Pneumothorax

Question 1

Lanky Schmidt is a tall, 29 year old male. He has presented to A+E feeling short of breath. He has right sided pleuritic chest pain. He is a non-smoker and otherwise healthy.

A chest radiograph shows a right sided pneumothorax 8mm in diameter.

How should the medical team proceed?

a) Reassure and Discharge
b) Observe for 6 hours and give Oxygen
c) List for elective Surgical Pleurodesis
d) Needle Aspiration and give Oxygen
e) Immediate wide bore cannula insertion at 2nd intercostal space

Answer 1

d)Needle Aspiration and give Oxygen - 1st line

c) Surgical pleurodesis is the conjoining of the parietal and visceral pleura in order to obliterate the pleural space. It is indicated in secondary pneumothoraces typically after multiple episodes.
e) Indicated in a tension pneumothorax (emergency)

Question 2

Define a pneumothorax

Answer 2

when air gains access to, and accumulates in, the pleural space

Question 3

What is a tension pneumothorax

Answer 3

a pneumothorax in which air enters the pleural cavity and is trapped during expiration;

• intrathoracic pressure builds to levels higher than atmospheric pressure,
• –> compresses the lung, AND
• ~ displace the mediastinum and its structures toward the opposite side, with consequent cardiopulmonary impairment.

Question 4

What does this CXR show

Answer 4

tension pneumothorax on the left side

Question 5

What are the risk factors for a pneumothorax?

Answer 5

• smoking
• FHx
• tall, slender
• age<40yrs
• recent invasive medical procedure
• chest trauma
• COPD
• TB
• CF

see image for rare risk factors

Question 6

What are the 3 main causes of pneumothoraces

Answer 6

• Spontaneous
• secondary
• traumatic

Question 7

Explain the cause of

a) spontaneous Pneumothorax
b) secondary Pneumothorax
c) traumatic Pneumothorax

Answer 7

Spontaneous

Occurs in people with typically normal lungs
Typically in tall, thin males
It is probably caused by the rupture of a subpleural bleb

Secondary

Occurs in patients with pre-existing lung disease (e.g. COPD, asthma, TB)

Traumatic

Caused by penetrating injury to the chest

Often iatrogenic (e.g. during jugular venous cannulation, thoracocentesis)

Question 8

Summarise the epidemiology of pneumothoraces

Answer 8

Annual incidence: 9/100,000 Mainly in 20-40 yr olds
4 x more common in MALES

Question 9

Name the presenting symptoms of a pneumothorax

Answer 9

May be ASYMPTOMATIC if the pneumothorax is small

• Sudden-onset SOB
• Pleuritic chest pain

Question 10

Name the presenting symptoms of a tension pneumothorax

Answer 10

Distress with rapid shallow breathing

Question 11

What are the signs of a pneumothorax O/E?

Answer 11

There may be NO signs if the pneumothorax is small

Signs of respiratory distress

• Chest expansion: eeduced
• Percussion: hyper-resonance
• Auscultation: reduced breath sounds

Question 12

What are the signs of a tension pneumothorax O/E?

Answer 12

Severe respiratory distress

• Tachycardia
• Hypotension
• Cyanosis
• Distended neck veins
• Tracheal deviation away from the side of pneumothorax

Question 13

What is the first investigation to be ordered for a ?pneumothorax

Answer 13

CXR

Question 14

What further investigations should be ordered for ?pneumothorax?

Answer 14

ABG –> check for hypoxaemia

Question 15

What is the management plan for a tension pneumothorax?

Answer 15

EMERGENCY

• Maximum O2
• Insert large bore needle into 2nd ICS MCL - up to 2.5 L of air can be aspirated
• Stop if patient coughs or resistance is felt
• Follow-up CXR 2 hrs and 2 weeks later

Question 16

How should a clinically stable spontaneous pneumothorax be managed?

Answer 16

• observation
• conservatively with supplemental high-concentration (10 L/minute) oxygen

Question 17

How should a larger pneumothorax be managed?

Answer 17

percutaneous needle aspiration

If aspiration fails, a chest tube or small-bore catheter should be inserted into the pleural space

Question 18

How should a larger secondary pneumthorax be managed?

Answer 18

• chest tube OR
• small-bore catheter

inserted into the pleural space

Question 19

How should recurrent pneumothoraces be managed?

Answer 19

• Chemical pleurodesis (fusing of visceral and parietal pleura with tetracycline or calc)
• Surgical pleurectomy

Question 20

What are the possible complications of a pneumothorax?

Answer 20

• re-expansion pulmonary oedema
• Recurrent pneumothoraces
• Bronchopleural fistula

Question 21

What is the prognosis for

a) primary pneumothorax
b) secondary pneumothorax

Answer 21

a) 30% - 50% of patients will have an ipsilateral recurrent pneumothorax
b) risk of contralateral pneumothorax