Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

Air between the visceral and parietal pleura

Question 2

How does a pneumothorax develop?

Answer 2

Normally, the pleural space is slightly negative pressure compared to the atmospheric pressure int eh lungs.

If the lung is damaged, the air in the lung preferentially moves into the pleura which is more negative.

This disrupts the balanced forces that hold the lung in place, and the lung will collapse.

Question 3

Signs and symptoms of pneumothorax?

Answer 3

Chest pain (pleuritic), dyspnea

Tachycardia

Hypoxia

Hyper-resonance, decreased or absence breath sounds

Tracheal shift (not midline)

Can be asymptomatic

Question 4

How do you diagnose pneumothorax?

Answer 4

CXR (standard)

High degree of clinical suspicion

US can be useful to rule out PTX in trained hands (not standard)

CT can pick up some small x-ray occult PTX

Question 5

What are the radiologic features of pneumothorax?

Answer 5

• Area of hyperlucency (absent of lung markings); often at the apex of the lungs because air rises up)
• Reflection of visceral pleua (pleural line) which is smaller than other lung
• May have small effusion (from iatrogenic PTX)

Question 6

How do we classify pneumothorax?

Answer 6

Primary spontaneous PTX (spontaneous, no underlying disease)

Secondary PTX (people with underlying lung disease)

Iatrogenic PTX (subclavian catheter, pacemaker, etc)

Traumatic PTX (check for rib fractures)

Tension PTX (any of the above can become a tension pneumo)

Question 7

22 yr old woman with sudden onset chest pain after acupuncture?

Answer 7

Iatrogenic pneumothorax

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Question 8

75 yr old man with sudden onset pleuritic chest pain and dyspnea, history of COPD?

Answer 8

Secondary PTX

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Question 9

55 yr old male, asymptomatic

Post pace-maker insertion

CXR show PTX

Answer 9

Iatrogenic PTX

These ones tend to heal very quickly

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Question 10

What does this CXR show?

Answer 10

Tracheal shift

Nearly complete collapse of left lung

Developing tension PTX

Question 11

20 yr old male with sudden onset pleuritic chest pain and dyspnea while showering

Answer 11

Spontaneous primary PTX

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Question 12

What is the cause of primary spontaneous PTX?

Answer 12

Cause: rupture of apical sub-pleural bleb or bullae

If it recurs, it will most likely happen in the first year

Incidence: 1.2-7.4/100,000

Question 13

What is a bleb in the lungs?

Answer 13

Small blister in the visceral pleura that is weaker than the rest of the pleura

Thoraco-scopic blebs are white

Question 14

Risk factors for primary PTX?

Answer 14

Tall, slim

Male

Younger age

Smoker

If a female has has a PTX, they are at higher risk for reoccurance than males

Question 15

Goals of management of pneumothorax?

Answer 15

• Stabilize the patient: ABCs, oxygen
• Manage air in the pleural space
• Prevent recurrence

Question 16

How do we manage the pleural air?

Answer 16

• Watch and wait; can reabsorb a small amount on its own
• Supplemental O2
• Aspiration
• Chest tube
• Needle decompression

Question 17

What are the indicators that we should treat a pneumothorax?

Answer 17

• Primary PTX, symptomatic, large (> 3 cm off the apex)
• Tension PTX (hemodynamic compromise)
• Secondary PTX
• Patient is ventilated; increase risk of more air leaking into pleural space
• Complex pleural disease
• Breathlessness indicates the need for a more active intervention

Question 18

Does every PTX need a chest tube?

Answer 18

NO!

Patients who are not breathless and have a small PTX can be discharged with early out-patient follow up

Question 19

How does a chest tube work?

Answer 19

Drains air from aroudn the lung, so that the lung can expand again. Done by attaching tube to a collection chamber.

Underwater seal creates a system that allows air out but not back into the pleural space.

Third compartment is a suction chamber, which allows us to control the suction on the pleural space.

Question 20

When can the chest tube be removed from a PTX patient?

Answer 20

• Air is evacuated from the pleural space, and lung is back up on CXR
• No more air leaking out of the lung; no air bubbling in water chamber (ie. when they cough); clamp the chest tube for 2-4 hrs and CXR to see if patient remains stable

If both of these conditions are satisfied, it is OK to remove the patient’s chest tube.

Question 21

What is a tension pneumothorax?

Answer 21

Tension PTX - when the air in the pleural space has increased to the point of becoming a positive pressure, that pushes on the rest of the thorax. Causes hemodynamic problems.

Mediastinal shift to the contralateral side

Collapsed lung

Depressed hemidiaphragm on affected side

Question 22

How does a tension ptx develop?

Answer 22

Tension ptx is when intrapleural pressure exceeds atmospheric pressure.

Can occur if a person has a sort of one-way valve in the lung, that only allows air INTO the pleural space, not back out.

Can occur if a patient has positive pressure ventilation.

V/Q mismatch –> profound hypoxia

Treat with a needle, to relieve the pressure. 2nd interspace, mid clavicular line. Can hear the pressure relieved with a hiss through the needle.

Question 23

How do we diagnose tension ptx?

Answer 23

Clinical diagnosis

High degree of suspicion

hyper-resonant to affected side

Diminished/absent breath sounds to affected side

Tracheal deviation to contralateral side; palpate on PE

Question 24

Management of tension ptx?

Answer 24

Medical emergency!

Decompression!!! Large bore needle 2nd intercostal space, mid clavicular line

Chest tube with water seal (like regular ptx)

Question 25

How do we prevent recurrence of pneumothorax?

Answer 25

• Mitigate risk factors (QUIT SMOKING)
• Pleurodesis - get the visceral and parietal pleura to stick together (sclerosing agent, VATS pleural abrasion); typically only after a second pneumo
• Bullectomy

Question 26

What procedure does this picture depict?

Answer 26

Thorascopic bullectomy