Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall

Question 2

What are the symptoms associated with a pneumothorax?

Answer 2

Unilateral chest pain
SoB
Tiredness

Question 3

What is a primary spontaneous pneumothorax?

Answer 3

Pneumothorax occuring in a young adult without underlying lung problems, and usually causes limited symptoms

Question 4

What is a secondary spontaneous pneumothorax?

Answer 4

individuals with significant underlying lung disease

Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the affected lungs

Question 5

What are signs of a pneumothorax?

Answer 5

Diminished breath sounds
Hyperresonance
CXR

Question 6

What is a tension pneumothorax?

Answer 6

Tension pneumothorax is generally considered to be present when a pneumothorax leads to significant impairment of respiration and/or blood circulation.

This causes a type of circulatory shock, called obstructive shock

Question 7

What is the most common cause of a secondary spontaneous pneumothorax?

Answer 7

COPD

Question 8

Why, in a physiological state, does air not enter the pleural space - despite its low pressure?

Answer 8

The lungs are fully inflated within the cavity because the pressure inside the airways is higher than the pressure inside the pleural space.

Despite the low pressure in the pleural space, air does not enter it because there are no natural connections to an air-containing passage, and the pressure of gases in the bloodstream is too low for them to be forced into the pleural space

Question 9

If someone is acute breathless, what oxygen will you give?

Answer 9

For other people who are acutely ill, use a simple face mask at 5-10 L/min or nasal cannulae at 2-6 L/min. Adjust the flow rate to achieve a target oxygen saturation of 94–98%.

Question 10

If someone is acute breathless with COPD, what oxygen will you give?

Answer 10

28% Venturi Mask at 4 L/min

Question 11

How are pneumothorex classified?

Answer 11

1. Primary spontaneous pneumothorax: pneumothorax occurring in healthy people.
2. Secondary pneumothorax:
   Associated with underlying lung disease - eg, rupture of a congenital bulla or a cyst in chronic obstructive pulmonary disease (COPD).
   The consequences of a pneumothorax in patients with pre-existing lung disease are significantly greater and the management is potentially more difficult.

Question 12

What is a catamenial pneumothorax?

Answer 12

Catamenial pneumothorax refers to pneumothorax at the time of menstruation.

Over 90% occur in the right lung and it occurs up to 24 hours before or within 72 hours from the onset of menstruation

Question 13

How would you treat a tension pneumothorax?

Answer 13

Treatment is with oxygen and emergency needle decompression.

Insert a large-bore needle into the pleural space through the second or third anterior intercostal space

Question 14

Who is at risk of a tension pneumothorax?

Answer 14

Ventilated patients.
Trauma patients.
Resuscitation patients
Lung disease, especially acute presentations of asthma and COPD.
Blocked, clamped or displaced chest drains.
Patients receiving non-invasive ventilation.
Patients undergoing hyperbaric oxygen treatment.

Question 15

There are different types of pneumothorax, what clinical sign would warn you of a tension pneumothorax?

Answer 15

HR > 135 beats/minute

Also hypotension and raised JVP

Question 16

What does pulsus paradoxical suggest in a pneumothorax?

Answer 16

Severe!

Pulsus paradoxicus occurs when the pulse slows on inspiration. This is the opposite to sinus arrhythmia where there is a slight acceleration of the pulse with inspiration

Question 17

What are the management options for primary and secondary spontaneous pneumothorax?

Answer 17

Observation
Simple aspiration
Tube drainage

Question 18

In pneumothorax, when would you choose a simple aspiration as your management plan?

Answer 18

PSP (any size) and small SSP in patients aged under 50 years

The puncture site is commonly in the second or third intercostal space in the midclavicular line or in the fourth or fifth intercostal space over the superior rib margin in the anterior axillary line

Question 19

In pneumothorax, when would you choose a tube drainage as your management plan?

Answer 19

A chest drain tube is usually required for SSP and for all large lesions (>50%)

Indications for a chest drain for pneumothorax include:

1. In any ventilated patient.
2. Tension pneumothorax after initial needle relief.
3. Persistent or recurrent pneumothorax after simple aspiration.
4. Large SSP in patients aged over 50 years.

Question 20

In pneumothorax, when would you choose observation as your management plan?

Answer 20

A small pneumothorax of 15% or less can be managed by observation, using both clinical assessment and CXR to ascertain that it is not enlarging

Question 21

What is the risk of recurrence in a primary spontaneous pneumothorax?

Answer 21

Up to 54% within the first four years

Question 22

What is the safe triangle and where is it located?

Answer 22

Damage to internal organs can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall (latissimus dorsi and pectoralis major)