not all collapsed lungs are punctured

Tuesday, November 15, 2016

It seems that Rob Gronkowski of the New England Patriots is teaching us about medicine, one injured body part at a time. This week it’s about the pneumothorax he sustained after a hard tackle and there is a reminder that the press tries hard but sometimes needs help getting the medical terminology just right. Gronkowski has been reported to have either a collapsed lung, a punctured lung, or both. But while all punctured lungs will result in a pneumothorax, not every pneumothorax is due to a punctured lung.



Normal Anatomy


Right Lung Pneumothorax

Let’s start with normal anatomy. We breathe like a bellows. The ribs swing out and the diaphragm, the muscle separating the chest and abdomen pushes down allowing air to be inhaled and sucked through the mouth and trachea into the lungs. Exhaling reverses the process. The lungs have to slide along the inside of the rib cage to inflate and deflate and for this to happen, both the lung and the ribs have a slippery lining called the pleura. The two are stuck together by negative pressure and should the seal between the two linings break, part of the lung can fall away from the chest wall and collapse. This is a pneumothorax (pneumo=air + thorax= chest) or air in the chest where it doesn’t belong.

Most often a pneumothorax happens spontaneously, when a bleb or weakened portion of lung leaks and breaks the negative pressure seal. It can happen in tall thin young people or in people with end stage COPD whose lungs are more fragile. A pneumothorax can also happen due to trauma and the jagged edge of a broken rib can damage lung tissue causing a leak. This is the punctured lung scenario that was reported to have happened to Mr. Gronkowski, though the broken rib idea wasn’t mentioned. Punctured lungs can also happen because of penetrating trauma like from a gunshot or stab wound and they have their own issues and complications.

The diagnosis is usually made by chest x-ray. In trauma, like Mr. Gronkowski, the x-ray is meant to look for the complications of the chest wall injury, including pneumothorax and pulmonary contusion, or bruising of the lung. Specific ribs x-rays tend not to be taken since it doesn’t really matter whether the ribs are bruised or broken…it’s all about what’s happening underneath. And for the doc, underneath may also include the upper abdomen, since the ribs protect the organs just below the diaphragm including the liver and spleen.

pneumothorax 2

Arrows show the collapsed lung edge pulled away from the ribs

The treatment of a pneumothorax depends upon how much of the lung has collapsed and whether the patient can tolerate the loss of lung function. If the percentage is small and the patient is doing well, delivering enough oxygen to their blood and not complaining of significant shortness of breath, watchful waiting may be the treatment of choice and the body will absorb the air and the lung will re-expand on its own.

If the pneumothorax is too large or if the patient is not doing well, the air in the pleural space between the two linings can be removed, either one time with a needle or by placing a tube into that space and sucking the air out under negative pressure causing the lung to expand. The tube may be left in place for a day or two to allow the lung to heal and the situation to settle down. Some people need operations to repair the weak areas of the lung to prevent repeat events and sometimes the damaged lung area is purposefully irritated so that it will scar down and adhere to the chest wall to prevent further collapse.

Not all collapsed lungs are easy to treat; they can be recurrent and treatment failures happen. There are also life threatening complications, including tension pneumothorax where the damaged lung tissue does not seal off and enough air flows into the pleural space to cause the heart to shift and prevent it from beating properly.

Since it appears that Mr. Gornkowski’s pneumothorax was small, the treatment was watchful waiting and if repeat x-rays show that the air has been reabsorbed, the ability to return to play will depend upon how much pain he has from his chest wall. Bruised ribs hurt and it can be tough to take a deep breath, and twist and turn. For mere mortals, chest wall pain can last a few weeks and can make routine daily activities tough to accomplish. For pro athletes, playing through pain is an expectation, as long as damage won’t result from ignoring the body’s message to rest.  And here is where the athlete and the doc share the same credo…first do no harm.

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chest wall injuries

Monday, March 18, 2013

There is a great regional rivalry when it comes to barbeque and which style makes ribs taste better. Is it the marinated Memphis, the Kansas City rub, the Carolina vinegar or the plain smoke of Texas? Regardless, we rarely think of the meat we eat as the muscles that help animals, including us humans, breathe. For those who have bruised or broken rib, or like David Wright of the Mets, pulled a rib muscle, it is an injury that is hard to ignore and harder to fix. After injuring an intercostal muscle, Mr. wright couldn’t play for the US national baseball team and returned to spring training to try to mend before the start of the baseball season.

Intercostal muscles are those that are attached to and located between the ribs and are responsible for moving the chest wall during breathing.  We breathe like a bellows with the ribs swinging out and the diaphragm (the muscle that divides the chest and abdomen) pushing down, sucking air into the lungs. Exhaling reverses the process and air is pushed out of the lungs. There are three layers of intercostal muscles that do the work of the rib movement, the external intercostal, the internal intercostals and the innermost intercostals, share the work of breathing and any injury to these muscles affects the ability of air to get into and out of the lungs. The muscle is often injured with a twisting motion; imagine a batter swinging while at bat, or lunging for a line drive in the field. But the injury can also be due to a direct blow, where the ribs don’t break but the muscle take the brunt of the injury.

Muscles don’t like to be hurt and when injured, go into spasm to protect themselves. The diagnosis is usually pretty easy. The patient often knows that they fell or twisted with immediate onset of pain. Sometimes, though the mechanism of injury is a little tougher to find and may be as simple as an aggressive cough or sneeze. Often a chest x-ray is done and not to look for broken ribs. Instead, the most important consideration is the under lying lung. Did the injury cause a collapsed lung (pneumothorax) or a pulmonary contusion (bruise)? It isn’t worth the extra x-rays and radiation to look for a broken rib, since it doesn’t affect treatment.

Chest wall pain, whether it is from the rib or intercostal muscle causes the body not to want to take a deep breath. It hurts too much and the body isn’t stupid. This is not necessarily a good thing when it comes to the ability to breathe. Failure to take a deep breath prevents the lung from fully expanding and those dark and warm crevices are prime breeding grounds for infection, leading to pneumonia. For that reason, treatment is focused on pain control and deep breaths. This plan, however, delays healing, trading length of recovery for pneumonia prevention.

Normally when a muscle is injured, the treatment is rest, ice and compression, allowing the damage to heal. Hurt your arm and a sling is prescribed. Hurt your leg and you get crutches. But the opposite treatment is recommended for the chest wall injury and with every breath the injured muscle fibers are ripped and stretched, delaying the healing process.

It may take 4-6 weeks for an injury to heal. Sleeping is tough and many patients find that sleeping upright or in a recliner is easier, since the ribs don’t have to lift up against gravity like they do when lying flat. Still after a few hours of sleep, those muscles go into spasm and the first twist and move in the morning after they finally get comfortable can be excruciating and dreaded beginning on morning number 2. Fortunately, one morning, perhaps in a couple of weeks, that first move hurts a little less and there is a light at the end of the tunnel.

Ice is one of the basics of treatment, as is ibuprofen as anti-inflammatory, but wrapping ribs prevents deep breaths and is no longer recommended. Instead, many patients get sent home with an incentive spirometer, a plastic toy that gives a visual clue about how deep the needed breath has to be. All this suffering is inflicted to prevent pneumonia, the lung infection characterized by fever, cough and shortness of breath.

Intercostal muscle injuries are frustrating. While Mr. Wright and the Mets hope that he heals quickly and is ready for opening day, there is no quick fix to shorten the recovery time.  And just like barbeque, you know it’s ready, when it’s ready…a not a moment sooner.

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