Pneumothorax

Pneumothorax

What is a pneumothorax?

A pneumothorax is a collection of free air in the chest outside the lung that causes the lung to collapse.

Types of pneumothorax

A spontaneous pneumothorax, also referred to as a primary pneumothorax, occurs in the absence of a traumatic injury to the chest or a known lung disease. A secondary (also termed complicated) pneumothorax occurs as a result of an underlying condition.

Causes

• Spontaneously (more commonly in tall slim young males and in Marfan syndrome)
• Following a penetrating chest wound
• Following barotrauma to the lungs^[2][3]

It may also be due to:

• Chronic lung pathologies including emphysema, asthma
• Acute infections
• Chronic infections, such as tuberculosis
• Lung damage caused by cystic fibrosis
• Lung Cancer
• Rare diseases that are unique to women such as Catamenial pneumothorax (due to endometriosis in the chest cavity) and lymphangioleiomyomatosis (LAM).

Symptoms

Almost everyone who has a collapsed lung has the following symptoms:

• Sharp chest pain, made worse by a deep breath or a cough
• Shortness of breath

A larger pneumothorax will cause more severe symptoms, including:

• Chest tightness
• Easy fatigue
• Rapid heart rate
• Bluish color of the skin caused by lack of oxygen

Note: Symptoms may begin during rest or sleep.

Other symptoms that can occur with a collapsed lung include:

• Nasal flaring
• Low blood pressure (hypotension)

Investigations

• Chest x-ray to tell whether there is air outside the lung
• Arterial blood gases

Treatment

A small pneumothorax may go away on its own. You may only need oxygen and rest. The health care provider may use a needle to pull the extra air out from around the lung so it can expand more fully. You may be allowed to go home if you live near the hospital.

If you have a large pneumothorax, a chest tube will be placed between the ribs into the space around the lungs to help drain the air and allows the lung to re-expand.

The chest tube can be left in place for several days. You must stay in the hospital while the chest tube is in place.

Some patients with a collapsed lung need extra oxygen, which helps the air around the lung be reabsorbed more quickly.

Lung surgery may be needed to treat your pneumothorax or to prevent future episodes. The area where the leak occurred may be repaired. Sometimes, a special chemical is placed into the area of the collapsed lung. This chemical causes a scar to form.

Expectations (prognosis)

If you have a collapsed lung, you are more likely to have another one in the future if you:

• Are tall and thin

• Continue to smoke

• Have had two collapsed lungs in the past

How well a person does after having a collapsed lung depends on what caused it.

Complications

• Another collapsed lung in the future

• Shock

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Posted in: Pneumothorax,Respiratory System

Pleural effusion

What is a pleural effusion?

A pleural effusion is an excess accumulation of fluid in the pleural space around the lungs. The pleura are thin membranes that enclose the lungs and line the inside of the chest cavity. The 'pleural space' describes the small space between the inner and outer layers of pleura, which normally contains a small volume of lubricating pleural fluid to allow the lungs to expand without friction. This fluid is constantly being formed through leakage of fluid from nearby capillaries and then re-absorbed by the body's lymphatic system. With a pleural effusion, some imbalance between production and reabsorption of pleural fluid leads to excess fluid building up in the pleural space.

There are two major types of pleural effusion:

• Transudative effusions, where the excess pleural fluid is low in protein; and
• Exudative effusions, where the excess pleural fluid is high in protein

Types of fluids

Four types of fluids can accumulate in the pleural space:

• Serous fluid (hydrothorax)
• Blood ([haemothorax])
• Chyle (chylothorax)
• Pus (pyothorax or empyema)

Causes of Pleural Effusions

Anything that causes an imbalance between production and reabsorption of pleural fluid can lead to development of a pleural effusion. Transudative pleural effusions (those low in protein) usually form as a result of excess capillary fluid leakage into the pleural space. Common causes of transudative effusions include:

• Congestive heart failure;
• Nephrotic syndrome;
• Cirrhosis of the liver;
• Pulmonary embolism; and
• Hypothyroidism.

