Pneumothorax

Question 1

Define pneumothorax

Answer 1

Air in the pleural space.

There are some other variants in which other substances are found in the pleural space:
Haemothorax - blood
Chylothorax- lymph

Question 2

Explain the aetiology/risk factors of pneumothorax

Answer 2

Spontaneous
Occurs in people with typically normal lungs
Typically in tall, thin males
It is probably caused by the rupture of a subpleural bleb

Secondary
Occurs in patients with pre-existing lung disease
(e.g. COPD, asthma, TB)

Traumatic
Caused by penetrating injury to the chest
Often iatrogenic (e.g. during jugular venous cannulation, thoracocentesis)

Risk Factors
Collagen disorders (e.g. Marfan’s syndrome, Ehlers
-Danlos syndrome)

Question 3

Summarise the epidemiology of pneumothorax

Answer 3

Annual incidence: 9/100,000
Mainly in 20-40 yr olds
4 x more common in MALE

Question 4

Recognise the presenting symptoms of pneumothorax

Answer 4

May be ASYMPTOMATIC if the pneumothorax is small
Sudden-onset breathlessness
Pleuritic chest pain
Distress with rapid shallow breathing in is tension pneumothorax

Question 5

Recognise the signs of pneumothorax on physical

examination

Answer 5

There may be NO signs if the pneumothorax is small

Signs of respiratory distress
Reduced expansion
Hyper-resonance to percussion
Reduced breath sounds

Tension Pneumothorax:
Severe respiratory distress
Tachycardia
Hypotension
Cyanosis
Distended neck veins
Tracheal deviation away from the side of the pneumothorax

Question 6

Identify appropriate investigations for pneumothorax

Answer 6

CXR:
It will show a dark area of film with no vascular markings
Fluid level may be seen if there is any bleeding

ABG:
Check for hypoxaemia

Question 7

Generate a management plan for pneumothorax

Answer 7

Tension Pneumothorax (EMERGENCY)
Maximum O2
Insert large bore needle into
2nd intercostal space MCL
Up to 2.5 L of air can be aspirated
Stop if patient coughs or resistance is felt
Follow-up CXR 2 hrs and 2 weeks later 

Chest Drain with Underwater Seal
Performed if:
Aspiration fails
Fluid in the pleural cavity
After decompression of a tension pneumothorax
Inserted in the 4th-6th intercostal space midaxillary line

Recurrent Pneumothoraces
Chemical pleurodesis (fusing of visceral and parietal pleura with tetracycline or calc)
Surgical pleurectomy

Advice
Avoid air travel until follow-up CXR confirms that pneumothorax has resolved
Avoid diving

Question 8

Identify the possible complications of pneumothorax

Answer 8

Recurrent pneumothoraces

Bronchopleural fistula

Question 9

Summarise the prognosis for patients with pneumothorax

Answer 9

After having one pneumothorax, at least 20% will have another.
Frequency increases with repeated pneumothoraces