Pneumothorax

Question 1

What is a Pneumothorax?

Answer 1

Air in the pleural sac that may occur spontaneously or occur as a result of trauma to chest.

Question 2

Which patient groups are Pneumothoraces more common in?

Answer 2

• More common in young males with male to female ratio at 6:1
• Often the patients are tall and thin
• In patients over 40 years of age, it is usually as a result of underlying COPD.

Question 3

What are some causes of a Pneumothorax?

Answer 3

• Rupture of pleural bleb usually apical
• COPD
• Bronchial asthma
• Carcinoma
• Breakdown of lung abscess leading to bronchopleural fistula
• Severe pulmonary fibrosis with cyst formation

Question 4

What are the physiological changes occurring in a Pneumothorax?

Answer 4

• Normally pressure in pleural space is negative but this is lost once communication is made with atmospheric pressure.
• Elastic recoil pressure of the lung as a result cases it to deflate partially.
• If communication between the airways and pleural space continues then bronchopleural fistula results.

Question 5

How does a Tension pneumothorax differ physiologically when compared to a pneumothorax?

Answer 5

• Valvular mechanism may develop through air being sucked into pleural space during inspiration but not being expelled during expiration.
• Intrapleural pressure remains positive throughout breathing causing the lung to deflate further.
• Mediastinum shift and venous return to heart decreases with increasing respiratory and cardiac needs.

*Rare except in patients with positive pressure ventilation

Question 6

What are symptoms of a Pneumothorax?

Answer 6

• Sudden onset unilateral pleuritic pain or progressively increasing breathlessness.
• Patient may develop pallor and tachycardia

Question 7

What are symptoms of a Tension Pneumothorax?

Answer 7

• Sudden onset unilateral pleuritic pain or progressively increasing breathlessness.
• Hypotension
• Tachycardia
• Deviation of trachea away from side of pneumothorax
• Mediastinal shift away from pneumothorax

Question 8

What is the management of a Small, Medium and Large Primary Pneumothorax?

Answer 8

Small (<2cm)

• Avoid strenuous exercise but conservatively treat and observe in 2 weekly intervals until air is reabsorbed
• Symptomatic patient should be considered for aspiration

Medium 20-50% and Large >50% (>2cm) and symptomatic patient

• Aspirate the air and if recurrence then insert a drainage tube with underwater seal. If no recurrence then conservative treatment
• Avoid smoking

Question 9

What is the management of a Tension Pneumothorax?

Answer 9

• Insert intercostal drainage tube with underwater seal for 2-3 days
• If unresolving then Surgery VAT for Pleurectomy or Talc Pleurodesis if surgery is contraindicated.
  
  • Also this is done if there is a recurrent pneumothorax

Question 10

How is the drainage tube inserted?

Answer 10

• Large bore intravenous cannula in 2nd Intercoastal Space at Mid-Clavicular Line (for instant relief)
• Chest Drain in 5th Intercostal Space at Mid-Axillary Line

Question 11

What is the management of Secondary Pneumothorax?

Answer 11

• If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is Short of Breath then a Chest Drain should be inserted.
• Aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
• If the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours