Pneumothorax

Question 1

What is pneumothorax?

Answer 1

Air getting into pleural space

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

Primary pneumothorax is associated with connective tissue disorders e.g. Marfan’s, EDS

Question 3

Investigations in suspected pneumothorax

Answer 3

Erect CXR - to diagnose and measure the size of the pneumothorax

• Will show absence of lung markings
• Also look for tracheal deviation (could indicate tension pneumothorax)

CT thorax can detect a small pneumothorax that is too small to see on a chest x-ray or be used to accurately assess the size of the pneumothorax.

Question 4

Management of primary pneumothorax

Answer 4

Bilateral or haemodynamically unstable - chest drain

> 2cm or breathless - needle aspiration
- If this doesn’t work - chest drain

If less than 2cm and asymptomatic can discharge with OP review

Question 5

Management of secondary pneumothorax (due to underlying disease)

Answer 5

Bilateral or haemodynamically unstable - chest drain

> 2cm or SOB - chest drain

1-2cm - needle aspiration and if not successful then chest drain

If 1cm can give O2 and admit for 24h for observation

All patients should be admitted for at least 24h

Question 6

What is the presentation of a pneumothorax?

Answer 6

Sudden onset symptoms of:

• Dyspnoea
• Chest pain - often pleuritic

Question 7

What is tension pneumothorax?

Answer 7

Trauma to chest wall that creates a one-way valve that lets air in but not out of the pleural space

So more air drawn in with each breath which cannot escape

Question 8

Signs of tension pneumothorax

Answer 8

Tracheal deviation away from side of pneumothorax

Reduced air entry to affected side

Increased resonant to percussion on affected side

Tachycardia
Hypotension

Question 9

Management of tension pneumothorax

Answer 9

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

Once pressure is relieved then a chest drain is required for definitive management

If tension pneumothorax is suspected - do not wait for any investigations

Question 10

What forms the triangle of safety for chest drain insertion?

Answer 10

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)

Obtain a chest xray to check the positioning.