Pneumothorax Flashcards
Pneumothorax refers to ___ within the pleural space
a) blood
b) pus
c) air
c) air
Pneumothorax refers to air within what?
Pleural space
What is the pleural space
The space between the parietal and visceral pleura
Which is more common:
unilateral or bilateral pneumothorax
Unilateral is more common
Bilateral pneumothorax can occur but very rare
How can a pneumothorax result in a collapsed lung
The air within the pleural space puts pressure on the lung and can lead to lung collapse
Pneumothorax can be broadly divided into two types.
Name these types?
Spontaneous pneumothorax - occurs without preceding trauma or precipitating event.
Traumatic pneumothorax - result of trauma
Young, tall, thin man is the characteristic presentation of which type of pneumothorax
Spontaneous pneumothorax secondary to primary cause i.e. no underlying lung pathology
If a patient has Marfan’s syndrome which type of pneumothorax are they most at risk of
Spontaneous pneumothorax secondary to secondary cause i.e. caused by an underlying lung pathology (in this case Marfan’s)
Define Spontaneous pneumothorax
It is when pneumothorax occurs without preceding trauma or precipitating event.
Normally in older patients with underlying lung disease or younger patients with apical blebs
Spontaneous pneumothorax can be subdivided further into two types.
Name them?
Primary and secondary causes
Primary causes – no underlying lung pathology – typically young, tall, thin man
Secondary causes – underlying lung pathology e.g. Marfan’s syndrome
Define Traumatic pneumothorax
It is when a pneumothorax develops as a consequence of trauma
Traumatic pneumothorax can be subdivided into two groups.
Name them
Iatrogenic causes e.g. insertion of a central line
Non-iatrogenic causes e.g. blunt trauma with rib fracture
Spontaneous vs Traumatic/Secondary Pneumothorax
Spontaneous - occurs without preceding trauma or precipitating event.
Secondary/traumatic - the result of trauma
Name the two risk factors for spontaneous primary pneumothorax
Tall and thin young male
Smoker
Name the three risk factors for spontaneous secondary pneumothorax
COPD
Asthma
Marfan’s syndrome
Name a risk factor for traumatic pneumothorax
For Iatrogenic cause - recent invasive medical procedure
For non-iatrogenic cause - recent chest trauma
What are the three key clinical features of a pneumothorax
Unilateral sudden onset pleuritic chest pain
Dyspnoea (SoB)
Signs of haemodynamic instability e.g. sweating, tachypnoea, tachycardia
Name some of the signs you may see on respiratory examiantion if there was a pneumothorax present
Reduced chest expansion of the affected side
Tracheal deviation away from side of pneumothorax
Reduced breath sounds on auscultation on affected side
Hyper-resonance to percussion on affected side
Absent tactile fremitus /vocal resonance
Tracheal deviation ___ from side of pneumothorax
a) away
b) to
a) away
What would you notice on percussion of the affected sign in pneumothorax
Hyper-resonance to percussion on affected side
What is the gold standard investigation for a pneumothorax
Erect chest X-ray
What are the classical features of pneumothoax on an erect chest x-ray
Absence of lung markings between the lung margin and chest wall i.e. area between the lung tissue and the chest wall where there are no lung markings
There will be a line demarcating the edge of the lung where the lung markings ends, and the pneumothorax begins
Trachea may be deviated away from the side of the pneumothorax
Erect chest x-ray may miss subtle pneumothorax.
What other imaging modality can be used to detect a small pneumothorax
CT thorax
In what patients does a primary spontaneous pneumothorax occur in
Occurs in young people without known respiratory illnesses
In what patients does a secondary spontaneous pneumothorax occur in
Occurs in patients with pre-existing pulmonary diseases.
What is the most common sign in tension pneumothorax
Ipsilateral reduced breath sounds
How can a size of a pneumothorax be measured
Measured using erect chest x-ray
It is most accurately measured using CT but not all patients will have a CT
Pneumothorax can be measured using imaging modalities.
What size is a large pneumothorax?
> 2 cm
Pneumothorax can be measured using imaging modalities.
What size is a small pneumothorax?
Less than or equal to 2 cm
What type of chest x-ray is used to quatify the size of the pneumothorax
Postero-anterior (PA) chest x-ray
The management of spontaneous pneumothorax depends on a combination of clinical features, size and type of pneumothorax.
