Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

Collection of air in the pleural space that causes an uncoupling of the lung from the chest wall

Question 3

Describe the clinical presentation of a pneumothorax

Answer 3

• May be aymptomtic in young patients with a small pneumothorax
• May present with a sudden onset of unilateral pleuritic pain, with progressive breathlessness
• There may the physical signs:
  
  • Reduced expansion
  • Increased resonance to percussion
  • Decreased breath sounds
  • Reduced vocal resonance

Question 4

What are the causes of a pneumothorax divided into?

What are the causes?

Answer 4

• Spontaneous pneumothorax
  
  • Primary: lung parenchyma otherwise normal, caused by rupture of the apical bleb, often in tall, thin young men
  • Secondary: underlying lung disease/abnormalitiy, e.g. COPD, pneumonia, cystic fibrosis, asthmatic, malignancy
• Traumatic pneumothorax
  
  • penetrating trauma e.g. rib fractures
• Iatrogenic pneumothorax
  
  • lung biopsy
  • endoscopy
  • subclavian cannulation
  • postive pressure ventilation

Question 5

What is the difference between a simple and tension pneumothorax?

Answer 5

Tension pneumothorax

• Air in the pleural space leading to cardiac compromise
  
  • Caused by a valvular mechanism allowing air entry to the pleural space during inspiration, but no exit during expiration
  • The intrapleural pressure is very high, deflating lung and decreasing venous return to the heart
• Suggested by:
  
  • tracheal deviation away from the affected side
  • respiratory distress
  • pallor
  • haemodynamic compromise
  • distended neck veins

Question 6

What investigations would you do for a patient with a suspected pneumothorax?

Answer 6

• Expiratory CXR
  
  • trace outline for areas devoid of lung markings and always look for tracheal deviation
• ABG:
  
  • Signs of respiratory distress or chronic lung disease

Question 7

What is the emergency treatment for a pneumothorax?

Answer 7

Aspiration:

Insert large bore needle attached to syringe partially filled with saline into the 2nd intercostal space in the mid-clavicular line on the side of the suspected lesion. Pull back on the syringe to allow air the bubble out until a chest drain can be inserted. Alternatively, insert a cannula at the same location, and allow air to flow out.

Chest drain:

Pneumothoraces may be aspirated using a chest drain. Chemical pleurodesis with talc is used for patients with contraindication to surgery. Video-assisted thoracoscopic approach may be used to resect a bleb and achieve pleurodesis.