Pneumothorax

Question 1

What is pneumothorax?

Answer 1

Air in pleural space

Question 2

Define primary and secondary spontaneous pneumothorax.

Answer 2

• PRIMARY - occurs in young people without known respiratory illnesses
• SECONDARY - occurs in patients with pre-existing pulmonary diseases

Question 3

What is tension pneumothorax?

Answer 3

• MEDICAL EMERGENCY
• Requires immediate decompression

Question 4

Describe primary spontaneous pneumothorax.

Answer 4

• Due to apical subpleural blebs that rupture into pleural cavity
• Thought to be due to increased negative pressure/mechanical alveolar stretch at apex of lungs
• RISK FACTORS - Smoking
• Recurrence is common

Question 5

What conditions can secondary spontaneous pneumothorax occur in?

Answer 5

• COPD
• Cystic fibrosis
• HIV
• Necrotising lung infections e.g TB

Question 6

What is the usual presentation for pneumothorax?

Answer 6

• Acute history
• Can be asymptomatic
• Sudden onset dyspnoea and pleuritic chest pain
• Usually unilateral but may be bilateral

Question 7

What are the physical signs of pneumothorax?

Answer 7

• INSPECTION - tachypnoea, reduced movement on affected side
• PALPATION - reduced expansion on affected side. Tracheal shift if tension pneumothorax
• PERCUSSION - resonate on affected side
• AUSCULTATION - absent breath sounds/vocal resonance

Question 8

How is pneumothorax size determined?

Answer 8

• Interpleural distance at hilum
• > 2cm is large

Question 9

What can be viewed on a CXR of a patient with pneumothorax?

Answer 9

• Visible lung edge
• Absent lung markings

Question 10

What usually occurs in normal pneumothorax?

Answer 10

• Entry of air into pleural space
• Disrupts negative pressure
• Lung collapses

Question 11

What occurs in tension pneumothorax?

Answer 11

• Air builds up in pleural space
• Compresses lungs and shifts mediastinum
• Elevated intrathoracic pressure
• Lowered venous return and cardiac output

Question 12

What is done during primary pneumothorax?

Answer 12

• If size > 2cm and/or breathless, aspirate through cannula. If success, consider discharge review. If not, chest drain.
• If size <2cm and/or breathless, consider discharge review

Question 13

What is done during secondary pneumothorax?

Answer 13

• If >2cm or breathless, chest drain
• IF NOT, check if size between 1-2cm, aspirate. IF SUCCESS, admit with high flow oxygen. IF NOT SUCCESS, Chest drain
• IF size also not in 1-2 cm, admit with high flow oxygen. Observe for 24 hours

Question 14

What are the different types of treatment for pneumothorax?

Answer 14

• Conservative (i.e do nothing)
• Pleural aspiration
• Intercostal and surgical drainage
• Pleural vent

Question 15

What are the boundaries of the triangle of safety?

Answer 15

• Inferiorly by line of fifth intercostal space
• Anteriorly by lateral edge of pectoralis major
• Superiorly by base of axilla
• Laterally by lateral edge of latissimus dorsi

Question 16

Describe the underwater seal for the chest drain.

Answer 16

• Chest drain connected to underwater seal - prevent air re-entering pleural cavity during inspiration
• Fluid level in tube varies with respiration = swinging
• If air still in pleural space, air bubbles through seal

Question 17

Describe pleural vents.

Answer 17

• Allows ambulatory management of primary spontaneous pneumothorax
• Stays in for few days until resolved

Question 18

What is done when chest drain continues to bubble (i.e persistent air leakage)?

Answer 18

• Indicates pneumothorax has not resolved
• Surgical treatment indicated if patient fit enough - VATS
• Pleurectomy/pleuradesis/stapling of holes and blebs