Pneumothorax

Question 1

Primary causes of pneumothorax

Answer 1

Rupture of visceral pleura with secondary airleak from lung
Rupture of bronchus or trachea
Rupture of esophagus
Loss of integrity of chest wall - stab, etc.

Question 2

Secondary causes of pneumothorax

Answer 2

Airway and pulmonary disease: COPD (most common), Asthma, CF
Interstitial Lung Disease: Pulmonary fibrosis, Sarcoidosis
Infectious: TB, HIV
Catamenial: younger women, with menses, small pneumo. via cervix
Neoplastic: Lung, Metastatic
Miscellaneous: Marfans, LAM (smooth mm problem), Hist X (histiocytosis)

Question 3

Pathophysiology of pneumothorax

Answer 3

Apex to base pressure gradient lower,
Lung compliance lower,
FRC lower,
Ventilation lower,
Oxygenation lower,
(Rupture of bleb or bullae)

Question 4

Why is Tension pneumothorax bad?

Answer 4

Extra air enters the pleural space but cannot get out, pushes over heart, can cut off inflow and outflow of heart. Bad!

Question 5

How does COPD lead to pneumothorax?

Answer 5

Common. Rupture a bulla, resulting in chest pain and resp distress, acute decompensation.

Question 6

Classification of pneumothorax

Answer 6

Spontaneous
-1˚ - Rupture of blebs
-2˚ - underlying lung disease, older, diffuse emphysema, higher mortality
Trauma, Iatrogenic

Question 7

Classic presentation of pneumothorax

Answer 7

Sudden
Chest pain
Shortness of breath
Tachypnea / tachycardia
Hypoxia
Hypotension
Elev. JVP
Dec breath sounds
Hyperessonance
Tracheal deviation

Question 8

Complications of pneumothorax

Answer 8

Persistent air leak - can get bigger and can lead to tension
Tension - push on heart
Pneumomediastinum – rule out other causes (rupture of esophagus) - bleb close to bronchus rupture and went into mediastinum - can’t do a lot
Hemothorax - if adhesion b/w the pleura, can tear and leak blood

Question 9

Exam and findings for pneumothorax

Answer 9

CXR - can show a tension but pt has no symptoms
-want exp and insp. views.
CT- rare

Question 10

Tx of pneumothorax

Answer 10

Usually tube thoracostomy to drain air. Needle in 2nd intercostal then chest tube.
-Make sure lung re-expands or else visceral pleura can scar and then it can’t expand
Chemical pleurodesis - tetracycline or talc - reaction b/w pleura, reduce chance of it happening again - uncommon
Sx (see next card)

Question 11

Sx details for pneumothorax

Answer 11

Sx in first episode if:
- prolonged airleak
- non reexpansion
- bilateral
- tension
- hemopneumothorax
- occupational hazard
- absence of facilities 
Sx in second episode: 
- ipsilateral recurrence
- contralateral after a first episode
Goal of Sx is to resect blebs and obliterate space - decrease recurrence