8.4 Pneumothorax

Question 1

A 20-year-old male brought to the Accident and Emergency
department following a traffic accident is complaining of pain in the pelvis.

Vital observations
Pulse: 100/min
Blood Pressure: 140/80 mmHg
Respiratory rate: 26/min
Spo2 96% on 8 litres of oxygen
GCS: E4V5M6
Chest X-ray provided in Figure 8.5.

How will you manage this patient
in A&e resus?

Describe the chest X-ray

Answer 1

• ATLS approach
• Primary survey, including monitoring and X-rays

. * Simple right apical pneumothorax; the lung border is visible.

Question 2

What is your management?

Answer 2

• ABC approach
• Assess whether the airway is patent and if the patient has adequate effort
  of ventilation
• Simple aspiration of the pneumothorax and intercostal tube drainage with
  an underwater seal

Question 3

How would you perform this procedure?

Answer 3

• Determine site of insertion. (This is usually the 5th intercostal space
  anterior to the mid axillary line on the affected site. The second
  intercostal space in the midclavicular line is sometimes chosen for apical
  pneumothoraces. But this is not recommended due to complications like
  vascular damage and discomfort.)
• Follow strict asepsis.
• Local anaesthetic infiltration of skin and rib periosteum.
• Make a 2–3 cm horizontal incision over the top of the rib.
• Perform blunt dissection of subcutaneous tissue.
• The parietal pleura is punctured and finger inserted to avoid organ injury
  and to clear adhesions.
• The proximal end of the thoracostomy tube is clamped and advanced
  directing it posteriorly in the chest wall.
• Connect end of tube to underwater seal.
• Suture in place and dress the wound.
• Look for bubbling in the underwater seal and fogging of tube.
• Order a chest X-ray.

Question 4

Describe the features of the underwater seal.

Answer 4

• The thoracostomy tube must be wide enough to avoid resistance with
  its volumetric capacity in excess of half the patient’s maximal inspiratory
  volume.
• The volume of water in the underwater seal should be in excess of half
  the patient’s maximal inspiratory volume to avoid water from being drawn
  in during inspiration.
• The drain must be 45 cm below the patient.

Question 5

Can you connect suction to the tube?

Answer 5

• Routine suction should be avoided.
• A persistent air leak with or without incomplete re-expansion of lung is
  the usual reason.
• High-volume, low-pressure suction systems are recommended by the
  British Thoracic Society

Question 6

How would the treatment differ if this were a tension pneumothorax?

Answer 6

• Tension pneumothorax is a medical emergency and is associated with
  cardiovascular instability.
• The treatment is with supplemental oxygen therapy and immediate
  needle decompression.
• A cannula can be introduced in the second anterior intercostal space in
  the mid-clavicular line on the side of the pneumothorax.
• This is then followed by a chest drain.

Question 7

What are the treatment options for a simple spontaneous pneumothorax?

Answer 7

According to the British Thoracic Society guidelines:
* Breathlessness indicates the need for active intervention and oxygen therapy.

• The size of the pneumothorax determines the rate of resolution and is a
  relative indication for active intervention.
• Small pneumothoraces
  (< 2 cm visible rim between the lung margin and chest wall at the level of hilum)
  in the absence of breathlessness may be managed with observation alone.

Question 8

this patient needs a general anaesthetic as he has a dislocated shoulder on the left side. How will you proceed?

Answer 8

• Intubation is the choice if fasting status is not known or with a full
  stomach.
• Trauma, pain, and opiate analgesics are associated with delayed gastric
  emptying, so this subgroup of patients is at high risk for aspiration of
  gastric contents.
• An intercostal drain with an underwater seal is necessary, prior to
  intubation, as otherwise a simple pneumothorax can be converted to a
  tension pneumothorax with positive pressure ventilation.
• Nitrous oxide should be avoided as it can rapidly increase the size of the
  pneumothorax.
• Brachial plexus blocks which carry a risk of pneumothorax, and phrenic
  nerve block which can cause diaphragm dysfunction must be avoided on
  the other side.