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.

 

pleura

Normal Anatomy

pneumothorax

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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collapsed lung

Sunday, December 7, 2014

The concept of transparency does not exist when it comes to trauma. For that reason, docs need a high index of suspicion when any victim walks or is carried through the door. The idea is this…most injuries can be taken at face value, but complications can exist, even in the most stable patient. For that reason, the concept of ruling out bad things is a routine thinking pattern in medicine. It does not mean that every test known to man has to be ordered, history and physical exam are powerful tools, but at least the doctor has to go through the mental gymnastics to be comfortable with the patient’s stability.

Every week, the NFL provides medical teaching moments. This time, it was learning that Dallas quarterback, Tony Romo, may have been playing for weeks with broken ribs. Bear receiver, Brandon Marshall goes down after a tackle, struggles to get up and ends up in the hospital with broken ribs and a collapsed lung. Same injury but Romo escapes without the complication that beset Marshall.

Breathing seems so simple and yet becomes very complicated when the chest wall is damaged. Normally, we breathe like a bellows, the ribs swing up and out, the diaphragm pushes down and air gets sucked into the lungs. That happens because the lungs are held against the chest wall by negative pressure between the two pleura, one lines the lung and the other lines the chest wall. Most people recognize pleural as the shiny skin when eating ribs. A pneumothorax or collapsed lung occurs when air gets into the space between those two linings and breaks the seal between the two. In trauma, a broken rib can cause a small tear into the lung tissue allowing that air leak to happen, but not always.

pleural-cavity-location

The pneumothorax is just one of the complications that have to be considered. It’s easy to be distracted by the pain of the broken fib and not concentrate on what’s important, the ability of the patient to breathe. The lung collapse is not all or nothing, it may be tiny and only seen as an incidental finding on a chest x-ray or Ct scan, it can be a complete collapse or the collapse can be somewhere in between. A smaller pneumothorax may not be appreciated on physical examination and for that reason a plain chest x-ray is an important screening tool in patients with chest injury. In addition to the collapsed lung, the doc will be looking for a contusion or bleeding in the chest. It is not meant to look for broken ribs. While more broken ribs presume increased force of trauma and increased risk of pneumothorax, the purpose of the test is to look for the lung damage and not any rib injury.

http://www.dreamstime.com/royalty-free-stock-photography-pneumothorax-image26701217

So Tony Romo keeps playing and Brandon Marshall goes to the hospital and gets a tube put in his chest. The way a traumatic pneumothorax is treated depends on how much air has escaped into the pleural space and how much the lung has collapsed. A tiny pneumothorax can be watched but larger ones need to have the air sucked out and the negative pressure re=established for the breathing mechanism to work again. A chest tube is placed through a stab incision in between the ribs and threaded into place. It is then hooked up to suct8ion and the patient is observed. If all goes well, the lung injury heals itself, the air leak stops and the tube can be removed in a couple of days. If all doesn’t go well, surgery may be required to repair the lung.

cchest tube

Aside from the lung, the ribs protect all sorts of vital structures from the heart and great vessels (think aorta, vena cava and others) in the chest, to the liver and spleen in the abdomen. Predicting the future is a fool’s game for doctors caring for trauma patients. Some, like Romo, will have an injury and do well. Others like Marshall will gradually decompensate with complications. Trauma is a worthy adversary and can lull doctors into a false sense of security when victims initially don’t look “too” injured. Just a reminder why medicine is a combination of science and art.

 

Image attriburions:

education-portal.com, dreamstime.com. @bmarshall twitter feed

 

 

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