Exudative effusions, which are high in protein, are often more serious than transudative effusions. They are formed as a result of inflammation of the pleura, which might happen for example in lung disease. Common causes of exudative effusions include:

• Pneumonia;
• Lung cancer, or other cancers;
• Connective tissue diseases, including rheumatoid arthritis and systemic lupus erythematosus;
• Pulmonary embolism;
• Asbestosis;
• Tuberculosis; and
• Radiotherapy.

Clinical Diagniosis;

Physical findings are variable and depend on the volume of the pleural effusion. Generally, there are no physical findings for effusions smaller than 300 mL. With effusions larger than 300 mL, findings may include the following:

• Dullness to percussion
• Decreased tactile fremitus
• Asymmetric chest expansion, with diminished or delayed expansion on the side of the effusion: Dullness to percussion, decreased tactile fremitus, and asymmetric chest expansion are the most reliable physical findings of pleural effusion.
• Diminished or inaudible breath sounds
• Egophony ("e" to "a" changes) at the most superior aspect of the pleural effusion
• Pleural friction rub
• Other findings that provide clues to the etiology of the effusion include the following:
  • Peripheral edema, distended neck veins, and S ₃ gallop, suggestive of congestive heart failure
  • Edema may also be a manifestation of nephrotic syndrome; pericardial disease; or, combined with yellow nails, the yellow nail syndrome.
  • Cutaneous changes with ascites, suggestive of liver disease
  • Evidence of malignancy such as lymphadenopathy or palpable mass

Investigations

During a physical examination, the doctor will listen to the sound of your breathing with a stethoscope and may tap on your chest to listen for dullness.

The following tests may help to confirm a diagnosis:

• Chest x-ray
• Pleural fluid analysis (examining the fluid under a microscope to look for bacteria, amount of protein, and presence of cancerous cells)
• Thoracentesis (a sample of fluid is removed with a needle inserted between the ribs)
• Thoracic CT
• Ultrasound of the chest

Treatment

Treatment may be directed at removing the fluid, preventing it from accumulating again, or addressing the underlying cause of the fluid buildup.

Therapeutic thoracentesis may be done if the fluid collection is large and causing pressure, shortness of breath, or other breathing problems, such as low oxygen levels. Removing the fluid allows the lung to expand, making breathing easier. Treating the underlying cause of the effusion then becomes the goal.

For example, pleural effusions caused by congestive heart failure are treated with diuretics (water pills) and other medications that treat heart failure. Pleural effusions caused by infection are treated with appropriate antibiotics. In people with cancer or infections, the effusion is often treated by using a chest tube for several days to drain the fluid. Chemotherapy, radiation therapy, surgery, or instilling medication into the chest that prevents re-accumulation of fluid after drainage may be used in some cases.

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Posted in: Pleural Effusion,Respiratory System

Pneumonia

What is pneumonia?

Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States.

How do people "catch pneumonia"?

Some cases of pneumonia are contracted by breathing in small droplets that contain the organisms that can cause pneumonia. These droplets get into the air when a person infected with these germs coughs or sneezes. In other cases, pneumonia is caused when bacteria or viruses that are normally present in the mouth, throat, or nose inadvertently enter the lung. During sleep, it is quite common for people to aspirate secretions from the mouth, throat, or nose. Normally, the body's reflex response (coughing back up the secretions) and immune system will prevent the aspirated organisms from causing pneumonia. However, if a person is in a weakened condition from another illness, a severe pneumonia can develop. People with recent viral infections, lung disease, heart disease, and swallowing problems, as well as alcoholics, drug users, and those who have suffered a stroke or seizure are at higher risk for developing pneumonia than the general population.

Once organisms enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight off the infection.

