Cardiothoracics Flashcards
Describe epidemiology of spontaneous pneumothorax
Typically occurs in young healthy men of taller than average height.
3-1 men vs women
Risk factors include
- smoking (MJ and cig)
- Ambient atmospheric pressure
- mitral valve prolapse
- marfans syndrome
Discuss secondary spontaneous pneumothorax
Spontaneous pneumothorax with underlying lung disease
- COPD is the most common underlying lung disease and has the highest risk
- Relatively common with cystic fibrosis
- Known complicaiton of Pneumocysitis jiroveci pneumonia in immunocomprised
- Malignancy especially those with lung mets
- TB and lung abcess in developing countries
Rare in children – asthma, CF, connective tissue disease such as those seen with juvenile idiopathic arthirtis
List causes of secondary spontaneous pneumothorax
Airway disease
- COPD
- CF
Infections
- PJP
- TB
- Necrotizing bacteral pneumonia, lung abscess
Interstitial disease
- Sarcoidosis
- Idiopathic pulmonray fibrosis
- Lymphangiomyomatosis
- Tuberous sclerosis
- Pneumoconioses
Neoplasms
- Primary lung CA
- Mets
Miscellaneous
- connective tissue disease
- Pulmonary infarct
- endometriosus
- Catamenial
Describe catamenial pneumothorax
Condition of recurrent spontaneous pneumothorax associated with menstrual period (within 72 hours of the same)
Due to thoracic endometriosis syndrome
Discuss clinical features of primary spont pneumo
Typically symptoms begin at rest
sharp chest pain initially with dyspnoea
settling into a dull ache
Physicall finding depend on degree of pneumothorax
- sinus tachy is most common finding
- large pneumo hypoxia and decreased or absent breath sounds, with hyper resonance and absent tactial fremitus.
- IN children breath sounds are distributed across the thorax which can make appreciated decreased breath sounds difficult
Described clinical features of a tension
Asphyxia and decreased CO
tachycardia and hypoxia common
Hypotnesion is a late and ominous sign
deviated trachea is pre-arrest sign if at all present
Described clinical features of secondary spont pneumo
Manifest different to primary due to underlying lung disease
Due to poor pulmonary reserve dyspnoea is nearly universal even with a small pneumo;
Physical finding such as hyperexpansion and decreased breath sounds often overlap with the undelrying lung pathology
Discuss DDX of spont pneumo
Lung
- PE
- Pneumonia
- TUmor
Pneumothorax can mimic an MI with ECG finding simulating an acute injury pattern or pericarditis
Cardiac
- Pericardial effusion
- pericarditis
Spontaneous pneumomediastinum is closley related - diganosed by the presence of subcut emphysema – usually occurs after exertion or valsalva- most cases of spont pneumomediastinmu have good outcome
Secondary spont pneumomediastinum (booerhaavés) are more serious
Spont haemopneumothorax is rare but potentially serious condition in which lung collapse is assocted with a rupture of a vessel in a parietopleural adhesion
Discuss diagnostic testing
CXR, US
Care needs to be taken with those with underlying COPD to ensure that the pathology is not just a bullae
one clue is that pneumothorax will generally run parralel where as a large bullae will be more concave . If unclear a CT should be performed prior to insertion of ICC if patient stable
Care should be taken using US in patient with pleural pathology – fibrosis , blebs, pneumonectomy or pleurodesis can given false positives.
Discuss evaluation of size of a pneumothorax
Britsh thoracic society define size based on measurement from the interpleural distance at the hilum
- small <1cm
- Mod 1-2
- Large >2cm
The american college of chest physians measures from the apex to the cupola
Small <3cm
Large >3cm
Rhea method: take apex to copula, inter-pleural distance upper half of the lung and interpleural distance lower half of the lung to estimate volume of pneumo – accurate with small may grossly underestimate large
Discuss management of spont pneumo
Management of spont pneumo has two goals
1) evacuate air from the pleural space
2) prevent re-accumulation
For small uncomplicated pneumothorax conservative management is appropriate – 1-2% reabsorption per day increased dramatically with 100% o2. observe for 4-6 hours
Discuss disposition
Most can be discharged home after 4-6 hours observation
If needed ICC likley hospitalation to observe for complications of tube palcement including
1) misplacement of tube
2) air leak
3) pain
4) pleural infection
Re-expansion pulmonary oedema and rexapnsion hypotension are rare complications
Recurrence is common
if repeated may need VATS to remove bullae and pleurdesis
Discuss spontaneous pneumo-mediastinum
like spont pneumo most common in adolecent thin males
Discuss food bolus and food impaction
Food bolus impaction usually occurs at a physiological (Ring) or pathological (stricture) site of narrowing of the oesophagus
Physiological narrowest points are
1) upper oesophageal sphincter
2) arch of the aorta
3) diaphragmatic hiatus
Structual abnormalities that can increase likleyhood of impaction include
- diverticula,
- webs,
- rings,
- strictures,
- achalasia,
- tumors
Discuss symptoms of food bolus
Dysphagia Choking hypersalivation retrosternal fullness regurgitation of undigested food wheeze blood stained sputum
Most patient are asymptomatic once bolus has passed
