Pneumothorax

Question 1

How do you measure the size of a pneumothorax?

Answer 1

• British: interpleural distance (recommended)

- American: apex distance

Question 2

What is the clinical presentation of a tension pneumothorax?

Answer 2

A clinical EMERGENCY & a CLINICAL DIAGNOSIS

• Haemodynamic instability
• U/L Reduced chest expansion
• U/L Reduced breath sounds
• +/- Elevated JVP
• +/- Tracheal deviation (a late development)

Question 3

What are the cause + management of a non spontaneous pneumothorax?

Answer 3

Can be traumatic / iatrogenic (ventilator use etc)

More likely to develop tension pneumothorax

Management

• If Cx by tension pneumothorax 🡪 emergent needle decompression
• If not Cx by tension pneumothorax 🡪 there is no guidelines on this matter 🡪 I think can consider chest thoracostomy

Question 4

What are the cause + management of a spontaneous pneumothorax?

Answer 4

Primary Pneumothorax

• Pneumothorax which presents w/o a precipitating external event in the absence of clinical lung disease
• Most affected patients have unrecognized lung abnormalities (mostly subpleural blebs) that likely predispose to pneumothorax
• Unlikely to progress and hence active intervention is only required if >2cm. Otherwise can give high flow O2 then discharge.

Secondary Pneumothorax

• Where there is an underlying pleural / lung / connective tissue disease
• Eg: COPD, Asthma, Marfan’s, Cystic Fibrosis, Lung Malignancies
• Higher chance of progression and thus should managed and even admitted no matter the size. (managed if >1cm; admitted even if <1cm)

Question 5

What is the management of pneumothorax?

Answer 5

CXR is CONTRAINDICATED, a purely CLINICAL diagnosis

Acutely: Thoracocentesis at 2nd ICS mid clavicular line

• If fails – don’t try again!
• There is high chance of failure due to issues w/ technique & thickness of the chest wall, but due to therapeutic urgency & speed of insertion, we will still try

Definitely: Thoracostomy in the triangle of safety at 4/5th ICS, Ant Axillary line

• Triangle of safety = between Lat Dorsi, Pec Major and Nipple Line
• Regardless of success of thoracocentesis, all patients w/ tension pneumo will require chest tube insertion

Question 6

What are the complications of chest tube insertion?

Answer 6

• Bleeding
• Infection
• Failure of procedure
• Damage to surrounding structures – lung, heart, IC Neurovascular bundle, liver

Question 7

What are the investigations to be performed for non tension spontaneous pneumothorax?

Answer 7

CXR +/- USS Scan

• Elucidate size of pneumothorax, which guides prognosis and Mx
• Compare between pre & post intervention to monitor efficacy of therapy
• Not the most sensitive, but is fast!
• When supine, pneumothorax may be hard to detect 🡪 look for deep sulcus sign

USS Scan – EFAST

• To elucidate pneumothorax by looking for LOSS OF LUNG SLIDING sign + BARCODE sign
• i.e. the movement of the 2 pleural layers against each other
• Lack of movement may indicate gas separating the layers apart. Gas might not be visible on USS even if sliding is absent.
• MOST Sensitive & Specific!
• Able to detect pneumothorax even in the supine position

Question 8

What is the management of non tension spontaneous pneumothorax?

Answer 8

Primary Spontaneous Pneumothorax

• If haemodynamically unstable 🡪 manage as per Tension Pneumo
• > 2cm or SOB 🡪 Thoracocentesis (2nd ICS mid clavicular line)
• <2cm interpleural distance 🡪 give O2, consider DISCHARGE

Secondary Spontaneous Pneumothorax

• If haemodynamically unstable 🡪 manage as per Tension Pneumo
• > 2cm or SOB 🡪 Thoracostomy
• 1-2cm interpleural distance 🡪 Thoracocentesis (2nd ICS mid clavicular line)
• <1cm interpleural distance 🡪 ADMIT + high flow O2 (hence resorb the leaked air)

Question 9

What are the indications for surgical management of non tension pneumothorax?

Answer 9

VATS pleurodesis (video-assisted thoracoscopic Sx) via:

• Chemical (instillation of talc/tetracycline derivative)
• Pleural abrasion
• Pleurectomy

Indications

• Recurrent, bilateral (2nd I/L or 1st C/L pneumothorax or synchronous bilateral)
• Persistent air leak despite 5-7/7 of thoracostomy or failure of lung re-expansion
• Tension pneumothorax, spontaneous haemothorax
• Pregnancy
• High risk occupation (eg pilot, diver)

Question 10

What advice will you give to all patients with pneumothorax?

Answer 10

Absolute C/I (even after resolution): Mountain climbing, deep sea diving (unless bilateral pleuredesis)

Relative C/I:

• Air travel 6/52 after full resolution
• Air travel: if current PTX C/I, 2/52 after CXR resolution, 3-4/52 after post-Sx PTX
• Strenuous activity (e.g. heavy weights) 4/52

Smoking cessation (↓ recurrence)