2.0 Pleural diseases - pneumothorax, mesothelioma

Question 1

What is the definition of pneumothorax

Answer 1

Presence of air within the pleural cavity due to a breach of visceral or parietal pleura with entry of air, lung collapses away from chest wall because of elastic recoil of the lung

Question 2

A pneumothorax can either be?

Answer 2

spontaneous or traumatic

Question 3

Define tension pneumothorax

Answer 3

progressive build-up of trapped air within the pleural spaceo the air pressure within the thorax mounts higher than atmospheric pressure - compressing the lung

Question 4

What is the possible outcome of tension pneumothorax

Answer 4

may displace the mediastinum and its structures (including the lung) toward the opposite side and lead to cardiopulmonary impairment

Question 5

What believed to be the cause of primary spontaneous pneumothorax

Answer 5

No apparent underlying disease

Believed to be due to weight of lung inducing development of apical blebs that rupture

Question 6

What is the cause of secondary spontaneous pneumothorax

Answer 6

Pre existing lung disease e.g. COPD, asthma, pneumonia, TB, cystic fibrosis etc

Question 7

What is an example of a non-iatrogenicTraumatic pneumothorax (not caused by a physician)

Answer 7

Penetration to the chest wall by a gun, knife

or a blunt chest injury

Question 8

What kind of Iatrogenic procedures can cause a traumatic pneumothorax
(ie due to therapy or by physician)

Answer 8

Pleural aspiration/biopsy
Sub-clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture

Question 9

When is pneumothorax asymptomatic

Answer 9

if small, good respiratory reserve

Question 10

What is the symptoms of pneumothorax

Answer 10

Acute breathlessness, worsening breathlessness
Pleuritic chest pain
dyspnoea

Question 11

What is the signs of pneumothorax - no tension

Answer 11

on the affected side:
reduced expansion 
hyper resonant 
absent or decreased breath sounds 
Subcutaneous emphysema

Question 12

What are the signs of a tension pneumothorax

Answer 12

Trachea deviated away from affected side
Haemodynamic compromise - abnormal heat rhythms
JVP - jugular vien pressure

Question 13

What is subcutaneous emphysema

Answer 13

trapped air under the skin, giving a bubble wrap appearance

Question 14

When is a chest drain performed in pneumothorax

Answer 14

Tension pneumothorax
Unsuccessful aspiration
Secondary pneumothorax

Question 15

Where is a chest drain inserted for a tension pneumothorax and a secondary pneumothorax

Answer 15

Tension - 2nd intercostal space mid-clavicular line

Secondary - 4th intercostal space mid-axillary line

Question 16

What is the management for a small pneumothorax, no breathlessness

Answer 16

check with a chest X-ray, keep patient overnight and observe, but no treatment is required
review 2 weeks later

Question 17

When would an aspiration be performed in a pneumothorax

Answer 17

small pneumothorax and patient is breathless

Question 18

When does aspiration of a pneumothorax stop

Answer 18

when you feel lung surface on the tip of the aspirating tube beneath the surface of the chest wall
or
after no more than 3L of aspiration

Question 19

What is the difference in management if pneumothorax causes subcutaneous emphysema,

Answer 19

Bigger chest tube is used with the addition of a underwater seal

Question 20

what is the benefit of the under water seal

Answer 20

prevents backflow of air or fluid into the pleural cavity

Question 21

How do you check the outcomes of a chest drain and what is the positive outcomes

Answer 21

Check outcome on CXR

    Lung inflates in 1-2 days 
Drain stops bubbling
CXR confirms lung inflated

Question 22

Why would you clamp the drain for 24 hours after the CXR confirms the lungs are inflated

Answer 22

detects small air leaks, avoids re-insertion of chest drains

Question 23

If lungs fail to inflate with a chest drain, what Investigation can take place after 3 days

Answer 23

thoracoscopic inspection of visceral pleura

Question 24

When would you refer a patient for surgica/chemical pleurodesis or pleuroectomy

Answer 24

HIGH RISK
second ipsilateral pneumothorax
first contralateral pneumothorax
first pneumothorax in high risk professions (pilots, divers)

Question 25

What is mesothelioma

Answer 25

Pleural malignancy

Question 26

What is the main cause of mesothelioma

Answer 26

exposure of asbestos

highly fibrous naturally occuring mineral woven into fabric

Question 27

What is the three main types of asbestos

What type of asbestos is worse for your health

Answer 27

Chrysotile (white)
Amosite (brown)
Crocidolite (blue) -this one is worse for your health

Question 28

What is the clinical presentations of mesothelioma

Answer 28

Breathlessness

Chest wall pain

Question 29

what shows on the radiology of mesothelioma

Answer 29

Diffuse or localised pleural thickening

Question 30

Is mesothelioma usually bilateral or unilateral

Answer 30

unilateral

Question 31

What is the main factors to consider in the treatment of pneumothorax

Answer 31

Is it tension
the size of the pneumothorax (>2cm)
Is patient breathless
Primary or secondary pneumothorax