Pleural Disease - Pneumothorax Flashcards
What is a pneumothorax
The presence of air within the pleural cavity
What causes a pneumothorax
A breach of the visceral or parietal pleura with the entry of air causing the lung to collapse away from the chest wall because of the elastic recoil of the lung
What are the two ways pneumothorax can come about
Spontaneously
Traumatically
What types of spontaneous pneumothorax are there
Primary spontaneous
Secondary spontaneous
What types of traumatic pneumothorax are there
Non-iatrogenic
Iatrogenic
What is a tension pneumothorax
The build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space
Is primary spontaneous pneumothorax a clinically apparent disease
No
Who does primary spontaneous pneumothorax tend to affect
Tall thin individuals
People under age of 45 (accounts for 81% of pneumothorax)
What is the cause of primary spontaneous pneumothorax
It is believed to be due to the weight of the lung which induces the development of apical blebs that rupture
How many men and women suffer from primary spontaneous pneumothorax
18-28 per 100,000 men per year
1.2-6 per 100,000 women per year
What is the peak incidence of primary spontaneous pneumothorax
It has a young peak incidence (20-30 years)
What is the cause of secondary spontaneous pneumothorax
Tends to occur due to a pre-existing lung disease (almost any lung disease)
What types of pre-existing lung diseases can cause secondary spontaneous pneumothorax
COPD Asthma Pneumonia TB Cystic fibrosis Fibrosing alveolitis Sarcoidosis Histiocytosis X
How many cases of secondary spontaneous pneumothorax are due to COPD
30-50%
How many asthmatics get secondary spontaneous pneumothorax
0.8%
How many TB patients get secondary spontaneous pneumothorax
1.4%
Name 2 causes of traumatic non-iatrogenic pneumothorax
Penetrating chest injury (stab, gunshot)
Blunt chest injury (rib fractures, bronchial rupture)
Name 4 causes of traumatic iatrogenic pneumothorax
Pleural aspiration/biopsy
Sub-clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture
What are the symptoms are of a pneumothorax
Small pneumothorax in a patient with a good respiratory reserve is normally asymptomatic
Acute breathlessness, worsening breathlessness and pleuritic chest can occur
What does extreme dyspnoea in a previously fit individual indicate
Tension pneumothorax
What does extreme dyspnoea in a person with chest disease indicate
Tension pneumothorax or severe lung disease
What are the signs of of a small pneumothorax
Normally no signs
What are the signs of a non-tension pneumothorax
Decreased expansion
Hyper resonant
Absent or decreased breath sounds
What are the signs of a tension pneumothorax
Trachea deviates away from the affected side
Haemodynamic compromise
Increased JVP
What type of investigation can be conducted for a pneumothorax
Chest X-Ray
What is considered a large or small pneumothorax
Large - over 2cm
Small - under 2cm
What are the 4 questions which should be asked when deciding treatment
1) Is it a tension pneumothorax?
2) Is the pneumothorax small or large?
3) Is the patient breathless?
4) Is the pneumothorax likely to be primary or secondary?
How is a tension pneumothorax treated
Cannula (large grey venflon) in the 2nd intercostal space min-clavicular line then insert an intercostal chest drain
How is a small primary pneumothorax (non-breathless) treated
Observed overnight
Repeat chest X-Ray
If no change then hole has sealed
Discharged
What should the patient be advised
Avoid vigorous activity
Return if they become breathless
How does a small primary pneumothorax resolve
1.25% per day
Should be reviewed in a chest X-Ray clinic 2 weeks
How is a breathless primary pneumothorax treated
Aspiration while the patient is at at 45˚ and lignocaine placed into the second intercostal space in the midclavicular line using a 50 ml syringe, venflon, 3 way tap and tube to water
How long is a breathless primary pneumothorax treated
Aspirated until the surface of the lung can be felt on the tip of the venflon just beneath the surface of the chest wall
What does it mean is over 3L is aspirated
Persistent air leak
If the aspiration is successful in a breathless primary pneumothorax what are the next steps
A chest X-Ray should be conducted after 24 hours
If the aspiration is unsuccessful in a breathless primary pneumothorax what are the next steps
Chest drain
Can a small breathless secondary pneumothorax be aspirated
Yes but it is less successful
What is the recommended treatment for breathless secondary pneumothorax
An intercostal chest drain should be inserted into the 4th intercostal space in the mid-axillary line using a small bore 10-14F
What three things should occur upon the successful insertion of an intercostal chest drain
Lungs should inflate within 1-2 days
Drain should stop bubbling
CXR should confirm that the lung has inflated
After inserting an intercostal chest drain what are the two next steps available
The drain can be clamped for 24 hours, repeat CXR done, if there is no change then the drain can be removed
A repeat CXR can be conducted after 24 hours and if there is no change then the drain can be removes
Why is clamping the intercostal chest drain for 24 hours a better choice
Allows the detection of small air leaks and avoids the re-insertion of chest drains
If the lungs fail to re-inflate and the drain continues to bubble 48 hours after inserting an intercostal chest drain what should be done
A suction should be applied to the drain (high volume, low pressure -10 to -20 cm H2O)
What should be done if the lungs still fail to re-inflate after applying suction
Thoracic surgeons should be contacted at 3 days for a thoracoscopic inspection of the visceral pleura, identification of blebs, tears, clipping and talc poudrage pleurodesis
What is the risk of a subsequent pneumothorax
High risk
54% recurrence within 4 years
10-25% in first 4 months
10-15% contralateral pneumothorax
Which 4 categories of patients should be referred for a surgical pleurodesis
Second ipsilateral pneumothorax
First contralateral pneumothorax
Bilateral spontaneous pneumothoraxes
First pneumothorax in high risk professions (pilots, divers)
What other types of management are there
Talc poudrage
Pleurectomy