Signs and symptoms

People with infectious pneumonia often have a cough producing greenish or yellow sputum, or phlegm and a high fever that may be accompanied by shaking chills. Shortness of breath is also common, as is pleuritic chest pain, a sharp or stabbing pain, either experienced during deep breaths or coughs or worsened by them. People with pneumonia may cough up blood, experience headaches, or develop sweaty and clammy skin. Other possible symptoms are loss of appetite, fatigue, blueness of the skin, nausea, vomiting, mood swings, and joint pains or muscle aches. Less common forms of pneumonia can cause other symptoms; for instance, pneumonia caused by Legionella may cause abdominal pain and diarrhea, while pneumonia caused by tuberculosis or Pneumocystis may cause only weight loss and night sweats. In elderly people, manifestations of pneumonia are seldom typical. They may develop a new or worsening confusion (delirium) or may experience unsteadiness, leading to falls. Infants with pneumonia may have many of the symptoms above, but in many cases they are simply sleepy or have a decreased appetite.

Symptoms of pneumonia need immediate medical evaluation. Physical examination by a health care provider may reveal fever or sometimes low body temperature, an increased respiratory rate, low blood pressure, a high heart rate, or a low oxygen saturation, which is the amount of oxygen in the blood as indicated by either pulse oximetry orblood gas analysis. People who are struggling to breathe, who are confused, or who have cyanosis (blue-tinged skin) require immediate attention.

Findings from physical examination of the lungs may be normal, but often show decreased expansion of the chest on the affected side, bronchial breathing on auscultation with a stethoscope (harsher sounds from the larger airways transmitted through the inflamed and consolidated lung), and rales (or crackles) heard over the affected area during inspiration. Percussion may be dulled over the affected lung, but increased rather than decreased vocal resonance (which distinguishes it from a pleural effusion). While these signs are relevant, they are insufficient to diagnose or rule out a pneumonia; moreover, in studies it has been shown that two doctors can arrive at different findings on the same patient

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Posted in: Pneumonia,Respiratory System

Diagnostic approach of shortness of breath

Diagnostic approach of shortness of breath

1. How long have you had the shortness of breath?

   Why: to determine if acute or chronic.

2. Was the onset of shortness of breath sudden or gradual?

   Why: if sudden consider adult respiratory distress syndrome, pulmonary embolism, pneumothorax, lung collapse. If gradual onset, consider chronic diseases such as congestive cardiac failure, emphysema and fibrosis.

3. What makes the shortness of breath worse?

   Why: e.g. exercise , laying flat in bed.

4. Recent history of bleeding?

   Why: e.g. heavy periods with clots, vomiting blood, bloody stools, rectal bleeding - may suggest anemia as the cause for shortness of breath.

5. Past Medical history?

   Why: previous respiratory illness (e.g. pneumonia, tuberculosis, chronic bronchitis); previous heart problems (heart disease, heart attack, heart valve disease); HIV infection ( at high risk for Pneumocystis carinii pneumonia); previous high blood pressure; deep venous thrombosis; Rheumatic fever.

6. Medications?

   Why: many different medications can produce lung problems and resultant shortness of breath e.g. pulmonary embolism from oral contraceptive pill; fibrotic lung diseases from cytotoxic agents such as methotrexate, cyclophosphamide and bleomycin; bronchospasm from beta-blockers or non-steroidal anti-inflammatory medications.

7. Cigarette smoking?

   Why: number of packets per day and number of years you have smoked. Smoking is a major cause of lung cancer, chronic bronchitis and emphysema. Passive smoking exposure is also regarded as a significant risk.

8. Drug taking history?

   Why: cocaine, amphetamines or injected narcotic drugs can cause shortness of breath.

9. Alcohol history?

   Why: The drinking of large amounts of alcohol in binges can sometimes result in aspiration pneumonia and alcoholics are also prone to develop pneumococcal or Klebsiella pneumonia.

