Pneumothorax Flashcards
What is pneumothorax
air gets into the pleural space separating the lung from the chest wall
Causes of pneumothorax
Spontaneous
Trauma
Iatrogenic such as due to lung biopsy, mechanical ventilation or central line insertion
Lung pathology such as infection, asthma or COPD
Diagnosis of pneumothorax
erect CXR
What can be used if pneumothorax too small to be assessed on CXR
CT thorax
When would you allow for spontaneous resolution of pneumothorax with no treatment
If no SOB and there is a < 2cm rim of air on the chest xray
Follow up 2-4 weeks is required
When is aspiration and reassessment for pneumothorax required
If SOB and/or there is a > 2cm rim of air on the chest xray then it will require aspiration and reassessment.
when is a chest drain advised for pneumothorax
If aspiration has failed
Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.
When is a tension pneumothorax
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
When can tension pneumothorax lead to
Cardiac arrest
Signs of tension pneumothorax
Tracheal deviation away from side of pneumothorax
Reduced air entry to affected side
Increased resonant to percussion on affected side
Tachycardia
Hypotension
Mx of tension pneumothorax
Insert a large bore cannula into the second intercostal space in the midclavicular line.
Once pressure is relieved, chest drain is definitive management
Where are chest drains inserted
‘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
What type of arrest rhythm can pneumothorax lead to
PEA
Who is appropriate for oropharyngeal airway(guedel)
Unconscious patients - Insertion in semi-comatose patients may provoke vomiting or laryngospasm
Preferred airway adjunct in patients who are not deeply unconscious
Nasopharyngeal airway - tolerated better
When should nasopharyngeal airways be used with caution
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
risk posed by bag valve mask
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
which airway adjuncts can be used when endotracheal intubation cannot be done
Supraglottic airways - I-gel, laryngeal mask - less chance of aspiration of stomach contents
Limitations of I-gel
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
When is a tracheostomy useful
Slow weaning
What might errors in endotracheal tube insertion cause
oesophageal intubation (therefore end tidal CO2 usually measured)
Bleeding
Infection
Perforation of oropharynx
Vocal cord injury
Contraindications to endotracheal tube
Severe airway trauma or obstruction
Severe cervical spine injury
BiPAP contraindications
Untreated pneumothorax
Structural abnormality of face, airway or GI tract
CPAP indications
Obstructive sleep apnoea
Congestive cardiac failure
Acute pulmonary oedema
Complications of CPAP/NIV
Hypotension
Stomach inflation increasing risk of aspiration
Pressure sores
Features of flail chest
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
What is an important aspect of management of flail chest
Over hydration and fluid overload
Important monitoring in pulmonary contusion
ABG and pulse oximetry
Early intubation within a hour if significant hypoxia
Features of aorta disruption - trauma
Deceleration injuries
Contained haematoma
Widened mediastinum
Features of diaphragm disruption in trauma
Most due to motor vehicle accidents and blunt trauma causing large radial tears (laceration injuries result in small tears)
More common on left side
Mx of diaphragm disruption
Insert gastric tube, which will pass into the thoracic cavity
What is a primary pneumothorax
A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.
Recommendations for initial step of secondary pneumothorax
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.
Mx of secondary pneumothorax if penumothorax is less than 1cm
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
Mx of primary pneumothorax if rim of air <2cm and patient is not SOB
Discharge
