Pneumothorax

Question 1

What is pneumothorax

Answer 1

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

Question 2

Causes of pneumothorax

Answer 2

Spontaneous
Trauma
Iatrogenic such as due to lung biopsy, mechanical ventilation or central line insertion
Lung pathology such as infection, asthma or COPD

Question 3

Diagnosis of pneumothorax

Answer 3

erect CXR

Question 4

What can be used if pneumothorax too small to be assessed on CXR

Answer 4

CT thorax

Question 5

When would you allow for spontaneous resolution of pneumothorax with no treatment

Answer 5

If no SOB and there is a < 2cm rim of air on the chest xray

Follow up 2-4 weeks is required

Question 6

When is aspiration and reassessment for pneumothorax required

Answer 6

If SOB and/or there is a > 2cm rim of air on the chest xray then it will require aspiration and reassessment.

Question 7

when is a chest drain advised for pneumothorax

Answer 7

If aspiration has failed

Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.

Question 8

When is a tension pneumothorax

Answer 8

caused by trauma to chest wall that creates a one-way valve that lets air in but not out of the pleural space. The one-way valve means that during inspiration air is drawn into the pleural space and during expiration, the air is trapped in the pleural space

Question 9

When can tension pneumothorax lead to

Answer 9

Cardiac arrest

Question 10

Signs of tension pneumothorax

Answer 10

Tracheal deviation away from side of pneumothorax
Reduced air entry to affected side
Increased resonant to percussion on affected side
Tachycardia
Hypotension

Question 11

Mx of tension pneumothorax

Answer 11

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

Once pressure is relieved, chest drain is definitive management

Question 12

Where are chest drains inserted

Answer 12

‘triangle of safety’

The 5th intercostal space (or the inferior nipple line)
The mid axillary line (or the lateral edge of the latissimus dorsi)
The anterior axillary line (or the lateral edge of the pectoris major)

Needle is inserted just above rib to avoid neurovascular bundle

Question 13

What type of arrest rhythm can pneumothorax lead to

Answer 13

PEA

Question 14

Who is appropriate for oropharyngeal airway(guedel)

Answer 14

Unconscious patients - Insertion in semi-comatose patients may provoke vomiting or laryngospasm

Question 15

Preferred airway adjunct in patients who are not deeply unconscious

Answer 15

Nasopharyngeal airway - tolerated better

Question 16

When should nasopharyngeal airways be used with caution

Answer 16

Suspected fracture of base of skull(can cause bleeding inside of nose)

Tube being too long can stimulate laryngeal or glossopharyngeal reflexes and laryngospasm or vomiting

Question 17

risk posed by bag valve mask

Answer 17

Excessive compression of the bag can when used with face mask can inflate stomach, further reducing ventilation and greatly increasing risk of regurgitation and aspiration

Avoid hyperventilation

Question 18

which airway adjuncts can be used when endotracheal intubation cannot be done

Answer 18

Supraglottic airways - I-gel, laryngeal mask - less chance of aspiration of stomach contents

Question 19

Limitations of I-gel

Answer 19

Risk of leak around cuff if there is pulmonary oedema, bronchospasm, COPD(due to airway resistance)

Risk of aspiration of stomach contents(low)

May cause coughing/laryngospasm if not unconscious

Question 20

When is a tracheostomy useful

Answer 20

Slow weaning

Question 21

What might errors in endotracheal tube insertion cause

Answer 21

oesophageal intubation (therefore end tidal CO2 usually measured)

Bleeding

Infection

Perforation of oropharynx

Vocal cord injury

Question 22

Contraindications to endotracheal tube

Answer 22

Severe airway trauma or obstruction

Severe cervical spine injury

Question 23

BiPAP contraindications

Answer 23

Untreated pneumothorax

Structural abnormality of face, airway or GI tract

Question 24

CPAP indications

Answer 24

Obstructive sleep apnoea
Congestive cardiac failure
Acute pulmonary oedema

Question 25

Complications of CPAP/NIV

Answer 25

Hypotension
Stomach inflation increasing risk of aspiration
Pressure sores

Question 26

Features of flail chest

Answer 26

Chest wall disconnects from thoracic cage
Multiple rib fractures (at least two fractures per rib in at least two ribs)
Associated with pulmonary contusion
Abnormal chest motion

Question 27

What is an important aspect of management of flail chest

Answer 27

Over hydration and fluid overload

Question 28

Important monitoring in pulmonary contusion

Answer 28

ABG and pulse oximetry

Early intubation within a hour if significant hypoxia

Question 29

Features of aorta disruption - trauma

Answer 29

Deceleration injuries
Contained haematoma
Widened mediastinum

Question 30

Features of diaphragm disruption in trauma

Answer 30

Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears)
More common on left side

Question 31

Mx of diaphragm disruption

Answer 31

Insert gastric tube, which will pass into the thoracic cavity

Question 32

What is a primary pneumothorax

Answer 32

A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.

Question 33

Recommendations for initial step of secondary pneumothorax

Answer 33

if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.

Question 34

Mx of secondary pneumothorax if penumothorax is less than 1cm

Answer 34

if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours

Question 35

Mx of primary pneumothorax if rim of air <2cm and patient is not SOB

Answer 35

Discharge