10. Occupational history?

    Why: e.g. exposure to dusts in mining industries and factories such as asbestos, coal, silica, iron oxide, tin oxide, cotton, beryllium, titanium oxide, silver, nitrogen dioxide, anhydrides; exposure to animals (e.g. Q fever or psittacosis); exposure to moldy hay, humidifiers or air conditioners may result in allergic alveolitis.

11. Family history?

    Why: asthma, cystic fibrosis, emphysema, alpha-1-anti-typsin deficiency, tuberculosis, heart attacks.

Sometimes, other symptoms may be present and may help your doctor analyse your condition. These may include:

1. Cough?

   Why: may be due to lung or heart disease.

2. Sputum

   Why: color and quantity? - e.g. large volume pus-like suggests bronchiectasis or pneumonia; foul smelling dark colored suggests lung abscess; pink frothy secretions may be due to left ventricular heart failure; blood in sputum can be a serious sign of lung disease and must always be investigated.

3. Audible wheeze?

   Why: may suggest asthma, chronic bronchitis, emphysema, airways obstruction (by a foreign body or tumor) or left ventricular heart failure.

4. Chest pain?

   Why: may be due to lung or heart disease.

5. Fever?

   Why: e.g. fever at night may suggest tuberculosis, pneumonia or mesothelioma ( tumor of lung lining due to asbestos exposure).

6. Orthopnea (breathlessness lying down flat)?

   Why: suggests left ventricular heart failure.

7. Paroxysmal nocturnal dyspnea (inappropriate severe breathlessness causing waking from sleep)?

   Why: suggests left ventricular failure.

8. Stridor (a rasping noise heard loudest on inspiration)?

   Why: indicates obstruction of the larynx, trachea or large airways by a foreign body, a tumor or infection (such as epiglottitis).

9. Ankle swelling
   

   Why: may suggest heart failure.

10. Palpitations of the heart?

    Why: may indicate that heart arrhythmia may be the cause of breath problems.

11. Fever and pus-like sputum?

    Why: suggests pneumonia.

12. Chest pain with blood in sputum?

    Why: need to rule out pulmonary embolism.

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Posted in: Diagnostic Approaches,Respiratory System

Shortness of breath

Breathing difficulty of any kind (or any kind of "shortness of breath") is a potentially life-threatening emergency. It can indicate numerous dangerous causes such as heart attack, pneumonia, or pulmonary embolism. There are other less serious causes, but these highly dangerous conditions need to be considered. Refer to the causes of breathing difficulty or causes of chest pain. These symptoms need to be diagnosed immediately by a medical professional because they can represent a life-threatening emergency.

The following medical conditions are some of the possible causes of Shortness of breath. There are likely to be other possible causes, so ask your doctor about your symptoms.

• Some possible causes of shortness of breath include:
  
  • Exercise
    
  • Exertion
    
  • Poor physical condition
  • Obesity
  • Pregnancy
    
  • Anxiety (type of Neurosis)
    
  • Stress
  • Tension
    
  • Smoking
    
  • Depression
  • High altitude location
  • Hyperventilation
    
  • High fever Wheezing - see also causes of wheezing
  • 
    
• Respiratory conditions causing shortness of breath include:
  
  • Common cold
  • Respiratory infection
    
  • Lung infection
    
  • Pneumonia
    
  • Bronchitis
  • Tuberculosis
    
  • Chronic bronchitis
  • Chronic lung disease (see Lung symptoms
  • Asthma
  • Emphysema
  • COPD
    
  • Cystic fibrosis
  • Bronchiectasis
  • Airway obstruction

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Posted in: Respiratory System,Shortness of breath

Asthma

Asthma is a breathing problem that results from the inflammation and spasm of the lung's air passages (bronchial tubes). The inflammation causes a narrowing of the air passages, which limits the flow of air into and out of the lungs. Asthma is most often, but not always, related to allergies. Common symptoms include:

• Shortness of breath
• Wheezing
• Coughing
• Chest tightness

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Posted in: Asthma,Respiratory System