Introduction
In pulmonology, pathological conditions can be divided based on the symptoms they present. Different symptoms together form a syndrome. Many syndromes exist in pulmonology that can be manifested by clinical presentation or also by Para clinical confirmation.
This includes consolidation syndrome, bronchial syndrome, cavity syndrome, pleural syndrome, vascular syndrome, hyperinflation syndrome, and many others.
Both these conditions presented in this article come under the pleural syndromes manifested clinically and radiologically.
Pneumothorax is defined as an accumulation of air in the pleural space with secondary lung collapse. This accumulation is of diverse derivations, but visceral pleural rupture with air leakage is the most common cause. An original possible ruptured esophagus with diminished chest wall integrity can cause free air in the pleural space, and more rarely a gas-forming organism.
By definition, hemothorax is presented by bloody pleural effusion associated with signs of severe bleeding in the patient.
Pneumothorax vs Hemothorax
Pneumothorax may occur due to traumatic or non-traumatic causes of pleural rupture that resulting air from the lungs leaking into the pleural which is the covering of lung parenchyma. This condition has added signs of secondary lung compression. In most instances, the pneumothorax presents with minor symptoms without any physiological changes. Rarely, a simple pneumothorax progresses and develops with significant hemodynamic and respiratory instability, hypoxia, and shock. This clinical presentation is accompanied by a tension pneumothorax and demands emergency treatment.
Haemothorax refers to a collection of blood within the pleural cavity. By definition, this bloody pleural effusion should contain a hematocrit value of at least 50% of the hematocrit of peripheral blood. Hence, Hemothorax presentation has added signs of severe bleeding in addition to local signs of lungs and mediastinal components compression.
Difference Between Pneumothorax and Hemothorax in Tabular Form
| Main parameters of comparison | Pneumothorax | Hemothorax |
| Definition | Accumulation of air in between the pleural layer of the lungs causes its compression. | Traumatic or non-traumatic causes result in blood accumulating between the pleura. In addition to compression, it also causes the severe bleeding syndrome. |
| Physical examination | The patient presents with dyspnea, and cyanosis depending on the severity and cause. On physical examination signs of air, accumulation is observed. It includes a decrease in vocal fremitus, hyper resonance on percussion, and a decrease in vesicular breath sounds. | On palpation, vocal fremitus decreases however felt more than that in pneumothorax. On percussion dull sounds were observed instead of hyper resonance as in the case of pneumothorax. |
| Etiology | There can be primary. Secondary, idiopathic, and traumatic causes for pneumothorax. | The etiology of hemothorax can be classified as spontaneous, iatrogenic, and secondary. It registers a high incidence in people with a clotting defect, pulmonary infarction, recent thoracic or heart surgery, tuberculosis, and other medical iatrogenic causes. |
| Diagnosis | Chest X-ray anterior-posterior and Lateral views, CT scan. | Diagnostic and therapeutic thoracocentesis can be also done in addition to the chest dray and CT scan that are non-invasive. |
| Management | 1. Aspiration and chest tube drainage2. Thoracostomy | Intra pleural anti fibrinolyticsProphylactic AntibioticsThoracostomy and chest tube drainageSurgery in acute cases |
| Complications | Persistent air leakage can cause progressive and worsening compression of the lung parenchyma along with a shift of other mediastina components. | Some possible complications of Hemothorax are:Active blood lossAdhesionsClots formation |
What is Pneumothorax?
Pneumothorax is the abnormal accumulation of air in the pleural space with secondary lung collapse. This accumulation is of diverse derivations, but visceral pleural rupture with air leakage is the most common cause.
Classification of different etiologic factors causing pneumothorax can be divided as.
Spontaneous
- Primary (healthy individuals)
- Secondary (underlying pulmonary disease)
- Chronic obstructive pulmonary disease Infection
- Neoplasm
- Miscellaneous
- Traumatic
- Blunt
- Penetrating
- Iatrogenic
- Inadvertent Diagnostic Therapeutic
Clinical Presentation
Although some patients have an asymptomatic pneumothorax, more often they present with acute chest pain and dyspnea.
