Pneumothorax Flashcards
What is another term for a pneumothorax?
Collapsed lung
What is a pnuemothorax?
It is a condition in which air enters the pleural space – resulting in separation of the lung and the chest wall
What is the pleural space?
It is the cavity between the visceral and parietal pleura
Describe how the lung physiologically inflates, and how this is disrupted in pneumothorax patients
In physiological circumstances, there is a negative intrapleural pressure, this is due to a combination of lung recoiling and expenditure of the chest wall
This negative pressure is present at all stages of respiration, enabling expansion of the lung as it is pulled towards the chest wall
In a pneumothorax, there is an increase in intrapleural pressure resulting in the lung being unable to fully reinflate
What are the three main classifications of pneumothorax?
Spontaneous pneumothorax
Traumatic pneumothorax
Tension pneumothorax
What is a spontaneous pneumothorax?
It is defined the sudden onset of a pneumothorax without any underlying trauma
What are the two subclassifications of a spontaneous pneumothorax?
Primary Spontaneous Pneumothorax
Secondary Spontaneous Pneumothorax
What is a primary spontaneous pneumothorax?
It is defined as the sudden onset of a pneumothorax without any underlying trauma, and in the absence of lung disease
What are the five risk factors of a primary spontaneous pneumothorax?
Tall Thin Young Male
Family History
Smoking
Pregnancy
Marfan’s Syndrome
What is a secondary spontaneous pneumothorax?
It is defined as the sudden onset of a pneumothorax without any underlying trauma, and in the presence of pre-existing lung disease
What five lung diseases are associated with secondary spontaneous pneumothorax?
COPD
Asthma
Pneumonia
Lung Cancer
Cystic Fibrosis
What is a traumatic pneumothorax?
It is defined as the sudden onset of a pneumothorax, related to trauma to the chest wall
What are the two subclassifications of traumatic pneumothorax?
Iatrogenic Traumatic Pneumothorax
Non-Iatrogenic Traumatic Pneumothorax
What is an iatrogenic traumatic pneumothorax?
It is defined as the sudden onset of a pneumothorax, related to trauma to the chest wall which is secondary to medical intervention
What four medical procedures are associated with iatrogenic traumatic pneumothorax?
Central Line Placement
Ventilation
Lung Biopsies
CPR
What is a non-iatrogenic traumatic pneumothorax?
It is defined as the sudden onset of a pneumothorax, related to trauma to the chest wall which is not secondary to
medical intervention
What are the four injured associated with non-iatrogenic traumatic pneumothorax?
Motor Vehicle Accident
Fractured Ribs
Contact Sport injuries
Stab Wounds
What is a tension pneumothorax?
It isn’t defined as a pneumothorax classification, however, is a term used to reflect its severity
It is caused by trauma to the chest wall that creates a one way valve that enables air into the pleural space, however not out
Why are tension pneumothoraxes life threatening?
They create increased pressure inside the thorax
This pushes the mediastinum across, kinks the big vessels in the mediastinum and causes cardiorespiratory arrest
What are the five clinical features associated with tension pneumothorax?
Tracheal Deviation
Air Entry Reduction
Increased Percussion Resonance
Tachycardia
Hypotension
In tension pneumothorax, which side does the trachea deviate to?
It deviates away from the side of the pneumothorax
In tension pneumothorax, which side is there reduced air entry?
The side affected by a pneumothorax
Which two clinical observations makes the diagnosis of tension pneumothorax more likely than simple pneumothorax?
Hypotension
Deterioratoin > Ventilation
How do we treat tension pneumothorax?
We insert a large bore cannula into the second anterior intercostal space in the midclavicular line
Once pressure has been relieved, a chest drain is inserted for definitive management
Do we conduct investigations in tension pneumothorax cases?
No it is important to start treatment immediately
What are the five risk factors of a pneumothorax?
Male Gender
Young Age
Pre-Existing Lung Disease
Connective Tissue Disease
Ventilation
What are the five lung diseases associated with pneumothorax?
