Pneumothorax

Question 1

Management for Primary Pneumothorax

Answer 1

All patients should be admitted for 24 hours

If the patient does not have lung disease and so the pneumothorax is primary:

• if the pneumothorax is greater than 2cm rim or patient is SOB then:
  i) Chest X ray
  ii) Aspirate
  iii) if that doesn’t work aspirate again
  iv) If that doesn’t work chest drain
• if the pneumothorax is less than 2cm rim AND not SOB
  i) aspirate

Question 2

Management for Secondary Pneumothorax

Answer 2

If the patient has lung disease and so the pneumothorax is secondary you need to treat:

Use Chest drain if:

i) patient is over 50 years old
ii) if rim is greater than 2cm
iii) patient is SOB - you aspirate if none of the above

Question 3

Management of tension pneumothorax

Answer 3

Insert a large bore cannula into the second intercostal space in the midclavicular line

If a tension pneumothorax is suspected do not wait for any investigations.

Once the pressure is relieved with a cannula then a chest drain is required for definitive management.

Question 4

Features of pneumothorax

Answer 4

reduced chest expansion of the affected side

hyper-resonant percussion note on the affected side

reduced or absent breath sounds on the affected side, with no added sounds.

vocal resonance (or tactile vocal fremitus) is reduced on the affected side.

Question 5

Features of a tension pneumothorax

Answer 5

Additional signs in a tension pneumothorax include:

• signs of haemodynamic compromise (tachycardia and hypotension)
• tracheal deviation to the contralateral side [I dart AWAY from TENSION]

Question 6

What is a tension pneumothorax? What is it caused by? Pathology? Why is it dangerous?

Answer 6

Tension pneumothorax is caused by trauma to chest wall that creates a one way valve that lets air in but not out of the pleural space. The one way valve means that during inspiration air is drawn into the pleural space and during expiration the air is trapped in the pleural space. Therefore more air keeps getting drawn into the pleural space with each breath and cannot escape. This is dangerous as it creates pressure inside the thorax that will push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.

Question 7

Where do you put a chest drain?

What defines that area?

Answer 7

In the triangle of safety: 5th intercostal space midaxillary line

The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.

Once the chest drain is inserted obtain a chest xray to check the positioning.