pneumothorax

Question 1

def pneumothorax

Answer 1

air can move in and out, or hole has just sealed so the air is just there

air in the pleural space (potential space between the vsiceral and parietal pleura)

Other variants depend on the substance in the pleural space (e.g. blood: haemothorax; lymph: chylothorax).

Question 2

def tension pneumothorax

Answer 2

emergency.

A functional valve lets air enter the pleural space during inspiration, but not leave in expiration

mediastinum pushed over to contralateral hemithorax, kinking and compressing the great veins

unless air rapidly removed - cardiovascular arrest will occur

1 way valve, air goes in but not out = increased pressure in the intrapleural space

causes haemodynamic instability - cause pressure on the mediastinum - tachycardic

Question 3

aetiology spontaneous pneumothorax

Answer 3

in individuals with previously normal lungs

typically tall thin males

probably by rupture of a subpleural bleb

Question 4

aetiology secondary pneumothorax

Answer 4

pre-existing lung disease (COPD, asthma, TB, pneumonia, lung carcinoma, cystic fibrosis, diffuse lung disease, lung abscess, lung fibrosis, sarcoidosis)

Question 5

aetiology traumatic pneumothorax

Answer 5

penetrating injury to chest

often iatrogenic - during subclavian/jugular venous cannulation, thoracocentesis, pleural or lung biopsy, positive pressure assisted ventilation, lung biopsy, transbronchial biopsy

Question 6

RF for pneumothorax

Answer 6

collagen disorders (eg Marfan’s disease and Ehlers-Danlos syndrome)

young, tall male +- connective tissue disorder

alveoli bleb that rupture

Question 7

epidemiology pneumothorax

Answer 7

Annual incidence of spontaneous pneumothorax is 9 in 100 000.

20–40 year olds.

Four times more common in males.

Question 8

sx pneumothorax

Answer 8

may be asymptomatic

sudden onset of breathlessness/chest pain, especially on inspiration

distress with rapid shallow breathing if tension pneumothorax

pts with asthma/COPD may present with a sudden deterioration

mechanically ventilated pts may present with hypoxia or an increase in ventilation pressures

Question 9

signs of pneumothorax

Answer 9

may be none if pneumothorax is small

signs of resp distress:

• reduced expansion
• hyper-resonance
• reduced breath sounds

Question 10

signs tension pneumothorax

Answer 10

• trachea shift away from pneumothorax
• severe resp distress
• tachycardia
• hypotension
• cyanosis
• distended neck veins
• increased percussion note
• reduced air entry/breath sounds on the affected side

Question 11

ix pneumothorax

Answer 11

CXR

• dark area of film where lung markings don’t extend to
• fluid level may be seen if blood present
• in small pneumothoraces, expiratory films may make it more prominent

ABG - see if hypoxaemia - particularly in secondary disease

Question 12

mx tension pneumothorax

Answer 12

max ox

insert large bore needle (14-16G) with a syringe, partially filled with 0.9% saline into 2nd intercostal space MCL, on side of pneumothorax to relieve pressure

• remove plunger to allow air to start bubbling through the syringe with saline as a water seal

Alternatively, insert a large-bore Venfl on in the same location

insert chest drain

Question 13

Mx small pneumothorax

Answer 13

(<2cm lung-pleural margin)

if no underlying lung disease, pleural fluid or clinical compromise:

• reassure
• analgesia

Question 14

mx moderate pneumothorax

Answer 14

(>2cm lung-pleural margin)

aspiration with large bore cannula or catheter with 3-way tap

• insert into 2nd ICS MCL
• up to 2.5L of air can be aspirated (stop if pt coughs or resistance is felt)
• follow up CXR should be performed just after, 2h and 2wk later
• advised to stop diving

chest drain with water seal

• if aspiration fails or if there is fluid in the pleural cavity or after decompression of a tension pneumothorax
• inserted into 4-6th ICS MAL

Question 15

mx recurrent pneumothorax

Answer 15

chemical pleurodesis (visceral and parietal pleura fusion with tetracycline or talc)

surgical pleurectomy

Question 16

advice for pneumothorax

Answer 16

avoid air travel until follow up CXR confirms resolution of pneumothorax

avoid driving unless bilateral surgical pleurectomy

Question 17

complications pneumothorax

Answer 17

Recurrent pneumothoraces, bronchopleural fistula.

Question 18

Px pneumothorax

Answer 18

After one spontaneous pneumothorax, at least 20% will have another, with the frequency increasing with repeated pneumothoraces.