Asthma
COPD
Cystic fibrosis
Lung cancer
Pneumocystis pneumonia
What are the two connective tissue diseases associated with pneumothorax?
Marfan’s syndrome
Rheumatoid arthritis
Describe the typical pneumothorax patient
A tall, thin young man presenting with sudden breathlessness and pleuritic chest pain - potentially whilst playing sports
What are the eight clinical features of a pneumothorax?
Shortness of Breath
Ipsilateral Pleuritic Chest Pain
Cyanosis
Tachycardia
Tachypnoea
Hypotension
Hyperresonance
Enlarged Jugular Vein
What are the two investigations used to diagnose a pneumothorax?
Chest X-Ray (CXR)
CT Scan
What is the first line investigation used to diagnose a pneumothorax?
CXR
What are the two signs of a pneumothorax on CXR?
No Peripheral Lung Markings
Mediastinal Shift
What is an additional function of a CXR in pneumothorax patients?
It can be used to measure the size of the pneumothorax
It would involve measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum
What is the second line investigation used to diagnose a pneumothorax? When is it usually required?
CT scan
In small pneumothoraxes which CXR scans are unable to detect
What is an additional function of a CT scan in pneumothorax patients?
It can be used to measure the size of the pneumothorax
It would involve measuring horizontally from the lung edge to the inside of the chest wall at the level of the hilum
When is pneumothorax treatment not recommended? What should be done in these patients?
Primary pneumothorax patients without dyspnoea and < 2cm rim of air on imaging
Dishcarge and review
How do we manage a secondary pneumothorax < 1cm?
We admit these patients, administer oxygen and review in 24 hours
What is fluid aspiration?
It involves collecting a sample of pleural fluid via the insertion of a needle
It is usually conducted under ultrasound guidance
In which pneumothorax patients is fluid aspiration recommended?
Dyspnoea features
AND/OR
< 2cm rim of air on imaging
What is a chest drain?
It involves collecting a sample of pleural fluid via the insertion of a drain
It is usually conducted under ultrasound guidance
In which four circumstances, do we recommend chest drain insertion to treat a pneumothorax?
Unstable Patients
Bilateral Pneumothorax
Secondary Pneumothorax > 2cm
Aspiration Failure On Two Attempts
In which region do we insert a chest drain?
Triangle of safety
What are the three borders that form the triangle of safety?
5th Intercostal Space
Mid-Axillary Line
Anterior Axillary Line
What anatomical landmark is used to locate the 5th intercostal space?
Inferior nipple border
Which border of the ‘triangle of safety’ does the 5th intercostal space form?
Inferior
What anatomical landmark is used to locate the mid-axillary line?
Lateral edge of the latissimus dorsi
Which border of the ‘triangle of safety’ does the mid-axillary line form?
Lateral border
What anatomical landmark is used to locate the anterior axillary line?
Lateral edge of the pectoris major
Which border of the ‘triangle of safety’ does the anterior axillary line form?
Anterior border
What investigation should be conduced after insertion of a chest drain? Why?
CXR
To confirm correct positioning
Do we insert the chest drain needle above or below the rib? Why?
Above the rib
To avoid the neurovascular bundle that runs just below the rib, containing the long thoracic nerve
What occurs when there is damage to the long thoracic nerve?
Winging of the scapula
What four lifestyle changes are advised to pneumothorax patients prior to discharge, in order to reduce the risk of recurrence?
Smoking Cessation
Fitness To Fly 1 Week > Post CXR Check
Diving Avoidance
Seadiving Avoidance Indefinitely
What is the single most important lifestyle change individuals can make to reduce their risk of further pneumothoraces?
Smoking cessation
What drug should not be administered to pneumothorax patients? Why?
Nitrous oxide
It can result in the development of a tension pneumothorax. This is due to the fact that nitrous oxide may diffuse into gas-filled body compartments and increase in pressure
