Pneumothorax

Question 1

What is a PTX?

Answer 1

Accumulation of air in the pleural space

Question 2

What is a closed PTX?

Answer 2

Intact chest wall

Air leaks from lung into pleural cavity

Question 3

What is an open PTX?

Answer 3

Wound in the chest wall

Allows communication between PTX and exterior - sucking

Question 4

What is a tension PTX?

What is it caused by?

Answer 4

Air enters through a one-way lung parenchymal flap and cannot escape

Causes pressure to rise = mediastinal shift + tracheal deviation

Caused by thoracic trauma

Question 5

Explain the spontaneous causes of PTX

Answer 5

Primary: no underlying lung disease

• Ruptured subpleural bulla: young, thin males
• Smokers

Secondary: underlying lung disease

• Asthma, COPD
• Connective tissue disease: e.g. Marfans, ehler-danlos

Question 6

Name 3 RF

Answer 6

Pre-existing lung disease e.g. asthma, COPD, CF

Connective tissue disease e.g. RA, Marfan’s

Artificial ventilation

Question 7

What other causes of PTX?

Answer 7

Trauma - penetrating chest injuries

Iatrogenic

Question 8

How does PTX present?

Answer 8

ASX - e.g. small PTX
Sudden onset SOB
Pleuritic chest pain 
Sweating 
Tachypnoea
Tachycardia

Question 9

How does a tension PTX present?

Answer 9

Haemodynamically unstable

SX:
Respiratory distress
Cardiac arrest
Pleuritic chest pain 
SOB

SIGNS:
Tracheal deviation**
Hyper-resonant percussion 
Increased HR, low BP
Decreased breath sounds

Question 10

What IX need to be done?

Answer 10

ABG - hypoxia, respiratory alkalosis (hypervent.)

US - ‘lung sliding’ (done in an acute setting)

CXR

Question 11

What is seen on CXR?

Answer 11

Haziness

Translucency + collapse (rim around lung)

Mediastinal shift - AWAY from PTX

Question 12

How is a tension PTX MX?

Answer 12

Immediate

Resus, no CXR

Needle decompression + large bore cannula
- LBC inserted into 2nd ICS, mid-clavicular line

Question 13

How do you MX a primary pneumothorax?

Answer 13

If pt ASX and rim <2cm
- Discharge

If pt is SOB and/or rim >2cm

• Aspirate
• If successful discharge

If aspirate unsuccessful
- Chest drainage

Advise to STOP SMOKING

Question 14

How do you MX a secondary pneumothorax?

Answer 14

If not SOB and >50y and rim <2cm

• Aspiration
• If successful admit for 24h
• If unsuccessful = chest drain

If SOB and >50y and rim >2cm
- Insert chest drain