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 classifications of pneumothorax?

Answer 2

Pneumothoraces can be classified as spontaneous pneumothorax, traumatic pneumothorax, and iatrogenic pneumothorax.

Question 3

What is primary spontaneous pneumothorax (PSP)?

Answer 3

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

Question 4

What is secondary spontaneous pneumothorax (SSP)?

Answer 4

SSP occurs in patients with pre-existing lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, or Pneumocystis pneumonia.

Question 5

What is traumatic pneumothorax?

Answer 5

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

Question 6

What is iatrogenic pneumothorax?

Answer 6

Iatrogenic pneumothorax occurs as a complication of medical procedures, such as thoracentesis, central venous catheter placement, ventilation, or lung biopsy.

Question 7

What is tension pneumothorax?

Answer 7

Tension pneumothorax is a severe pneumothorax resulting in the displacement of mediastinal structures, potentially causing severe respiratory distress and haemodynamic collapse.

Question 8

What is catamenial pneumothorax?

Answer 8

Catamenial pneumothorax accounts for 3-6% of spontaneous pneumothoraces in menstruating women and is thought to be caused by endometriosis within the thorax.

Question 9

What are the common symptoms of pneumothorax?

Answer 9

Symptoms tend to come on suddenly and include dyspnoea and chest pain, often pleuritic.

Question 10

What are the signs of pneumothorax?

Answer 10

Signs include hyper-resonant lung percussion, reduced breath sounds, reduced lung expansion, tachypnoea, and tachycardia.

Question 11

What are the signs of tension pneumothorax?

Answer 11

In tension pneumothorax, signs include respiratory distress, tracheal deviation away from the side of the pneumothorax, and hypotension.

Question 12

What did the British Thoracic Society (BTS) publish in 2023?

Answer 12

Updated guidelines for the management of spontaneous pneumothorax.

Question 13

What is the emphasis of the updated BTS guidelines regarding pneumothorax?

Answer 13

Less emphasis on size and more on patient symptoms and high-risk characteristics.

Question 14

What is the first step in the decision algorithm for pneumothorax management?

Answer 14

Assess whether the patient is symptomatic.

Question 15

How does the BTS define minimal symptoms in pneumothorax?

Answer 15

‘No significant pain or breathlessness and no physiological compromise.’

Question 16

What is the management approach for patients with no or minimal symptoms?

Answer 16

Conservative care, regardless of pneumothorax size.

Question 17

What should be assessed if a pneumothorax is symptomatic?

Answer 17

Assessment for high-risk characteristics.

Question 18

What are the high-risk characteristics for pneumothorax?

Answer 18

Haemodynamic compromise, significant hypoxia, bilateral pneumothorax, underlying lung disease, age ≥ 50 with significant smoking history, haemothorax.

Question 19

What interventions are available if no high-risk characteristics are present?

Answer 19

Conservative care, ambulatory device, or needle aspiration.

Question 20

What intervention is indicated if high-risk characteristics are present?

Answer 20

Chest drain.

Question 21

How is the safety of intervention determined for pneumothorax?

Answer 21

Based on clinical context, usually 2cm laterally or apically on chest x-ray, or any size on CT scan accessible with radiological support.

Question 22

What should be done if needle aspiration of a pneumothorax is unsuccessful?

Answer 22

A chest drain should be inserted.

Question 23

What is the follow-up procedure after resolving a pneumothorax?

Answer 23

Discharge and follow-up in the outpatients department in 2-4 weeks.

Question 24

What should be considered for persistent or recurrent pneumothorax?

Answer 24

Video-assisted thoracoscopic surgery (VATS) for mechanical/chemical pleurodesis +/- bullectomy.

Question 25

What discharge advice is given regarding smoking?

Answer 25

Patients should avoid smoking to reduce the risk of further episodes.

Question 26

What is the lifetime risk of developing a pneumothorax in healthy smoking men?

Answer 26

Around 10% compared to around 0.1% in non-smoking men.

Question 27

What is the fitness to fly advice after successful drainage of pneumothorax?

Answer 27

Patients may travel 2 weeks after successful drainage if there is no residual air.

Question 28

What did the British Thoracic Society previously recommend regarding air travel?

Answer 28

Not traveling by air for a period of 6 weeks, now changed to 1 week post check x-ray.

Question 29

What does the BTS state about scuba diving after pneumothorax?

Answer 29

Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.

Question 30

What is tension pneumothorax?

Answer 30

Tension pneumothorax is a life-threatening condition characterised by the 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.

Question 31

What are the causes of tension pneumothorax?

Answer 31

Causes include traumatic (penetrating or blunt chest trauma), iatrogenic (thoracentesis, central venous catheter placement, positive pressure mechanical ventilation), and spontaneous (particularly in patients with underlying lung diseases such as COPD or cystic fibrosis).

Question 32

What is the pathophysiology of tension pneumothorax?

Answer 32

Tension pneumothorax develops when air enters the pleural space and is unable to escape, creating a one-way valve effect. This leads to increased intrapleural pressure, causing lung collapse, mediastinal shift, impaired venous return, and reduced cardiac filling.

Question 33

What are the clinical features of tension pneumothorax?

Answer 33

Clinical features include acute onset of dyspnoea, pleuritic chest pain, tachypnoea, hyperresonance on percussion, diminished breath sounds on the affected side, and tracheal deviation away from the affected side.

Question 34

What is the management for tension pneumothorax?

Answer 34

Management involves decompression of the pleural space, initially performed via needle thoracostomy, followed by placement of a chest drain (tube thoracostomy) in the safe triangle of the chest.