Pneumothorax

Question 1

pathophysiology of pneumothorax

Answer 1

air gets into the pleural space separating the lung from the chest wall

Question 2

causes of pneumothorax

Answer 2

• spontaenous
• secondary to trauma
• medical interventions (iatrogenic) (medical ventilator, central line insertion)
• lung pathology (asthma, infection, COPD)

Question 3

investigations for a pneumothorax

Answer 3

1. erect CXR (this will show an area between the lung and chest wall where there are no lung markings and there will be a line demarcating the edge of the lung where the lung marking ends and the pneumothorax begins)
2. CT thorax (if too small to be seen on CXR)

Question 4

measuring pneumothorax (BTS guidelines)

Answer 4

horizontally from lung edge to inside the chest wall at the level of the hilum

Question 5

what is the management for pneumothorax?

Answer 5

1. if no SOB and <2cm = no treatment required. follow up in 2-4 weeks, will spontaenosly resolve
2. if SOB and/or >2cm = aspiration and reassess
3. if aspiration fails= chest drain
   * unstable or bilateral or 2’ generally require chest drain

Question 6

what is a tension pneumothorax?

Answer 6

trauma to the chest wall
this creates a one way vale (lets air in but does not let air out)
during inspiration, air is drawn into the pleural space and then during expiration it is trapped in the pleural space

increases pressure in the thorax that will push the mediastinum and kink the big vessels, can cause cardiorespiratory arrest

Question 7

signs and symptoms of a tension pnuemothorax

Answer 7

Tracheal deviation (away from side of pneumothorax)
Reduced air entry to affected side
Increased resonant to percussion on affected side
Tachycardia
Hypotension
elevated JVP
sweating

Question 8

management of a tension pneumothorax

Answer 8

“Insert a large bore cannula into the second intercostal space in the midclavicular line.”

once pressure is received- chest drain for definitive management

administer high flow O2
insert cannula 2ICS, mid clavicular line
insert intercostal drain into pleural space through 4th/5th ICS mid axillary lain

once drain is bubbling and tension relieved, remove and arrange CXR. remove when stops bubbling and repeat CXR

Question 9

triangle of safety for a chest drain

Answer 9

5th ICS (inferior nipple line)
mid axillary (lat edge of latissimius doors)
anterior axillary (lateral edge of pectoris major)

insert needle above rib to avoid neurovascular bundle (VAN)

obtain CXR to check positioning of chest drain

Question 10

hemithorax

Answer 10

penetrating trauma hx
falling o2 sats
CVS compromise
reduced breathsounds

tx: immediate needle decompression with large bore cannula into second ICS, mid clavicular line

temp to buy time for chest drain placement

Question 11

management of types of pneumothorax

Answer 11

primary
*<2cm discharge and review in 2-4 weeks

*>2cm and or breathless aspirate with 16-18G cannula (needle thoracocentesis)

secondary
<1cm high flow o2 and observe for 24 hrs
1-2cm aspirate 16-18G cannula
>2cm chest drain (8-14 Fr)

tension
high flow o2
aspirate using 16-18G cannula in second anterior intercostal space mid-clavicular line. do not wait for chest X-ray