PE, Pneumothorax and Pleural Effusion

Question 1

What usually causes a PE?

Answer 1

Venous thrombosis from the pelvis or leg, clot breaks off and travels through the heart and lodges in pulmonary circulation

Question 2

Rarer causes of PE

Answer 2

Right ventricular thrombus (after MI)
Right atria from AF 
Septic emboli (right-sided endocarditis)
Fat (long-bone fracture)
Neoplastic cells

Question 3

Risk factors for PE

Answer 3

Recent surgery (especially abdo/pelvis)
Thrombophilia 
Leg fracture
Prolonged bed rest/immobility  
Malignany 
Pregnancy/post partum, HRT/OCP 
Previous PE

Question 4

Symptoms of PE

Answer 4

Depend on size
Pleuritic chest pain 
Acute breathlessness
Haemoptysis
Dizziness
Syncope

Question 5

Signs of PE

Answer 5

Pyrexia, cyanosis 
Tachycardia, tachypnoea 
Hypotension 
Raised JVP 
Pleural rub 
Pleural effusion

Question 6

CXR in PE

Answer 6

May be normal 
May show oligaemia of affected segment 
Dilated pulmonary artery 
Liner atelectasis 
Small pleural effusion

Question 7

ECG in PE

Answer 7

May be normal 
Or may have
Tachycardia 
RBBB
right ventricular strain

Question 8

Treatment of PE

Answer 8

Anticoagulate - LMWH
Start warfarin and then stop heparin when INR >2
Continue warfarin for at least 3 months aiming for an INR of 2-3

Thrombolyse if massive PE - alteplase 10mg IV over 1min then 90mg IV over 2h

Question 9

PE Prevention

Answer 9

Heparin to all immobile patients
TED stockings
Encourage early mobilisation
Stop HRT and OCP pre-op

Question 10

When perform a D-Dimer in PE diagnosis

Answer 10

Only if patient without a high probability of PE
Negative D-dimer will exclude PE
+ve D-dimer does not give diagnosis - will need imaging as well to confirm (CTPA)

Question 11

Most common cause of pneumothorax

Answer 11

Spontaneous - especially in young thin men

Due to rupture of a sub-pleural bulla

Question 12

Other causes of pneumothorax

Answer 12

Underlying lung pathology
Trauma
Iatrogenic - subclavian CVP line insertion, pleural aspiration/biopsy, liver biopsy

Question 13

Risk factors for pneumothorax

Answer 13

Physical height - increased distending pressure on alveoli

Smoking increases risk of first spontaneous pneumothorax by 20x in men and nearly 10x in women

Underlying lung disease eg. COPD

Question 14

Main physiological consequences of a pneumothorax

Answer 14

Decreased vital capacity and paO2
Young and otherwise healthy can tolerate this well and may have minimal signs

But underlying lung disease may develop respiratory distress

Question 15

Clinical Features of pneumothorax

Answer 15

Sudden onset dyspnoea
Sudden onset chest pain (tearing of pleura, bleeding into pleural space)

If asthma or COPD - will present as sudden deterioration

Question 16

Signs in pneumothorax

Answer 16

Reduced expansion unilaterally
Hyperresonant percussion
Reduced breath sounds
Reduced vocal fremitus

Tachypnoea - pain, anxiety or response to hypoxia
Tachycardia

Question 17

What happens in tension pneumothorax

Answer 17

One way valve therefore air continues to enter pleural space - pressure builds up and mediastinum displaces

CO drops due to decreased cardiac filling - urgent ventilation required

Distended neck veins

Question 18

CXR in pneumothorax

Answer 18

Tension - tracheal deviation

Reduced lung - can see air where collapsed lung usually is

Question 19

Management of pneumothorax if patient is stable

Answer 19

Small rim of air seen with minimal symptoms

Avoid strenuous exercise and observe at 2-weekly intervals until air is resorbed

Question 20

Management if more than 20% radiographic volume in primary pneumothorax

Answer 20

Aspirate air
If no recurrence, send home
If recurs - insert chest drain

Question 21

Aspiration of pneumothorax

Answer 21

2nd intercostal space midclavicular line or 4th-6th midaxillary line

Infiltrate 1% lidocaine down to pleura overlying pneumothorax

Insert 16G cannula
Aspirate up to 2.5L of air - stop if resistance is felt or if patient coughs excessively

CXR to check resolution 2h and 2week later

Question 22

What to do if pneumothorax remains or if tube bubbling

Or recurrent pneumothorax

Answer 22

Pleurectomy - no recurrence

Talc pleurodesis - some recurrence

Question 23

Management of secondary pneumothorax with >2cm rim of air on CXR

Answer 23

Chest drain

If less than 2cm - aspirate

Question 24

Management of tension pneumothorax

Answer 24

Medical emergency

Insert a large-bore needle (14-16) with syringe into 2nd intercostal space mid clavicular line

Remove plunger and allow trapped air to bubble through syringe (with saline in it as water seal)

This is until chest drain can be put in place

THEN AFTER THIS - request Chest xray