Pneumothorax

Question 1

Describe the pleural space

Answer 1

-Visceral pleura warps tightly around the lungs and connects to parietal pleura at mediastinum at hilum
-Parietal pleura wraps rightly around chest wall
-Between, only 1mm of fluid to allow frictionless movement throughout respiratory cycle
-The pleural space has negative pressure relative to atmosphere- pressure changes throughout resp cycle

Question 2

The clinical importance of the pleural space

Answer 2

-Pleural space= self-contained compartment that air can build up in (air can leak from a defect in the lung to pleural space)
-A connection between the normal pleural space and the atmosphere would result in air being sucked into the space

Question 3

Risk factors for primary spontaneous pneumothorax

Answer 3

-Typically, young and male (6:1)
-Tall, thin: greater pressure gradient
-Smoking increases risk (20:1) more for males than females
-Apical blebs/ emphysema like changes (ELCs)- rupture creating air leak
-Cannabis
-Check for FHx of PTX (folliculin gene disorders)

Question 4

Presentation of primary spontaneous pneumothorax

Answer 4

-Often acute but can be subacute- pleurisy, SOB, cough
-Presence of SOB crucial to management
-History not reliable indicator of size

Question 5

Signs of primary spontaneous pneumothorax

Answer 5

-Reduced expansion
-Hyper-resonant
-Reduced breath sounds and vocal resonance
-Tracheal deviation and mediastinal shift (tension pneumothorax)

Question 6

X-Ray of PSP

Answer 6

-Lung edge identified
-Loss of lung markings

Question 7

Causes of secondary spontaneous pneumothorax

Answer 7

-Any chronic lung disease
-Emphysema 60%
-Asthma
-ILD (edges of lung)
-CF
-Infections (TB, PCP)
-Rare: LAM, Histiocytosis, BHD
=Multicystic lung disease
-Associations: Catamenial, Marfans

Question 8

Considerations for management of any PTX

Answer 8

-Breathlessness
-Hypoxia
-Haemodynamic compromise
-PTX size
-Underlying lung disease (how well/ poorly is PTX tolerated?)

Question 9

When should a PTX require a chest drain?

Answer 9

-If bilateral/ haemodynamically unstable
-Secondary pneumothorax size >2cm or breathless

Question 10

When should a PTX be aspirated?

Answer 10

-Primary pneumothorax size >2cm and/or breathless
-Secondary pneumothorax size 1-2cm

Question 11

How do we measure pneumothorax size?

Answer 11

-Measured from chest wall to lung edge at level of hila
-2cm= 50% pneumothorax

Question 12

Surgical techniques for pneumothorax

Answer 12

-Therapeutic aspiration- 2nd ICS mid clavicular line
-Seldinger Intercostal Drain (needle over guide wire technique)
=Surgical emphysema?

Question 13

Intercostal Chest Drain Review

Answer 13

• Swinging: (normal movement with respiratory cycle)
• Swinging and Bubbling: (draining air)
• Neither (Tube blocked and in need of flush,
  kinked, pneumothorax resolved)
• Suction (2.5-5kPa)

Question 14

Indication for thoracic surgery

Answer 14

-Video-assisted thoracoscopic surgery (VATS)
-Bleb removal, apical stapling, talc pleurodesis, abrasion
-Where chest drainage not successful or electively for a patient with recurrent PTX or bilateral PTX

Question 15

Advice for after PTX

Answer 15

-No scuba-diving
-No flying for at least 2 weeks
-No heavy-lifting (work or recreational)
-25% patients suffering PSP will have recurrence

Question 16

Causes of traumatic PTX

Answer 16

-Iatrogenic
=CT guided biopsies
=Central venous lines
=Pacemakers

-Chest trauma (RTA)

-Barotrauma
=Mechanical ventilation
=Diving