Pneumothorax Flashcards
What is it?
Air trapped in the pleural cavity either can be spontaneous, traumatic or iatrogenic
What are the different types of pneumothorax?
- Spontaneous
- Primary- healthy lung (PSP)
- Secondary- have lung pathology (SPP)
- Traumatic
- Iatrogenic
- simple
- TENSION: emergency
What can be the cause of spontaneous pneumothorax?
- some risk factors
- usually due to pleural blebs / bullae
- Lung disease
What are risk factors for pneumothorax?
- Pre-existing lung disease
- young tall male -> flying
- Smoking/ Cannabis (x9)
- Diving
- Trauma/ Chest procedure
- Association with other conditions e.g. Marfan’s syndrome
What iatrogenic causes?
- central lines- femoral, subclavian, jugular veins (Prevent with USS guidance)
- Thoracotomy- surgery on pleura
- Pacemaker fitting- left side preferred
- Ventilation- positive pressure and disease lung can puncture
- Resuscitation
- Lung biopsy
What trauma causes?
- Severe chest wall injury → stab wound or gunshot wound
- Rib fracture
What are other differentials ?
PE - X-Ray changes, auscultation and percussion
Bullae- no collapsed marking, in one area of lung
Surgical emphysema- air in subcutaneous tissue over ribs
What is a tension pneumothorax?
- haemodynamic instability
- caused by the one-way flow of air valve
- causes tracheal deviation (mediastinal deviation- pressing on heart)
Lots of air in the pleural cavity
What symptoms are common in simple ?
chest pain - pleuritic, sudden onset, sharp
SOB
Signs on examination?
- Trachea - deviation in tension
- Chest movement- reduced on affected side
- Hyperresonance- percussion
- Reduced/Loss of breath sounds on pneumothorax side -auscultation
- Vocal resonance- reduced on affected side
Symptoms in tension ?
chest pain - pleuritic, sudden onset, sharp
SOB
+ one of
- resp distress
- cyanosis
- tachycardia
- hypoxaemia
What investigation can be done and in which type of pneumthorax?
Tension- no time for imaging must do emergency decompression
In simple:
- Erect CXR
- CT (GOLD STANDARD)- small pneumothorax
- USS
Why would you see on an erect CXR?
Simple :
- Hyperlucency
- Absent lung markings
- White pleural line
- no midline shift
Tension:
- Hyperlucency
- White pleural line
+ - Tracheal deviation away from affected side [midline shift]
- Depressed hemidiaphragm
- Absent lung markings >3cm
When to use CT ?
detects small pneumothorax not detected by CXR, allows accurate estimation of the size.
- differentiate complex bullous disease from pneumothorax
- emphysema obscuring CXR
- May be used by interventional radiologist to place chest drains in the presence of significant bullae or surgical emphysema.
When is USS used?
typically used in the trauma setting to complete a FAST scan.
Therapeutically may be used to aid drain placement.
Treatment for primary spontaneous - small and asymptomatic
- Observation with outpatient follow-up
- no treatment required, will resolve spontaneously -follow up in 2-4 weeks
- Patients should be advised to return if they develop breathlessness
Treatment for primary spontaneous - large or symptomatic (SOB)
- Oxygen and needle aspiration (14-16G needle)
- If unsuccessful consider re-aspiration or intercostal drain
- Remove drain after full expansion/ cessation of air leak
Treatment for secondary spontaneous - small <1cm and 1-2cm
Size < 1cm:Admit and observe for at least 24h, consider supplemental oxygen.
Size 1-2cm:Needle aspiration (14-16G needle) is typically advised first, Stop after 2.5L has been aspirated.
Treatment for secondary spontaneous - Large >2cm or symptomatic (SOB)
Place a small bore (<14 F) chest drain
How to treat tension pneumothorax ?
Emergency needle decompression
Large Bore cannula into second intercostal space at mid-clavicular line
High flow oxygen
Insert chest drain after decompression
What is the safety triangle for chest drains? what should you use to guide the chest drain insertion?
- Base of the axilla
- Lateral pectoralis major
- lateral latissimus dorsi
- 6th rib/ 5th intercostal space
USS
Should you put in the chest drain above or under the rib and why?
chest drain above the rib
costal groove with neurovascular bundle is on inferior rib
Discharge advice given to pt?
clear advice to return if they develop breathlessness or chest pain should be given
- no flying - until full resolution
- diving avioded- until resolved
- Smoking cessation as associated with recurrence
When should you refer to thoracic surgeons?
-If persistent air leak >5 days (bronchopleural fistula)
- Ipsilateral recurrence
- Bilateral (synchronous) pneumothoraces
-Contralateral non-synchronous pneumothoraces
- Pregnancy
- At risk occupations (e.g. pilots)
What can pneumothorax occur with? hybrid conditions?
Hydropneumothorax- Pleural effusion and pneumothorax
Pyopneumothorax- empyema and pneumothorax
