pneumothorax

Question 1

what is pneumothorax?

Answer 1

Pneumothorax is a condition characterized by the accumulation of air in the pleural space, resulting in the partial or complete collapse of the affected lung.

Question 2

what are the types/

Answer 2

primary spontaneous
secondary spontaneous
traumatic
iatrogenic
tension
catamenial

Question 3

what is primary PTX?

Answer 3

Occurs without underlying lung disease, often in tall, thin, young individuals. PSP is associated with the rupture of subpleural blebs or bullae.

Question 4

what is secondary PTX?

Answer 4

Occurs in patients with pre-existing lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia. Certain connective tissue diseases such as Marfan’s syndrome are also a risk factor

Question 5

what is traumatic PTX?

Answer 5

results from penetrating or blunt chest trauma, leading to lung injury and pleural air accumulation.

Question 6

what is iatrogenic PTX?

Answer 6

occurs as a complication of medical procedures, such as thoracentesis, central venous catheter placement, ventilation, including non-invasive ventilation or lung biopsy.

Question 7

what is catamenial PTX?

Answer 7

the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax.

Question 8

what are features?

Answer 8

sudden onset dyspnoea + chest pain: often pleuritic

hyper-resonant lung percussion
reduced breath sounds
reduced lung expansion
tachypnoea
tachycardia

Question 9

how do you categorise PTX mx?

Answer 9

the BTS define minimal symptoms as ‘no significant pain or breathlessness and no physiological compromise’
no or minimal symptoms → conservative care, regardless of pneumothorax size
symptomatic → assess for high-risk characteristics

Question 10

what are high risk characteristics?

Answer 10

haemodynamic compromise (suggesting a tension pneumothorax)
significant hypoxia
bilateral pneumothorax
underlying lung disease
≥ 50 years of age with significant smoking history
haemothorax

Question 11

what are mx for no high risk?

Answer 11

conservative care
ambulatory device
needle aspiration

Question 12

what is mx for high risk?

Answer 12

chest drain

Question 13

what is conservative care?

Answer 13

patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
if stable, follow-up in the outpatients department in 2-4 weeks

Question 14

what is ambulatory care?

Answer 14

an example of an ambulatory device is the Rocketµ Pleural Vent„
it includes an 8FG catheter mounted on an 18G needle and a pigtail catheter to minimize the risk of occlusion
ambulatory devices typically have a one-way valve and vent to prevent air and fluid return to the pleural space while allowing for controlled escape of air and drainage of fluid

Question 15

what is needle aspiration?

Answer 15

a chest drain should be inserted if needle aspiration of a pneumothorax is unsuccessful
if resolved, discharge and follow-up in the outpatients department in 2-4 weeks

Question 16

what do you do for persistent/recurrent pTX?

Answer 16

video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.

Question 17

what is discharge advice for PTX?

Answer 17

avoid smoking
absolute contraindication to flying for 2 weeks
never scuba dive unless bilateral surgical pleurectomy

Question 18

what is tension PTX?

Answer 18

accumulation of air in the pleural space under positive pressure, leading to the collapse of the lung on the affected side and a shift of the mediastinum towards the contralateral side. This process results in impaired venous return to the heart and subsequent reduction in cardiac output, posing a significant risk of cardiovascular collapse.

Question 19

features of tension PTX?

Answer 19

acute onset of dyspnoea
pleuritic chest pain
tachypnoea
signs:
hyperresonance on percussion, diminished breath sounds on the affected side
tracheal deviation away from the affected side
in severe cases, patients may also exhibit signs of shock such as hypotension and tachycardia.

Question 20

mx of tension PTX?

Answer 20

the aim is decompression of the pleural space
this is initially performed via needle thoracostomy, inserting a cannula into the second intercostal space in the midclavicular line on the affected side
this is followed by the placement of a chest drain (tube thoracostomy) in the safe triangle of the chest to allow continuous drainage of air.