Pneumothorax

Question 1

What is the pneumothorax?

What is the typical patient in exams?

What are the causes of pneumothorax?

What is the first line investigation for pneumothorax?

Answer 1

Build up of air in the pleural cavity .

Typical patient
Young tall man, presenting with a sudden onset of SOB, and pleuritic chest pain, possibly whilst playing sports.

Causes

• Spontaneous
• Lung pathology e.g. asthma, COPD, infection
• Medical interventions (iatrogenic) e.g. lung biopsy, mechanical ventilation, or insertion of a central line.

Ix
- Erect chest x ray which would show no lung markings between the edge of lung tissue and the chest wall.

Question 2

What are the guidelines for aspiration and chest drain for primary pneumothorax?

Answer 2

Primary pneumothorax
- If rim of air < 2cm, and patient is not SOB, then discharge the patient.

• If rim of air > 2cm and/or patient has shortness of breath, then aspirate the patient.

Aspiration: take cannula and insert at 90 degrees into the second intercostal space, midclavicular line.

• If aspiration of patient does not help (i.e. patient still has SOB and/or rim of air >2cm, then a chest drain should be inserted).
• Patient should be advised not to smoke as smoking increases a patient’s risk for future episodes.

Question 3

What are the guidelines for aspiration and chest drain insertion in patients with secondary pneumothorax?

Answer 3

If patient is > 50 years old, and patient has SOB and/ or rim of air >2cm, then a chest drain should be inserted.

If the rim of air is between 1-2cm, then an aspiration should be carried out. If aspiration fails (pneumothorax >1cm), then a chest drain should be inserted.

If rim of air <1cm, then the patient should just be admitted for 24 hours and given oxygen if necessary.

It is important to strongly discourage scuba diving in these patients, unless the patient has undergone bilateral pleurectomy and has had normal lung function tests and CT scan post-operatively.

Question 4

What are the guidelines for aspiration and chest drain insertion for iatrogenic pneumothorax?

Answer 4

• Most iatrogenic pneumothoracies resolve with observation.
• If treatment is required, then patient should be aspirated.
• If patient is ventilated or in some COPD patients, then a chest drain may be necessary.

Question 5

What is tension pneumothorax?

What are signs of tension pneumothorax?

What is the management of tension pneumothorax?

Answer 5

• One way valve created
• Rapid air build up within the pleural space, resulting in lung collapse, mediastinal shift, tracheal deviation. and kinking of large vessels (e.g. super vena cava) leading to cardiorespiratory arrest.

Signs of tension pneumothorax?

• Decreased breath sounds in the affected side
• Tracheal deviation towards the unaffected lung
• Hyper-resonance on percussion of affected side
• Cardiorespiratory compromise e.g. hypotension, tachycardia

Management
- Large bore cannula inserted into second intercostal space, midclavicular line. Then a chest drain should be inserted for definitive management.

Question 6

What are the landmarks for aspiration?

What are the landmarks for chest drain insertion?

Answer 6

Aspiration
- 2nd intercostal space, midclavicular line

Chest drain insertion
- Triangle of safety

Borders of triangle of safety

• 5th intercostal space ( inferior nipple line)
• Anterior axillary line (lateral border of the pectorals major muscle)
• Midaxillary line (lateral border of the latissimus doors muscle)