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Sunday, 24 November 2013

Pleural disease – Pneumothorax – The Causes

The pleura is a thin tissue covered by a layer of cells (mesothelial cells) that surrounds the lungs and lines the inside of the chest wall.
A. Pneumothorax is defined as a condition of collection of air within the pleural cavity, from either the outside or from the lung of which affect the lung breathing.
B.1. Causes
1. Chest injuries Severe thoracic, trauma to your chest can cause lung collapse. In the study to review CT scans and supine chest X-ray of 47 patients affected by severe thoracic, trauma, examined in 1985-86 and to compare the two methodologies in the assessment of pneumothorax, conducted by Ospedale Generale Regionale SS. Annunziata, indicated that CT detected 25 pneumothorax, whereas supine chest X-ray allowed a diagnosis in 18 cases only. In 8 of the latter (44.4%) the diagnosis was made possible by the presence of indirect signs of pneumothorax only–the most frequent being the deep sulcus sign(6).

2. Lung diseases causes of pneumothorax
a. Emphysema

Emphysema is also known as chronic obstructive pulmonary disease (COPD) involving
the destruction of lung tissue around the air sacs (alveoli) in the lungs. Secondary spontaneous pneumothorax is life-threatening for patients with pulmonary emphysema. There is a remarkable increase in the number of young patients who presented with lung emphysema and secondary spontaneous pneumothorax (SSP) at our institution for over a period of 30 months; most of them have a common history of marijuana abuse, according to the study by the University Hospital Berne(7).
b. Pneumonia
Pneumonia is defined as a condition of the inflammation of the lung as a result of infection, caused by bacteria, such as bacteria Streptococcus pneumoniae or influenza viruses in most cases. Fungi, such as Pneumocystis jiroveci, certain medication such as PPI Stomach Acid Drugs and other conditions such as impaired immune systems can also induced the disease. There is a report of a 7-year-old girl presented with subcutaneous emphysema, pneumomediastinum (PM), pneumoretroperitoneum, and pneumothorax caused by Mycoplasma pneumoniae (MP), according to the study by Nihon University Nerima-Hikarigaoka Hospital(8).

c. Cystic fibrosis
 In the study to identify risk factors associated with pneumothorax and to determine the prognosis of CF patients following an episode of pneumothorax, showed that pneumothorax is a serious complication in CF patients, occurring more commonly in older patients with more advanced lung disease. Nearly 1 in 167 patients will experience this complication each year(9).

d. Lung cancer 
  There is a report of 2 cases of lung cancer incidentally detected following pneumothorax. d.1. Case 1:A 40-year-old man complaining of dyspnea was admitted with right pneumothorax. Chest computed tomography (CT) after chest drainage showed a cavitary nodule with pleural indentations in the right lower lobe. It was indicated at surgery that pneumothorax was caused by perforation of the tumor into the pleural cavity. d,2, Case 2:A 47-year-old man who admitted with right pneumothorax was found to have a nodule with pleural indentations closely a bulla at the apex of the right lung by chest CT after chest drainage. Pneumothorax was indicated to be caused by rupture of the bulla at surgery. Right upper lobectomy was performed because the pathological diagnosis of the nodule was a squamous carcinoma(10).
e. Pulmonary fibrosis
 In the study to evaluate the relation between the severity of idiopathic pulmonary fibrosis (IPF) and the incidence of pneumothorax on computed tomography (CT) images, showed that pneumothorax in IPF patients is associated with lower VC and rapid deterioration of CT findings. The findings suggest that pneumothorax is a complication of advanced IPF(11).

f. Sarcoidosis
There is a report of four patients with sarcoidosis who developed pneumothorax. In one of the patients who had a thoracotomy, non-caseating granulomata were seen to be extensively involving the pleura. Whether pneumothorax and sarcoidosis are two independent processes occurring in the same individual or whether the pneumothorax is causally related to the sarcoidosis has not been determined.(12).

3. Ruptured visceral pleural bleb
Spontaneous pneumothoraces are believed to arise when air from the supplying airway exit via a ruptured visceral pleural bleb into the pleural cavity. Endobronchial one-way valves (EBVs) allow air exit (but not entry) from individual segmental airways(13).

4. Mechanical insufflation-exsufflation
Mechanical insufflation-exsufflation (MI-E) is a respiratory aid used by patients with weak respiratory muscles to increase cough peak flows and improve cough effectiveness. Relative contraindications to MI-E are said to include susceptibility to pneumothorax. There is a report of two cases of pneumothorax in patients with respiratory muscle weakness associated with daily use of MI-E: one was a 58-yr-old male with C4 ASIA C tetraplegia, and the other was a 26-yr-old male with Duchenne muscular dystrophy(14).

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