Pneumothorax Flashcards
What is pneumothorax? What are its causes?
Pneumothorax occurs when air gets into the pleural space, separating the lung from the chest wall. It can occur spontaneously, or secondary to trauma, medical interventions (“iatrogenic”) or lung pathology.
What does a typical patient with pneumothorax look like?
The typical patient in exams is a tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports.
What are the causes of pneumothorax?
- spontaneous
- trauma
- iatrogenic, for example due to lung biopsy, mechanical ventilation or central line insertion
- lung pathologies such as infection, asthma, COPD
What are the investigations for pneumothorax?
- erect chest X-ray
- CT thorax- can detect a pneumothorax that is too small to see on a chest x-ray
How do you manage a pneumothorax that is less than 2 cm of air of CXR with no SOB, and one with more than 2 cm rim of air and SOB?
Less than 2cm:
- No treatment required, will spontaneously resolve
more than 2 cm:
- aspiration
- when aspiration fails twice, a chest drain is required.
Where is the triangle of safety located?
1) The 5th intercostal space (or the inferior nipple line)
2) The midaxillary line (or the lateral edge of the latissimus dorsi)
3) The anterior axillary line (or the lateral edge of the pectoralis major)
Where is the needle inserted in a chest drain?
The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.
How do you know that you have inserted the chest drain successfully?
- air will bubble through the fluid in the drain bottle
- there will be swinging of the water with respiration
- on a repeat CXR, there will be re-inflation of the lung
What are the 2 complications of chest drains?
- air leaks around the drain site (indicated by persistent bubbling of fluid, particularly on coughing
- surgical emphysema, aka subcutaneous emphysema
When is surgical management of pneumothorax indicated?
When:
- a chest drain fails to correct the pneumothorax
- there is persistent air leak in the drain
- the pneumothorax reoccurs
What is the surgery used to correct pneumothorax, and what are the different surgical options, and how do they work?
- video-assisted thoracoscopic surgery (VATS)
surgical options:
- abrasie pleurodesis (using physical irritation of the pleura)
- chemical pleurodesis (using chemicals such as talc powder to irritate the pleura)
- Pleurectomy (removal of the pleura)
Pleurodesis involves creating an inflammatory reaction in the pleural lining so the pleura sticks together and the pleural space becomes sealed. This prevents further pneumothoraces from developing.
What is tension pneumothorax? Explain what happens in it.
Tension pneumothorax is caused by trauma to the chest wall that creates a one-way valve that lets air in but not out of the pleural space. The one-way valve means that during inspiration air is drawn into the pleural space and during expiration, the air is trapped in the pleural space. Therefore, more air keeps getting drawn into the pleural space with each breath and cannot escape. This is dangerous as it creates pressure inside the thorax that will push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.
What are the signs of tension pneumothorax?
- Tracheal deviation away from side of the pneumothorax
- Reduced air entry on the affected side
- Increased resonance to percussion on the affected side
- Tachycardia
- Hypotension
What is the management for tension pneumothorax?
- insert a large bore cannula into the second intercostal space in the midclavicular line.
- However, the Advanced Traumatic Life Support (ATLS) recommendations from 2018 recommend for adults, using the “fourth or fifth intercostal space, anterior to the midaxillary axillary line”. The reason for choosing this is this site is that the chest wall thickness may be smaller than in the second intercostal space.
