PNEUMOTHORAX

Isnin Anang Marhana, dr.,

Sp.P(K), FCCP, FIRS, FAPSR
Division of Interventional Pulmonology
Departmen of Pulmonology
Universitas Airlangga
Definisi

• Pneumotoraks adalah kolapsnya paru akibat kebocoran udara

ke dalam rongga pleura (ruang antara dinding dada dan paru)
• Berdasarkan etiologi atau bagaimana proses terjadinya,
pneumotoraks terbagi atas pneumotoraks spontan dan
pneumotoraks traumatik
• Pneumotoraks spontan timbul tanpa adanya suatu trauma,
terbagi menjadi dua:
• Pneumotoraks spontan primer (PSP)
• Pneumotoraks spontan sekunder (SSP)
 Epidemiology

PSP has an annual incidence of 7.4 Cannabis smoking, causing

01 per 100000 population in males and bullous disease, is another risk
1.2 per 100000 in females. factor for pneumothorax.

Bimodal distribution, a peak Male sex, height and a low BMI

incidence in young aged 15-34 05 are also associated with increased
years and another in >55 years. risk of PSP.

Smoking is the most important risk

factor in PSP. The relative risk 22-
fold in men and 9 fold in women
Pathophysiology

• High intrathoracic pressure  pleural rupture  open

thoracic cavity  lung pushed by air  collaps
• Air enter pleural space primary/ secondary, spontaneous,
traumatic, iatrogenic, or catamenial.
 Etiologies

Nearly every lung disease can be complicated by secondary spontaneous

pneumothorax (SSP), the most commonly are COPD, cystic fibrosis, lung
malignancy, and necrotizing pneumonia (eg, bacterial or fungal, PCP, and
tuberculosis)
Chronic Obstructive
Chronic
Pulmonaryobstructive
Disease
pulmonary disease
(COPD) is the most
common cause of
SSP, with 50 to 70
percent of SSP in
case series
attributed to
COPD.

Severity of COPD
correlates with the
likelihood of developing
SSP.

Chen et al, 2012

Guo et al, 2005
 Lung Malignancy

• Both primary and

metastatic lung
malignancy have
been associated
with SSP
• The underlying
malignancy was
more commonly
primary than
metastatic

Chen et al, 2012

 Necrotizing
Pneumonia

SSP can complicate the course of necrotizing

pneumonia due to bacterial infection, Pneumocystis
jirovecii, tuberculosis, and less often fungi.
Chen et al, 2012
Pneumocystis
Jirovecii
Among patients with
acquired immunodeficiency
syndrome (AIDS) who develop
SSP, greater than 80
percent
In the have
era current
of or
potent
previous P. jirovecii
antiretroviral
pneumonia (PCP). therapy
(ART), the frequency of
pneumothorax
complicating PCP is
approximately 5 to 10
percent, although data
The pathogenesis of SSP
are limited.
in PCP is likely
alveolar and pleural
tissue invasion and
rupture of large
subpleural cysts that
Radhi et al, 2008
 Bacterial
Pneumonia
• Among 168 patients
with SSP, bacterial
pneumonia was the
etiology in 11
percent
• SSP has been
associated with
bacterial pneumonias
caused by
Staphylococcus, Chen et al, 2012
Tuberculosis
SSP occurs in 1 to 3
percent of patients
hospitalized with
pulmonary
tuberculosis.
The pneumothorax is
usually due to
rupture of a
tuberculous cavity
Chen et al, 2012
Classification
Primary
Spontaneous
Secondary Intervensional
procedure

