Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

Where air gets into the pleural space, separating the lung from the chest wall

Question 2

What are ways a pneumothorax can occur?

Answer 2

Spontaneously, secondary to trauma, by medical interventions or by lung pathology.

Question 3

What is a primary pneumothorax?

Answer 3

Occurs in a patient without a known respiratory disease

Question 4

What is a secondary pneumothorax?

Answer 4

Occurs in a patient with a pre-existing respiratory disease?

Question 5

What is a tension pneumothorax?

Answer 5

Caused by trauma to the chest wall that creates a one-way valve that lets air in but not out of the pleural space.

Question 6

What is the cause of primary pneumothorax?

Answer 6

Often unknown but may be due to rupture of subpleural air bleb, the bleb is caused by alveolar rupture, which lets air travel through the interlobular septum into the subpleural space.

Question 7

What conditions can cause secondary pneumothorax?

Answer 7

COPD, Asthma, Cystic fibrosis, Marfan syndrome

Question 8

What is the cause of secondary pneumothorax with COPD and asthma?

Answer 8

rupture of the air bulla

Question 9

What is the cause of secondary pneumothorax with Cystic fibrosis?

Answer 9

endobronchial obstruction causing increased pressure in the alveoli, leading to alveolar rupture.

Question 10

What is the cause of secondary pneumothorax with marfan syndrome?

Answer 10

increased formation of air bulla rupture
tall body habitus increased mechanical stress on lung apices (exacerbating the bulla rupture)

Question 11

What are the main causes of a tension pneumothorax?

Answer 11

Penetrating/blunt trauma, mechanical ventilation or non-invasive ventilation, conversion of a tension pneumothorax

Question 12

How is the physiological function affected by a pneumothroax?

Answer 12

A one-way valve means air is trapped in the pleural space, intrapleural pressure exceeds atmospheric pressure, leading to the collapse of the ipsilateral lung.

Question 13

What has pushed away from the pneumothorax in a tension pneumothorax?

Answer 13

The mediastinum and kink are the big vessels

Question 14

What effect does a shift in the mediastinum have on the heart?

Answer 14

It can compress the heart and surrounding vasculature, reducing the cardiac output and venous return. If untreated it can lead to cardiac arrest.

Question 15

What are the signs of a tension pneumothorax?

Answer 15

Tracheal deviation, reduced air entry to the affected side, increased resonance to percussion on the affected side, tachycardia, hypotension

Question 16

What are the clinical findings of a tension pneumothorax?

Answer 16

Hyper-resonant lung percussion, reduced breath sounds, reduced lung expansion

Question 17

What are the bedside investigations performed in a pneumothorax?

Answer 17

Pulse oximetry and lung ultrasound (absenece of lung sliding) in supine trauma patients.

Question 18

What are the laboratory investigations performed?

Answer 18

FBC (blood transfusion), clotting screen (correct coagulopathy) and ABG (respiratory alkalosis)

Question 19

What imaging would be connducted?

Answer 19

Chest x ray and CT

Question 20

What would you be looking for on a chest x-ray of a patient with a pneumothorax?

Answer 20

Visible rim between the lung margin and chest wall, with an absence of lung markings

Question 21

What measurement does a pneumothorax get classified as a “large” pneumothorax?

Answer 21

> 2cm

Question 22

Where is the size of a pneumothorax measured?

Answer 22

Hilum

Question 23

Why would a CT be used?

Answer 23

To identify small pneumothoraces or the cause (can show air bulla or emphysematous changes)

Question 24

Where should you insert an aspiration cannula?

Answer 24

‘Insert a large bore cannula into the second intercostal space in the midclavicular line’.

Question 25

Where should you insert a chest drain?

Answer 25

In the triangle of safety, the 5th intercostal space, the mid axillary line and the anterior axillary line

Question 26

What should you look out for once the chest drain is inserted?

Answer 26

Swinging and bubbling.

Question 27

What should the persistence of bubbling for >48 hours indicate?

Answer 27

An air leak, which is the connection between the bronchial tree and pleural space.

Question 28

When should you aspirate?

Answer 28

If there is greater than >2cm rim of air on the CXR

Question 29

What should you do to prevent the lung from collapsing?

Answer 29

chemical pluerodesis or surgery

Question 30

What is chemical pleurodesis?

Answer 30

Make insertion and inserts a tube, then use chemicals to attach the lung to the chest cavity, eliminating extra space in the chest cavity

Question 31

What is VATS?

Answer 31

A minimally invasive procedure than uses a small camera to help the surgeon remove lung tissue