Pleural Disease - Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

Air in pleural cavity due to a breach of parietal or visceral pleura with entry of air

Causes lung to collapse

Question 2

What is a tension pneumothorax

Answer 2

When air keeps flowing in during inspiration but doesn’t flow out during expiration due to a flap of skin creating a one way valve

Pressure gets so great it shifts the mediastinum

Question 3

What are the different types of pneumothoraxes?

Answer 3

Regular
Tension
Spontanous - either 1y or 2y
Traumatic

Question 4

What is the difference in primary and secondary spontaneous pneumothoraxes?

Answer 4

1y - no clincal disease behind it

2y - Due to almost any underlying lung disease

Question 5

What are the two types of traumatic pneumothoraxes?

Answer 5

Iatrogenic - caused by medical staff - pleaural aspiration/biopsy

Non-iatrogenic - stab, gunshot, blunt trauma

Question 6

Symptoms?

Answer 6

Acute dyspnoea

Pleuritic chest pain

Question 7

Signs?

Answer 7

Surgical/subcutaneous emphysema - gas under skin, bubble wrap appearance

Reduced expansion
Reduced breath sounds
Hyper-resonant percussion

Question 8

Signs specific to non-tension p.thorax?

Answer 8

Trachea deviated to the affected side

Question 9

Signs specific to tension p.thorax?

Answer 9

Trachea deviated away from the affected side

Haemodynaic compromise causing a raised JVP

Question 10

Management for a tension p.thorax?

Answer 10

Medical emergency - do not delay management by ordering a CxR

Cannula in 2nd intercostal space mid-clavicular line
Insert intercostal drain with underwater seal for 2/3 days
If not bubbling remove and x-ray to exclude any recurrence
If still bubbling after 3 days consider surgical options

Question 11

What is considered before treatment?

Answer 11

Tension or non-tension
Small or large
Breathless or not breathless
Primary or secondary

Question 12

Treatment for a small, non-breathless, primary p.thorax?

Answer 12

Observe overnight

Repeat CxR - if no change hole has sealed

Discharge and warn against heavy activity

Will resolve slowly - review again after 2 weeks

Question 13

A primary breathless p.thorax? Treatment?

Answer 13

Aspirate the p.thorax:

Patient at 45 degrees
Lidocaine at 2nd intercostal space, mid-clav line
to numb the area
50ml syringe, cannula, 3 way tap and a tube to water
Aspirate until you feel the cannula on the lung surface just beneath chest wall
Observe after 24 hrs with a CxR if it was successful
If it failed - do a chest drain

Question 14

Breathless and secondary p.thorax treatment?

Answer 14

Intercostal chest drain - 4th space mix axilliary line with a needle
If surgical emphysema present - use needle with large air leak tap and a underwater seal

Question 15

What is the ideal outcome of an intercostal chest drain? What should be done if these outcomes are achieved?

Answer 15

Drain should stop bubbling after 1-2 days
CxR confirms inflated lung

Then - clamp and drain for 24 hours to get smaller fluid build ups, re-CxR and if no change remove the drain

Question 16

What is a less ideal outcome of a chest drain? What should be done?

Answer 16

Drain keeps bubbling after 2 days

Apply suction to drain - high volume low pressure
At 3 days involve surgeons if lung fails to re-inflate

Question 17

What can the surgeons do?

Answer 17

Thorascopic inspection if visceral pleura - IDs blebs, tears and clippings
Talc poudrage
Pleurectomy