Pneumothorax

Question 1

Describe the pathophysiology of a tension pneumothorax. (3)

Answer 1

1. Breach in the pleura forms a one-way valve: air goes in, but not out
   a. This causes increased intrapleural pressure
2. This causes impaired venous return, leading to:
   a. Reduced cardiac output
   b. Decreased BP
3. This eventually causes pulseless electrical activity in the heart
   a. This can be fatal if not treated

Question 2

Describe the pathophysiology of primary spontaneous pneumothorax. (2)

Answer 2

1. Development of bullae/subpleural blebs in the lung apex

2. Spontaneous rupture of these blebs causes pneumothorax

Question 3

Describe the pathophysiology of secondary spontaneous pneumothorax. (2)

Answer 3

1. Underlying pathology causes structural abnormalities, e.g.
   a. Inherent lung weakness (e.g. emphysema)
   b. Increased airway pressure (e.g. asthma)
   c. Increased lung elasticity (e.g. pulmonary fibrosis)
2. This makes rupture much more likely

Question 4

List 4 risk factors for spontaneous pneumothorax.

Answer 4

Male
Smoking
Tall height
Underlying lung disease

Question 5

Describe the clinical features of pneumothorax.

What are the symptoms? (3)

What are the signs O/E? (5)

Answer 5

SYMPTOMS:
Pleuritic chest pain
Respiratory distress
SOB

SIGNS:
Reduced air entry
Hyper-resonance on percussion
Reduced vocal resonance
Absent lung markings on CXR
Tracheal deviation

Question 6

Describe the management of a primary pneumothorax. (3)

Answer 6

Observation, if:

• Small (<2cm on CXR)
• Asymptomatic

Aspiration, if:

• Large (2+cm on CXR)
• Breathless

Chest drain and admission, if:
-Aspiration unsuccessful

Question 7

Describe the management of a secondary pneumothorax. (2)

Answer 7

Admission and aspiration, if:

• Small (<2cm on CXR)
• Asymptomatic

Admission and chest drain, if:

• Large (2+cm)
• Breathless
• Aspiration unsuccessful

Question 8

Describe how to put in a chest drain. (2)

Answer 8

Small bore tube placed in axilla

Underwater seal:

• Air drains into a water bottle (so that it can’t go back in)
• Drain removed once bubbling stops

Question 9

In extreme cases of pneumothorax, what further treatment could you do?

List 3 methods which you might do in this procedure.

Answer 9

Video assisted thoracic surgery (VATS)

METHODS:
Stapling blebs (to prevent rupture)
Talc pleurodesis (to cause inflammation and adhesions)
Pleural abrasion/stripping

Question 10

List 4 indications for VATS in pneumothorax.

Answer 10

Unresolved pneumothorax after 5 days
First contralateral pneumothorax
Second ipsilateral pneumothorax
High risk of recurrence (e.g. due to occupation, e.g. pilots, scuba divers)