Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

A collapsed lung due to air leakage into the pleural cavity

Question 2

What is a tension pneumothorax?

Answer 2

Medical emergency

Air drawn into pleural space with each inspiration

No route of escape during expiration

Mediastinum is pushed over into the contralateral hemithorax - kinks and compresses the great veins

If air is not rapidly removed a cardiorespiratory arrest will occur

Question 3

What are the signs of a pneumothorax?

Answer 3

Reduced chest expansion

Hyper-resonance to percussion

Reduced breath sounds on the affect side

Question 4

What are the signs of a tension pneumothorax?

Answer 4

Respiratory distress

Tachycardia

Hypotension

Distended neck veins

Deviated trachea (away from the affected side)

Increased percussion note

Reduced air entry/breath sounds on the affected side

Question 5

What are the causes of a pneumothorax?

Answer 5

Spontaneous (esp. in young thin men) - due to rupture of subpleural bulla

Chronic lung disease - e.g., asthma, COPD, CF, lung fibrosis, sarcoidosis

Infection - TB, pneumonia, lung abscess

Traumatic - inc. iatrogenic (e.g., CVP, line insertion, pleural aspiration or biopsy, percutaneous liver biopsy, positive pressure ventilation)

Carcinoma

Connective tissue disorder - e.g., Marfan’s syndrome, Ehlers-Danlos syndrome

Question 6

What are the symptoms of a pneumothorax?

Answer 6

Sudden onset dyspnoea and/or pleuritic chest pain (i.e., pain worse on inspiration)

Patients with asthma or COPD may present with a sudden deterioration

Mechanically ventilated patients can develop hypoxia or an increase in ventilation pressures

Question 7

What tests should be done for a pneumothorax?

Answer 7

CXR - look for an area without lung markings, peripheral to the edge of the collapsed lung

Make sure the suspected pneumothorax is not a large emphysematous bulla

ABG - in dyspnoeic/hypoxic patients and in those with chronic lung disease

Question 8

What test should not be done in a suspected tension pneumothorax?

Answer 8

CXR

As it delays Tx

Question 9

What is the Mx for a pneumothorax?

Answer 9

Depends on whether it is primary or secondary (i.e., due to an underlying cause), the size and the symptoms

A pneumothorax due to trauma or mechanical ventilation requires a chest drain

Aspiration

Chest drain (insert and manage)
- tube can be removed 24h after the lung has re-expanded and air leak has stopped. This is done during expiration or a Vasalva manoeuvre

Question 10

What size chest drain should be inserted for Tx of a pneumothorax?

Answer 10

Small tube - 10-14F

Unless blood/pus is also present

Question 11

When should you arrange surgical advice for a pneumothorax?

Answer 11

Arrange if:
- bilateral pneumothoraces

• lung fails to expand within 48h or intercostal drain insertion
• persistent air leak
• 2 or more previous pneumothoraces on the same side
• Hx of pneumothorax on the opposite side

Question 12

How would you manage a tension pneumothorax?

Answer 12

Insert a large-bore (14-16G) needle with a syringe partially filled with 0.9% saline

Into 2nd intercostal space, midclavicular line on the side of the suspected pneumothorax

Remove the plunger and allow the trapped air to bubble through the syringe (with saline water as a water seal) until a chest tube can be placed

Alternatively insert a large-bore Venflon in the same location

Do this BEFORE requesting a CXR

Then insert a chest drain

Question 13

Algorithm for acute Mx of pneumothorax from Oxford Handbook for Clinical Medicine

Answer 13

Question 14

Sources

Answer 14

Oxford Handbook of Clinical Medicine ed 10 pg 814-815

https://www.blf.org.uk/support-for-you/pneumothorax