Pleural space pathology: Pneumothorax Flashcards
Definition
Abnormal accumulation of air within the pleural space.
Types of pneumothorax’s
Primary spontaneous = No underlying cause, happens in an otherwise healthy individual
Secondary spontaneous = Due to rupture of bulla due to underlying disease, common in smokers
Tension = Due to penetrating chest injury or iatrogenic (lung biopsy, mechanical ventilation or central line insertion), medical emergancy
Primary spontaneous
Typical presentation: A young, tall, healthy, male presents with sudden onset breathlessness and chest pain
Pathogenesis: Spontaneous rupture of a subpleural bleb
Risk factors:
- Tall, slender, young (aged 20-30)
- Marfan syndrome
- Rheumatoid arthritis
- Family history
- Homocystinuria
- Diving or flying
Secondary spontaneous
Typical presentation: A middle-aged patient with COPD presents with sudden onset breathlessness and chest pain
Pathogenesis: Rupture of damaged pulmonary tissue
Risk factors:
- smoking
- Underlying lung disease: COPD, asthma, lung cancer
- Tuberculosis
- Pneumocystis jirovecii
Traumatic
Typical presentation: A middle-aged male presents to the emergency department after being stabbed in the chest with a knife
Pathogenesis: A one-way valve is formed in the pleural space (letting the airflow in but not to flow out)
Risk factors:
Non-iatrogenic
- Open: e.g. stab or gunshot wound
- Closed: e.g. impact following road traffic accident
Iatrogenic e.g. central line insertion, lung biopsy
Epidemiology (PS)
Tall
Young (under 40)
Thin
Male
Sudden breathlessness when playing sports
Epidemiology (SS)
Chest pain
Middle aged
Male
COPD
Sudden breathlessness
Risk factors
Pre-existing lung disease:
- COPD
- Asthma
- CF
- Lung cancer
- Pneumocystis pneumonia
Connective tissue disorders:
- Marfans
- EhlersDanlos
- Rheumatoid Arthritis
Ventilation: including non-invasive
Catamenial pneumothorax: caused by endometriosis, which occurs within 72 hours before or after start of menstruation
Pathophysiology SS
Rupture of a bulla (air filled sac). Bullae arise when there is a small leak in the alveoli which allow the air to leak out + form air filled sac. The bullae can break into the visceral pleura + will go into the pleural space
Pathophysiology Tension
Rips into the parietal pleura allowing air from outside to enter the pleural space
Injury acts like one way valve meaning air can enter but no leave
The increase in pressure can press on the heart or press on the trachea causing tracheal deviation away from the affected side
Signs
Double T, C + H, one R
- Tachycardia and tachypnoea
- Cyanosis
- Hyperresonance ipsilaterally
- Reduced breath sounds ipsilaterally
- Hyperexpansion ipsilaterally: associated with tension pneumothorax
- Contralateral tracheal deviation and shock in tension pneumothorax (emergency)
Symptoms
Sudden-onset pleuritic chest pain
Sudden-onset dyspnoea
Sweating: may be present
Diagnosis
1st line = Erect CXR
- Trachea deviation to the unaffected side
- Pleural space
- Collapsed lung
- Tension pneumo = displacement of chest structures
Do not bother with tension pneumothorax as it will delay immediate necessary treatment
GOLD STANDARD = CT
- Done if CXR diagnosis is uncertain or if pneumo.t too small to see
- Can accurately assess the size of pneumo.t
- Size is measured from the visible lung margin at level of hilum
DDx
Asthma
COPD
Pulmonary embolism
Pleural effusion
Management
Primary spontaneous
- If no SOB + less than 2cm rim on X-ray = discharge + follow up in 2 weeks
- no driving
- no flying1 week post x-ray or 2 weeks post drainage
- >2cm + SOB = needle aspiration, if unsuccessful do chest drainage
Secondary spontaneous
- <1cm = admit 24 hrs + O2
- 1-2cm = needle aspiration
- > 2cm (or if patient +50) = chest drainage
Surgical intervention: If chest drain fails or there is persistent air leak
- Pleurodesis
