Pneumothorax

Question 1

Definition

Answer 1

Air in the pleural space. May occur with apparently normal lungs (10 pneumothorax) or in the presence of underlying lung disease (2 pneumthorax). May occur spontaneously or following trauma

Question 2

Tension pneumothorax

Answer 2

Rare unless the patient is on mechanical ventilation or nasal non-invasive ventilation. The pleural tear acts as a one way valve through which air passess during inspuration but is unable to exit on expiration

Question 3

Aetiology of spontaneous pneumothroax

Answer 3

• occur in youn men (typically tall and thin) and is the result of a pleural bleb which is though to be due to a congenital defect in the connective tissue of the alveolar wall

Question 4

Secondary pneumothorax

Answer 4

• due to underlying diseases: COPD (60%), asthma, ILD

Question 5

Symptoms

Answer 5

• acute onset of pleuritic chest pain and/or breathlessness
• may be no symptoms (especially if fit, yound and small)

Question 6

Signs

Answer 6

• rachycardia
• reduced expansion
• hyper-resonance to percussion
• diminished breath sounds on the affected side
• Hamman’s sign - refers to click on ausculatation in with with heart sounds due to movement of pleral surfaces with a left sided pneumothorax
• bubbles and crackles under the skin of the torso and neck if there is subcutaenous emphysema
• Tension- trachea will be deviated Away from the affected side

Question 7

Investigations

Answer 7

• standard PA chest xray
  
  • area of devoid lung markings, peripheral to the edge of the collapsed lung
  • blunting of the ipsilateral costophrenic angle
• CT- differentiate pneumothorax from bullous disease
• ABG- hypoxia and hypercapnia

Question 8

Management

Answer 8

1. Decide whether primary or secondary( known lung dsease/evidence of lung disease or age>50 with significant smoking), size and symptoms
   * pneumothorax due to trauma or mechanical ventillation requires a chest drain

Question 9

Aspiration of pneumothorax technique

Answer 9

• indentify the 2nd intercostal space in the midclavicular line and infiltrate with 1% idocaine down to the pleura overlying the pneumothorax
  
  • insert 16g cannula into the pleural space
  • remove the needles and connect cannua to three way tap and a 50ml syringe
  • aspirate up to 2.5L of air
  • stop if resistance is felt, or if patient coughs
• request a CXR to confirm resolution of pneumothorax. If successful discharge patient and repeat CXR 24h after to exclude reccurrence and again after 7-10 days. Advice to avoid air travel for 6 weeks after a normal CXR.
• if aspiration unsuccessful, insert intercostal frain

Question 10

Indications of aspiration

Answer 10

• Primary - Consider aspiration if patient breathless, hypoxic, and pneumothorax large
• Secondary- consider aspiration if evidence of underlying lung disease (or patient with significant smoking history, aged >50y) with small pneumothorax and breathlessness

Question 11

Indications of chest drain

Answer 11

• pneumothrax: ventilated’ tension, persistent/reccurrent despite aspiratio; large 2nd spontaenous pneumothroz
• malignant pleural effusion, empyema
• post operatively

Question 12

Chest drain insertion procedure:

Answer 12

• identify the point for drainage (effusions under ultrasound guidnace)
• preparation: trolley with dressing pack, 2% cholrhexidine, needles; 10ml syringe, 1% lidocaine. saloel, suture, chest drain kit, connecting tubes
• choose insertion site: 4th-6th intercostal space, anterior to mid axillary line - the safe triangle)
• sterile technique
• underwater drian with sterile water
• infiltrate down to the pleura with 10ml 1% lidocaine and a 21g needles. Check that air/fluid can be aspirated from the proposed insetion site
• attach seldinger needle to syringe containing sterile saline.
• insert needle, aspirating constant. When fluid air is obtained stop and note insertion site