Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

accumulation of air in the pleural space that can lead to pulmonary collapse.

Question 2

What type of pneumothorax is usually found in tall, thin young men?

Answer 2

Primary spontaneous pneumothorax. Usually due to rupture of a subpleural bullae.

Question 3

What are the main causes of pneumothorax?

Answer 3

Trauma

Iatrogenic (central line, thoracentesis, biopsy, positive pressure vent)

Chronic lung disease

Infection

Malignancy

Connective tissue disorder

Ruptures subpleural bullae

Question 4

True or false: The trachea deviates away from a collapsed lung.

Answer 4

Depends if it is partially or totally collapsed!

Trachea can shift towards a partial collapse such as a spontaneous pneumothorax, but away from a tension pneumothorax.

Question 5

Which of the following is NOT a sign of tension pneumothorax:

A. Absent breath sounds
B. Hemodynamic instability
C. Ipsilateral tracheal deviation
D. Distended neck veins

Answer 5

C. Ipsilateral tracheal deviation

Tension pneumothorax may present with:

• Diminished or absent breath sounds
• Severe respiratory distress e.g. cyanosis/hypoxia
• Hemodynamic instability e.g. tachycardia, hypotension
• Contralateral tracheal deviation
• Distended neck veins 2° to compression of the SVC

Question 6

In a tension pneumothorax, do the following increase or decrease?

1. Tactile fremitus
2. Vocal fremitus
3. Percussion resonance
4. Breath sounds
5. Chest expansion

Answer 6

1. Tactile fremitus ↓
2. Vocal fremitus ↓
3. Percussion resonance ↑
4. Breath sounds ↓
5. Chest expansion ↓

Question 7

How might a pneumothorax present?

Answer 7

P-THORAX:

Pleuritic pain
Tracheal deviation Hyperresonance
Onset sudden
Reduced breath sounds (and dyspnoea)
Absent fremitus (asymmetric chest wall)
X-ray shows collapse

Question 8

Why should you never see a tension pneumothorax on CXR?

Answer 8

Once a suspicion is made clinically, intervention should follow without delay!

Question 9

What are the borders of the safe ‘triangle’ for inserting a chest drain?

Answer 9

Lateral border of pectoralis major

Anterior border of latissimus dorsi

Superior to the horizontal level of the nipple

Apex is the axilla.

Question 10

Pneumothorax case presentation 1

Answer 10

A 20-year-old man presents to the emergency department with complaints of left-sided chest pain and shortness of breath. He states that these symptoms began suddenly 4 days ago while he was working at his computer. He initially thought that he might have strained a chest wall muscle, but because the pain and dyspnoea had not resolved, he decided to seek medical attention. He has no significant past medical history but has smoked cigarettes since the age of 16 years. His older brother suffered a pneumothorax at the age of 23 years. The patient’s vital signs are normal. He appears in mild discomfort. Examination of his chest reveals that the left hemithorax is mildly hyperexpanded with decreased chest excursion. His left hemithorax is hyper-resonant on percussion, and breath sounds are diminished when compared with the right hemithorax. His cardiovascular examination is normal.

Question 11

Pneumothorax case presentation 2

Answer 11

A 65-year-old patient with COPD presents to the emergency department with complaints of worsening shortness of breath and right-sided chest discomfort. He states that these symptoms occurred suddenly 1 hour prior to presentation. He denies fevers and chills. He also denies increased sputum production and a change in the colour or character of his sputum. He continues to smoke cigarettes against medical advice. The patient’s blood pressure is 136/92 mmHg, heart rate is 110 beats per minute, and respiratory rate is 24 breaths per minute. Chest excursion is decreased on the right more than the left. His right hemithorax is more hyperinflated than the left. His right hemithorax is hyper-resonant on percussion. Breath sounds are distant bilaterally but more diminished on the right.