Pneumothorax

Question 1

Pneumothorax:

Answer 1

The presence of air within the pleural cavity.
This causes the lung to collapse.
This can occur either spontaneous, or due to iatrogenic injury, trauma, to the or chest wall.

Question 2

Pneumothorax: Primary Spontaenous

Answer 2

Occurs in patients with no history of lung disease.

Question 3

Pneumothorax: Secondary Spontaenous

Answer 3

Occurs in patients with pre-existing lung disease, and is associated with higher mortality rates.

Question 4

Pneumothorax: Symptoms

Answer 4

Breathlessness (acute or worsening)
Chest Pain (pleuritic)
Shoulder Pain
If he patient is fit, young, and has a small pneumothorax, then they may have no symptoms.

Question 5

Pneumothorax: Signs:

Answer 5

Decreased Chest Expansion
Decreased/Absence Breathsounds
Increased Resonance on Percusion
Raised JVP
In Tension Pneumothorax = Tachycardia, Tachypnoea, hypotension, Cyanosis, Deviated Trachea, Sweating.

Question 6

Pneumothorax: Investigations:

Answer 6

CXR
CT
ABGs

Question 7

Small Pneumothorax: Management if NOT breathless, and small (< 2cm)

Answer 7

Observe overnight, repeat CXR, if no change hole has sealed

Discharge

Question 8

Primary Pneumothorax: Management if Breathless (> 2cm)

Answer 8

Aspirate the 2nd ICS, Mid-Clavicular Line with patient at 45’. Continue to aspirate until you feel the lung wall, and aspirate more than 3L.
If successful, do a CXR after 24 hours.
If unsuccessful, insert Chest Drain.

Question 9

Secondary Pneumothorax: Management if Breathless

Answer 9

Insert Chest Drain into 4th ICS Axillary Line.

Question 10

Small Pneumothorax: Management if and no SOB & if…
< 1cm
= 1-2 cm
> 2cm

Answer 10

<1cm:
Admission 
Oxygen 
Reassess in 24 hours
1-2cm:
Aspirate
> 2 cm:
Chest Drain

Question 11

Tension Pneumothorax: Emergency Management:

Answer 11

14G Cannula to 2nd ICS Mid-Clavicular Line.
Insert Chest Drain 4th ICS Mid-Axillary Line.
Repeat CXR
Lung should inflate after 2 says, drain stops bubbling
CXR to confirm lung re-expansion.

Question 12

After using an Intercostal Drain: Ideally:

Answer 12

Lung inflates in 1-2 days, drain stops bubbling, CXR confirms lung inflated
then 2 choices:
1. Clamp & drain for 24 hours, re CXR, no change, remove drain.
2. Re CXR after 24 hours, no change, remove drain.

Question 13

After using an Intercostal Drain: Less than Ideally:

Answer 13

Lung fails to re-inflate after 48 hours
Drain continues bubbling
1. Apply suction to drain: high vol low pressure -10 to -20 cm H2O
2. If fails to re-inflate: contact thoracic surgeon at 3 days.
3. Thoracoscopic inspection of visceral pleura
4. Identification of blebs, tears -> clipping and talc pourdrage pleurodesis.

Question 14

After Pneumothorax: Advice

Answer 14

Smoking cessation to reduce risk of recurrence. The lifetime risk of developing a pneunothorax in healthy smoking men is around 10% and 0.1% in non-smoking health men.