Pneumothorax

Question 1

Pneumothorax

What is a primary spontaneous pneumothorax?

Answer 1

one that presents in the absence of an external event in an individual who is without underlying clinical lung disease.

Question 2

Pneumothorax

What is Secondary spontaneous pneumothorax (SSP)?

Answer 2

presents as a complication of underlying lung disease

Question 3

Pneumothorax

Nearly every lung disease can predispose SSP development, but the most common are ____ and, in endemic areas, ____.

Answer 3

COPD

TB

Other common causes include cystic fibrosis, primary or metastatic lung malignancy, and pneumonia.

Question 4

Pneumothorax

What is the most common cause of iatrogenic pneumothorax?

Answer 4

central venous catheterization

Question 5

Pneumothorax

What is the most typical presentation of a primary vs secondary pneumothorax? Describe the pts.

Answer 5

1. young male with acute onset dyspnoea and pleuritic chest pain
2. tends to occur in older patients with underlying lung diseases such as COPD.

Question 6

Pneumothorax

Physical examination findings can be minimal in a small pneumothorax.

In a larger pneumothorax one can expect to find:

5

Answer 6

• Reduced chest expansion on the affected side
• Chest hyper-expansion of the affected side
• Diminished breath sounds
• Absent tactile or vocal fremitus
• Hyperresonant percussion

Question 7

Pneumothorax

What is the 1st line investigation for pneumothorax?

Answer 7

cxr

Question 8

Pneumothorax

What is the preferred view for the cxr?

Answer 8

on inspiration

Question 9

Pneumothorax

How do we diagnose pneumothorax on an xray?

Answer 9

• when the visceral pleural line is visualised
• Absence of symmetrical lung markings can also help in detection.

Question 10

Pneumothorax

What is regarded as the best modality for measuring the size of a pneumothorax?

Answer 10

ct

Question 11

Pneumothorax

When is a pneumothorax counted as small?

Answer 11

if the distance from the chest wall to the visceral pleural line at the level of the hilum is <2 cm, and large if the distance is ≥2 cm.

Question 12

Pneumothorax

How do we manage clinically stable pts with a small (rim of air <2cm on cxr) primary spontaneous pneumothorax?

Answer 12

discharge can be considered

otherwise, observation and high flow O2

Question 13

Pneumothorax

How do we manage clinically stable pts with a large (rim of air >2cm on cxr) primary spontaneous pneumothorax?

Answer 13

• percutaneous needle aspiration
• try twice, if doesnt work, chest drain

Question 14

Pneumothorax

In the case od secondary pneumothorax, when would a fine needle aspiration be performed?

Answer 14

• if the patient is less than 50 years of age
  or
• pneumothorax is small (<2cm on x-ray)

otherwise
- chest drain

Following either treatment, the patient is admitted for 24 hours for observation prior to discharge.

Question 15

Tension Pneumothorax

What is it?

What can it be caused by?

Answer 15

caused by the gradual build-up of air in the pleural space

• a one-way valve forms in chest wall/airway/lung
• allows air into the pleural space on inspiration however, it cannot exit on expiration.

Question 16

Tension Pneumothorax

What is the most common cause of tension pneumothorax?

some other causes?

Answer 16

the mechanical ventilation of a patient with a simple pneumothorax before a chest drain has been inserted

• blunt trauma
• penetrating injury
• central venous catheter placement
• lung biopsy.

Question 17

Tension Pneumothorax

The build-up of air in the pleural space causes ____lateral lung collapse and hypoxia, mediastinal shift to the ____lateral side of the chest and impaired venous return to the heart.

Answer 17

ipsi

contra

Question 18

Tension Pneumothorax

How does it present?

11

Answer 18

• chest pain
• Tachypnoea
• Tachycardia
• Raised JVP and distended neck veins
• Pulsus paradoxus
• Reduced breath sounds on the affected side
• Hyper-resonant to percussion on the affected side
• Decreased chest movement
• Tracheal deviation away from the affected side
• Hypotension
• Loss of consciouness

Question 19

Tension Pneumothorax

What are 2 other emergency ddx that must be excluded?

Answer 19

• cardiac tamponade
• diaphragmatic injuries

Question 20

Tension Pneumothorax

What would a cxr of a tension pneumothorax show?

Answer 20

• hemi-diaphragmatic depression
• ipsilateral flattening of the heart border
• contralateral mediastinal deviation.

Question 21

Tension Pneumothorax

If needle decompression is not successful, what is the next step?

Answer 21

chest drain should be inserted into the pleural space within the safe triangle

Question 22

Tension Pneumothorax

What are some severe complications of pneumothorax?

Answer 22

resp and cardiac arrest

Question 23

Tension Pneumothorax

Under what conditions would be an immediate decompression in a conscious pt where imaging in not immediately available?

5

Answer 23

• Systolic BP <90 mmHg
• Respiratory rate <10/min
• SpO₂ <92% on oxygen
• Reduced consciousness whilst on oxygen
• Cardiac arrest

Question 24

Pneumothorax

How do we manage a tension pneumothorax where a pt is unstable?

Answer 24

DO NOT WAIT FOR IMAGING

• need to decompress urgently
• needle decompression with cannula at 2nd intercostal space midclavicular line or 4th intercostal space mid-axillary line

this converts tenion pneumothorax to a simple one

Question 25

# Tension pneumothorax What do we prescribe as part of management?

Answer 25

* high-flow oxygen (target SpO₂ **>96**%) * analgesia (morphine) * if trauma: prophylactic antibiotics (prevent pneumonia or an empyema occurring after chest drain insertion)

Question 26

# Tension pneumothorax What are the borders of the 'safe triangle'?

Answer 26

- lateral border of the **pectoralis major** - anterior border of the **latissimus dorsi** - superior to the horizontal line of the **nipple base** - apex of the triangle in the **axilla**.