Physical findings may be absent if the collapse is minimal, while substantial collapse is defined as decreased chest wall movement on the affected side. Percussion of the chest cavity is hyper resonant and tympanic, and on auscultation breath sounds are decreased or absent. A pleural friction rub can sometimes be heard. Tachycardia is found in most patients.
Diagnosis
The clinical diagnosis of a pneumothorax is best confirmed by erect posterior-anterior and lateral chest radiographs. Expiration posterior-anterior chest radiography may be useful to demonstrate a small pneumothorax not seen on standard film.
Computed tomography scanning is generally not necessary unless abnormalities are noted on the plain chest radiograph or for further evaluation (e.g. suspected secondary pneumothorax), or if an aberrant chest drain emplacement is suspected.
Complications
Air leakage may persist for .48 h after the treatment of a pneumothorax. Often the air leak is seen in patients with a secondary pneumothorax, but occasionally patients with a primary spontaneous pneumothorax develop this complication. In this instance, surgery must be considered.
Management
The different clinical situations in spontaneous pneumothorax require different therapeutic approaches. The non-operative approach includes observation, simple aspiration, and thoracostomy with ambulatory chest drainage.
- Aspiration and small chest tube drainage - Simple aspiration of air with a 16-gauge intravenous cannula connected to a three-way stopcock and a 60-mL syringe is an option.
- Conventional tube thoracotomy - Conventional tube thoracostomy remains the procedure of choice for the management of moderate-to-large pneumothoraces. The drain allows for rapid and complete evacuation of air from the pleural space. Although underwater-seal drainage is sufficient for most cases of pneumothorax, the current author prefers the use of negative intrapleural pressure to maintain lung re-expansion over 5 days.
What is Hemothorax?
Haemothorax on the other hand refers to the abnormal collection of blood within the pleural cavity. By definition, it is presented by bloody pleural effusion associated with signs of severe bleeding in the patient.
Etiology
The primary cause of haemothorax is sharp or blunt trauma to the chest. Iatrogenous and spontaneous haemothorax occur less frequently.
- Latrogenous haemothorax is known to occur as a complication of cardiopulmonary surgery, placement of subclavian- or jugular-catheters or lung- and pleural biopsies.
- Spontaneous haemothorax is generally caused by rupture of pleural adhesions and tumors, and as a complication of anticoagulant therapy for pulmonary embolism.
- Less frequent causes reported in the literature are rupture of aneurysmatic thoracic arteries such as the aorta, mammalian arteries, and intercostal arteries (e.g. Ehlers Danlos syndrome)
Pathogenesis
Bleeding into the pleural space can occur with virtually any disruption of the tissues of the chest wall and pleura or the intra thoracic structures. Blood that enters the pleural cavity within several hours of cessation of bleeding, lysis of existing clots by pleural enzymes begins.
This membrane continues to thicken by progressive deposition and organization of the coagulum within the cavity.
Clinical Presentation
Patients with hemothorax may present with dyspnea, low blood pressure (circulatory shock0, rapid heart rate, pale cool and clammy skin, rapid a d shallow breathing, chest pain, restlessness, etc.
It is also important to know the possible complications following this clinical condition. Some of them listed could be adhesion, fibrosis, scarring of pleural membranes, collapsed lung leading to respiratory failure, shock, death, etc.
Initial Treatment
- Chest tube drainage - In most cases, chest tube drainage using a large caliber (!28 French) tube is an adequate initial approach unless an aortic dissection or rupture is suspected.
- After the tube thoracostomy is performed, a chest radiograph should always be repeated to identify the position of the chest tube, reveal other intrathoracic pathology, and confirm whether the collection of blood within the pleural cavity has been fully drained.
- Surgical approach in the acute phase - The criteria for surgical exploration, as detailed in the literature, are blood loss by chest tube 1.500 ml in 24 h or 200 ml per hour during several successive hours and the need for repeated blood transfusions to maintain haemo-dynamic stability.
- Patients with active blood loss but with stable hemodynamics can be treated with Video-Assisted Thoracoscopic Surgery (VATS), not only to stop the bleeding but also to evacuate blood clots and break down adhesions. A series of 50 VATS procedures, performed in patients with traumatic haemothorax, demonstrated active blood loss in eleven subjects.