Pneumothorax
Iatrogenic Ventilator

Traumatic
Penetrating trauma
Non-iatrogenic

Blunt trauma

Light RW, Lee YCG. Textbook of Pleural Diseases, 2008

 Pneumotoraks berdasar fistel
a. Pneumotoraks Terbuka
• Adanya hubungan antara rongga
pleura dengan bronkus yang
menghubungkan dengan dunia
luar
b. Pneumotoraks Tertutup
• Udara yang berada di rongga
pleura ‘terjebak’ dan tidak dapat
keluar
c. Pneumotoraks Ventil / Tension
/ Valvular
• Pada keadaan ini udara masuk ke
dalam rongga pleura ketika
Klinis
• Keluhan nyeri dada, napas terasa berat, atau sesak napas yang
makin lama makin berat dirasakan oleh 95% penderita
pneumotoraks, kadang disertai batuk kering
• Pada pneumotoraks spontan, keluhan tersebut didahului
pencetus atau auslosend moment misalnya, batuk keras,
bersin, mengangkat barang-barang berat, kencing atau
mengejan
Pemeriksaan Fisis
• Inspeksi : Bentuk dada asimetris dengan sisi yang sakit tampak lebih
cembung, sisi toraks yang sakit tampak tertinggal saat gerak napas,
serta trakea dan jantung terdorong ke sisi sehat.
• Palpasi : Ruang antar iga normal/ melebar pada sisi yang sakit, iktus
jantung terdorong ke sisi toraks yang sehat, fremitus raba atau suara
melemah bahkan menghilang pada sisi yang sakit.
• Perkusi : Suara ketok hipersonor hingga timpani pada sisi sakit,
batas jantung terdorong ke arah toraks yang sehat apabila tekanan
intrapleura tinggi.
• Auskultasi : Suara napas melemah sampai menghilang pada sisi
paru yang sakit, bila didapatkan fistel bronkopleura yang cukup
besar pada pneumotoraks terbuka maka dapat terdengar suara
amforik.
 Imaging and
Diagnosis

The chest radiograph provides the If the diagnosis of SSP is unclear on

diagnosis of secondary spontaneous
pneumothorax (SSP) with the finding
of a visceral pleural line, which
defines the interface of the lung and
pleural air.
the conventional chest radiograph,
chest computed tomography is the
best modality for determining the
presence, size, and location of
intrapleural air.

MacDuff et al,
 CT
CXR USG
Scan
 Derajat Kolaps
• ACCP  mengukur jarak dari apeks
paru hingga puncak parietal kubah
rongga toraks (posisi berdiri), large
bila a ≥ 3 cm, small bila a < 3 cm
• BTS  jarak interpleura setinggi
hilus, jarak 2 cm diperkirakan setara
dengan kolaps paru hingga 50%
sehingga digunakan sebagai nilai
cut-off
Tindakan Medis
a. Pneumotoraks Tertutup (Simple Pneumothorax)
• Bila kolaps paru <20%, udara di rongga pleura akan diresorbsi
secara spontan dalam beberapa hari sampai kurang lebih satu
minggu
• Apabila luas kolaps sekitar ≥20% dan disertai keluhan sesak,
maka perlu dilakukan penghisapan secara berkala
Tindakan Medis…
b. Pneumotoraks Terbuka
• Sering disebabkan oleh suatu
proses penyakit paru,
sehingga pengobatan
pneumotoraks terbuka
terutama ditujukan pada
penyakit dasar tersebut.
• Pada pneumotoraks terbuka
yang tidak mengembang
dalam waktu 2 minggu, perlu
dilakukan torakoskopi guna
melihat kemungkinan
 Tindakan Medis…
Pneumotoraks Ventil (Tension
Pneumothorax)
• Penderita pneumotoraks ventil sering
didapatkan dengan sesak napas berat.
• Hal ini diakibatkan oleh tekanan intrapleura
yang tinggi, kolaps paru dan penekanan pada
mediastinum dan jantung.
• Himpitan pada jantung akan mengganggu
kontraksi dan “venous return”
• Tindakan utama yang harus dilakukan adalah
dekompresi terhadap tekanan intrapleura yang
tinggi tersebut, yaitu dengan membuat
hubungan dengan udara luar.4
 air leak and failure to
re-expand

SUCTION SURGERY PLEURODESIS

 Suction

The use of suction too early

can precipitate re-expansion
pulmonary oedema. High-
The routine pressure, high-volume suction
use of early

“ ”
may lead to perpetuation and/or
suction is not worsening of the air leak. The
typical pressure used is
recommended by between−10 cmH2O and −20
the BTS cmH2O.
guidelines.
 Pleurodesis

Pleurodesis by Chemical pleurodesis

chemical by a sclerosing agent
irritant, can be delivered by

“ ”
mechanical chest tube, medical
thoracoscopy or
abrasion or VATS.
parietal
pleurectomy aims
to achieve
adherence of the
pleural membranes
by promoting
inflammation.
 Surgery
There are two
main types of
surgery,
Surgery thoracotomy and

“ ”
carries a VATS, with both
performed under
low
general
morbidity anaesthetic.
risk and
has good
the standard posterolateral thoracotomy or methods
success using a smaller incision, such as axillary thoracotomy,
rates. anterior thoracotomy or various mini-thoracotomies.
KOMPLIKASI
• Timbul cairan intra pleura, baik berupa cairan efusi maupun
hematotoraks
• Bronkopleural fistel
• Emfisema subkutis
• Syok kardiogenik
• Edema paru (Re-expansion Pulmonary Oedema/REPO)
• Gagal napas
• Kematian