Pneumothorax

Question 1

what is a pneumothorax

Answer 1

air in pleural space

(either from outside trauma or lung rupture itself)

Question 2

what are the symptoms of a pneumothorax

Answer 2

sudden onset of symptoms

dypnoea
pleuritic chest pain
sweating
tachpnoea
tachycardia

often young, tall + thin man

Question 3

what are the different types of pneumothorax

Answer 3

**spontaneous: **
primary - no pre- exisiting lung patholoy
secondary - previous lung pathology e.g. COPD, marfan’s

traumatic:
iatrogenic - insertion of a central line or +ve pressure ventilation
non-iatrogenic - e.g blunt force trauma

Question 4

what is a tension pneumothorax

how is it life threatening

Answer 4

medical emergency
one way valve –> air can enter pleural space but can’t leave it
It gets large with each inspiration

progressive accumulation of air in pleural space –> cardiorespiratory compromise –> +ve pressure –> mediastinal shift –> obstructs venous flow to heart (causes obstructive shock) –> reduced diastolic filling –> eventual cardiac arrest

Question 5

what are the examination findings in a pneumothrax

Answer 5

reduced chest expansion on affected side
hyper resonant percussion on affected side
reduced or absent breath sounds on affect side
reduced vocal resonance on affected side

in tension pneumothorax:
haemodynamic instability –> hypotension + tachycardia
tracheal deviation away from affected side

Question 6

what are the investigations in a suspected pneumothorax

Answer 6

chest x ray is most important if patient is stable

look for air rim between lung edge and chest wall at the level of the hilum
if air rim <2cm –> small pneumothorax
if air rim >2cm –> large pneumothorax

if tension pneumothorax –> straight to treatment, no investigations

patient needs to be stable and able to sit up for CXR

Question 7

what is the management of pneumothorax

Answer 7

tension pneumothorax is emergency

primary:
<2cm + no SOB –> O2 + discharge –> review in 2-4 weeks
otherwise you aspirate (e.g. if SOB or >2cm) –> then discharge
if aspiration doesnt work (rim is still >2cm or patient still SOB) –> chest drain

secondary/patient is smoker and over 50:
SOB or rim >2cm –> chest drain
1-2cm rim –> aspirate, –> if doesnt decrease to <1cm –> chest drain
<1cm –> High flow O2 + observe

Question 8

where do you insert chest drain

Answer 8

triangle of safety:

arm is abducted

inferior - 5th ICS
anterior - lateral edge of pec major
posterior - lateral edge of lat dorsi

insert the needle just above the rib below –> to avoid neurovascular bundle injury