- Prophylactic antibiotics - Antibiotic treatment following haemothorax reduces the rate of infectious complications.
- Intrapleural fibrinolytic therapy - Intrapleural fibrinolytic therapy (IPFT) can be applied in an attempt to evacuate residual blood clots and break down adhesions when initial tube thoracostomy drainage is inadequate. Retention of blood in the pleural cavity may lead to lung entrapment, chronic fibrothorax, impaired lung function, and infection. Several small non-randomized studies report on IPFT with streptokinase or tissue plasminogen activator (TPA).
Other symptomatic treatments that would be necessary include:
- Breathing support
- Blood tests and transfusions.
Main Difference Between Pneumothorax and Hemothorax in Points
Definition
Haemothorax refers to a collection of blood within the pleural cavity. Pneumothorax is the abnormal accumulation of air in the pleural space with secondary lung collapse
Etiologic Factors And Their Classification
Pneumothorax etiology can be classified as primary, secondary, iatrogenic, and traumatic causes. The primary most common occurrence is due to pleural rupture with air leakage.
Hemothorax causes can be divided into spontaneous, traumatic, and secondary causes. The most common developed Hemothorax cases are due to sharp or blunt trauma to the chest.
Physical Examination
Even if both conditions present with similar signs on inspection, they differ in percussion especially. In percussion, pneumothorax gives hyper resonance sounds indicating (the presence of air or less dense medium). On the other hand, hemothorax gives a dull sound. This dullness can be defined as shiftable dullness.
Paraclinical Diagnosis
The main initial para clinical methods used are Chest Xray with two views, and Ct to determine the presence of any complication. Additional ultrasound could be used to check for fluid accumulation in hemothorax. Also, thoracocentesis is considered both a diagnostic and therapeutic procedure.
Management Techniques
Thoracotomy and chest tube drainage form the mainstay of initial management in both cases. However, the choice depends on the patient's presentation, the severity of the disease, and other contra-indications if any.
Complications
In the case of pneumothorax continuing or progressive air leakage can occur despite the management of the patient, hence needs to be continuously monitored for the vital signs.
Whereas in the case of hemothorax, blood clots could form that could travel secondarily to other areas, adhesion between the pleural layers, and active blood loss can be some complications presented in a patient with hemothorax.
Conclusion
Haemothorax is a relatively common problem, most often resulting from injury to intrathoracic structures of the chest wall. Non-traumatic haemothorax can be a complication due to various causes. The primary cause of haemothorax is sharp or blunt trauma to the chest.
Rapid identification of the cause and initiation of treatment is essential. In both these cases with hemodynamically unstable patients, tube drainage and surgery are indicated. In a hemodynamically stable patient evacuation of blood from the pleural cavity by chest tube with or without IPFT should be performed. If this treatment is not successful, surgery is indicated to prevent long-term complications and impaired pulmonary function.
The clinical diagnosis of a pneumothorax is best confirmed by erect posteroanterior and lateral chest radiographs. Computed tomography scanning is generally not necessary unless abnormalities are noted on the plain chest radiograph or for further evaluation. Many syndromes exist in pulmonology that can be manifested by clinical presentation or also by Para clinical confirmation.
This includes consolidation syndrome, bronchial syndrome, cavity syndrome, pleural syndrome, vascular syndrome, hyperinflation syndrome, and many others.
These clinical conditions are primarily diagnosed as different a syndrome later on which helps in the differential diagnosis. Both pneumothorax and hemothorax present pleural syndrome clinically and on chest x-ray, CT scan, etc.
On chest X-ray, there will be presented clear markings of lung parenchyma and pleura which is usually not visible. Also local signs of compression could be observed on also adjacent mediastinal organs including the trachea, cardiac shadow and esophagus bronchi etc. Presence of air in pleura causes usually a sucking effect and pulls these organs towards the collapsed lung, whereas in hemothorax the excess mass of fluid pushes it away from the affected lung side.
References
- https://www.vumc.org/trauma-and-scc/sites/vumc.org.trauma-and-scc/files/public_files/Protocols/Hemothorax%20guidelines%202018.pdf
- https://www.resmedjournal.com/article/S0954-6111(10)00351-3/pdf
