breathlessness/ Pneumothorax Flashcards
DD for sharp chest pain and shortness of breath.
Pulmonary embolism
Pneumothorax
Infection - LRTI/CAP
Acute asthma attack!!!!
Aortic dissection (unlikely)
Musculoskeletal chest pain (diagnosis of exclusion)!!!!!
Cardiac e.g. pericarditis. (ACS is very unlikely in this patient but worth considering)!!!!1
AE for breathlessness ?
a
B - assess the trachea and chest expansion
C -
modified wells score ?
PE likely (>4 points) = do CTPA
or unlikely (≤4).
clinical signs of IF DVT - yes 3 points
PE first diagnosis or equally likely - yes 3 points
heart rate >100 - yes 1.5 points
immobilisation at least 3 days or surgery in the previous 4 weeks - yes 1.5 points
previos diagnosis of PE or DVT - yes -1.5 points
hemoptysis - yes 1 point
malignancy treatment within 6 months or palliative - yes 1 point
causes of pneumothorax ?
Spontaneous (especially in young thin men) due to rupture of a subpleural bulla
- Chronic lung disease: asthma; COPD; cystic fibrosis; lung fibrosis; sarcoidosis
- Infection: TB; pneumonia; lung abscess
- Traumatic: including iatrogenic (CVP line insertion, pleural aspiration or biopsy,
percutaneous liver biopsy, positive pressure ventilation). - Carcinoma
- Connective tissue disorders: Marfan’s syndrome, Ehlers–Danlos syndrome
pneumothorax management ?
BTS define minimal symptoms as ‘no significant pain or breathlessness and no physiological compromise’
no or minimal symptoms → conservative care, regardless of pneumothorax size
if a pneumothorax is symptomatic, the next step is assessment for high-risk characteristics
high-risk characteristics are defined as follows:
haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax
what to do if there is high risk characteristics ?
see if it is safe to intervene - does th pneumothorax have sufficient size
if yes = put chest drain in
(usually more than 2cm laterally or apically on CXR )
if not save to internet - CT imaging and reassess
if the patient is symptomatic and if there are no high risk characteristics ?
check what is the patients main priority
if it is procedure avoidance / CONSERVATIVE OPTION
if it is PSP = review as outpatient every 2-4 days , and when patients symptoms has resolved follow up in OPD in 2-4 weeks
SSP - review as inpatient
if stable follow up as OPD in 2-4 weeks with repeat cxr
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rapid symptom relief
suggest an ambulatory pleural vent device if available
regular review as outpatient every 2-3 days
remove the device when symptoms have resolves
when stable follow up as OP in 2-4 weeks with repeat cxr then
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rapid symptoms relief with short term drainage
= go for needle aspiration (if not resolved needs a chest drain)
if symptoms have resolved discharge with repeat CXR and review in OPD in 2-4 weeks time
when is talc pleurodesis considered ?
on the first episode of pneumothorax in high risk patients n whom repeat pneumothorax would be hazardous - such as severe COPD patients
If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion?
vaccum
video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy
patients should be advised to avoid
smoking to reduce the risk of further episodes
The British Thoracic Society not travelling by air for 1 week post check x-ray
Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively
Mx of tension pneumothorax ?
tachycardia, hypotension, distended neck veins, trachea deviated away from side of pneumothorax
DO this BEFORE REQUESTING CXR
immediate needle decompression by inserting a large-bore (eg, 14- or 16-gauge) needle into the second intercostal space in the midclavicular line
then insert a chest drain
