temporary decompression can be obtained and

venous return restored by implanting several

large-bore needles into the upper chest wall and

asking the patient to cough;

this opens the pneumothorax ,while large enough

to ease tension , the needles are of sufficientlysmall caliber (compared with the glottis )not to

induce mediustinal flutter.


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Alternatively a large-lore needle can be

implanted through a finger cot.

These ploys are largely expedient. Under normal circumstance, the basic

maneuver is to evacuate the thorax through an

intercostal tube (with suction if possible).


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Definitive TreatmentDefinitive Treatment


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Definitive TreatmentDefinitive Treatment

Needle puncture or drainage with underwater

seal or, in most instances, suction drainage

followed by:

1)X-ray to verify pulmonary expansion,

2)investigation of the cause if the lung has not re-

expand,

3) thorcotomy in the even of a massive air leak .


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52


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52

80% 1200

l

2 Male,52y, abruptly chest pain , dyspnea,for 4days ,spontaneous pneumothorax on right chset wall lung

compression 80%, air exhaust about 1200ml

soon

cough


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pleural perfusion

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