If a asymptomatic patient has small (< 2cm) primary pneumothorax.
How are they managed?
discharge and reviewed in the outpatient department in 2-4 weeks
If a patient has large (> 2cm) primary pneumothorax.
How are they managed?
Aspirate with 16-18G cannula
If a patient has large (> 2cm) primary pneumothorax.
They are initially managed by aspiration with a 14-16G cannula which was unsuccessful.
What is the next step of management?
Insert chest drain
If a patient has small (less than or equal to 2cm) primary pneumothorax but is breathless
How are they managed?
Aspirate with 14-16G cannula
Patient has small (less than or equal to 2cm) primary pneumothorax but is breathless
They were initially managed with aspiration with a 14-16G cannula which was unsucessful.
What is the next step of management?
Chest drain
Patient has a asymptomatic small (between 1-2cm) secondary pneumothorax
What is the first step of management?
Note these patients have underlying lung pathology and thus requires more intervention than primary
Aspirate with 16-18G cannula
Patient has a asymptomatic small (between 1-2cm) secondary pneumothorax
It was initially managed with aspiration with a 14-16G cannula which was unsuccessful.
What is the next step of management?
Insert chest drain
Patient has a symptomatic small (< 2cm) secondary pneumothorax
What is the initial step of management?
Insert chest drain
Patient has a large (> 2cm) secondary pneumothorax
What is the initial step of management?
Insert chest drain
Patient has a secondary pneumothorax which is <1cm in size and the patient is not short of breath.
What is the next step of management?
Do not require further invasive intervention but should be admitted for observation for 24 hours and administered oxygen as required
What is a tension pneumothorax
In tension pneumothorax the air in the pleural space gets trapped by the one way valve this is created as a result of thoracic trauma
Medical emergency requiring immediate decompression
What creates the characteristc one way valve of a tension pneumothorax
Created as a result of thoracic trauma
Describe the pathogenesis of tension pneumothorax
Trauma to the thorax creates a one way valve which trapped the air in the pleural space i.e. air is drawn into the pleural space during inspiration however during expiration this air is not able to move out.
Thus, with each breathe the pressure in the pleural space gets greater as more air gets trapped.
This pressure displaces mediastinal structures, impairing venous return to the heart and compromising cardiopulmonary function.
How will a patient with tension pneumothorax present
Will present with signs of:
Respiratory distress e.g. SoB, laboured breathing
Shock e.g hypotension, tachycardia
If you suspect a tension pneumothorax.
What must you immediately do?
If suspected, put an immediate cardiac arrest call and give high flow oxygen
Immediate decompression is required; do not wait for imaging results to confirm the diagnosis
How is a tension pneumothorax managed
Managed with needle decompression (first) and chest drain insertion (Second)
Needle Decompression
- Large-bore cannula is inserted in the 2nd intercostal space midclavicular line on the side of the pneumothorax
- This cannula should be left in place until a formal chest drain is correctly place
Chest drain
- Once the pressure is relieved with needle compression, chest drain is required for definitive management and to reduce the risk of an immediate recurrence of the tension pneumothorax
- Inserted at the 5th intercoastal space in the mid axillary line
Tension pneumothorax is managed with needle decompression and chest drain insertion.
What is done first?
needle decompression
Tension pneumothorax is managed with needle decompression and chest drain insertion.
When can the cannula used for the needle decompression be removed?
Should be left in place until a formal chest drain is correctly placed
What kind of cannula is used in the management of spontaneous pneumothorax management
14-16G cannula
What kind of cannula is used for needle compression in the management of tension pneumothorax
Large bore cannula
Where is a cannula inserted for needle compression in the management of tension pneumothorax
Large-bore cannula is inserted in the 2nd intercostal space midclavicular line on the side of the pneumothorax
Where is a chest drain inserted in the management of tension pneumothorax
Inserted at the 5th intercoastal space in the mid axillary line
Where is a chest drain inserted in the management of spontaneous pneumothorax
Inserted at the 5th intercoastal space in the mid axillary line
Where is the cannula inserted to aspirate the pneumothorax in the management of spontaneous pneumothorax
Inserted in the 2nd intercostal space midclavicular line on the side of the pneumothorax
