Pneumothorax

Question 1

What are the main causes of a pneumothorax?

Answer 1

• Often spontaneous (especially in young, thin men) due to rupture of a subpleural bulla
• Chronic Lung Disease: Asthma, COPD, Cystic Fibrosis, Lung fibrosis, Sarcoidosis
• Infection: TB, Pneumonia, Lung abscess
• Carcinoma
• Connective Tissue disorders: Marfan’s syndrome, Ehlers-Danlos syndrome
• Trauma: (including) Iatrogenic (subclavian CVP line insertion, pleural aspiration/biopsy, transbronchial biopsy, liver biopsy, positive pressure ventilation)

Question 2

What are the main symptoms of a pneumothorax?

Answer 2

• May be asymptomatic (fit, young and small pneumothorax)
• Sudden onset of dyspnoea and/or pleuritic chest pain
• Patients with asthma or COPD may present with a sudden deterioration
• Mechanically ventilated patients may present with hypoxia or an increase in ventilation pressures

Question 3

What are the main signs of a pneumothroax?

Answer 3

• Reduced expansion
• Hyper-resonance to percussion
• Diminished breath sounds on the affected side
• With a tension pneumothorax the trachea will be deviated away from the affected side and the patient will be acutely unwell

Question 4

What tests should be performed if a pneumothorax is suspected?

Answer 4

• A CXR should not be performed if a tension pneumothorax is suspected, as it will delay necessary immediate treatment
• If a tension pneumothorax is not suspected request an expiratory film:
o Look for an area devoid of lung markings, peripheral to the edge of the collapsed lung
• Ensure suspected pneumothorax is not a large emphysematous bulla
• ABG in dyspnoeic/hypoxic patients and those with chronic lung disease

Question 5

What are the signs of a tension pneumothorax?

Answer 5

• Respiratory distress
• Tachycardia
• Hypotension
• Distended neck veins
• Trachea deviated away from affected side of pneumothorax
• Increased percussion note
• Decreased air entry/breath sounds on affected side

Question 6

What occurs in a tension pneumothorax?

Answer 6

• Air drawn into the pleural space with each inspiration has no route of escape during expiration
• The mediastinum is pushed over into the contralateral hemithorax, kinking and compressing the great veins
• Unless the air is rapidly removed, cardiorespiratory arrest will occur

Question 7

What is the treatment used for a tension pnuemothorax?

Answer 7

• To remove the air, insert a large bore (14-16G) needle with syringe, partially filled with 0.9% saline, into 2nd intercostal space in the mid clavicular line on the side of the suspected pneumothorax
• Remove plunger to allow the trapped air to bubble through the syringe until chest tube can be placed
• OR insert a large bore Venflon in the same location
• DO THIS BEFORE REQUESTING A CXR