Pneumothorax Flashcards
What is pneumothorax?
air in the pleural cavity (between lung + chest wall) resulting in collapse of the lung on the affected side
Describe the aetiology of spontaneous pneumothorax
Occurs in young, healthy people
Typically in tall, thin males
Probably caused by rupture of a subpleural bleb
What are 2 variants of pneumothorax?
Haemothorax: blood
Chylothorax: lymph
Describe the aetiology of secondary pneumothorax
Occurs in patients with pre-existing lung disease (e.g. COPD, asthma, TB)
Describe the aetiology of traumatic pneumothorax
Caused by penetrating injury to the chest e.g. stab wound
Often iatrogenic
List 7 iatrogenic pneumothorax
Mechanical ventilation with high PEEP
NIV
Hyperbaric O2 therapy
Thoracocentesis
Central line placement
Bronchoscopy
Lung biopsy
Which types of pneumothorax can lead to a tension pneumothorax?
Any
Which structural disorders predispose to pneumothorax? Give 2 examples
Collagen disorders
Marfan’s syndrome
Ehlers-Danlos syndrome
What is the most important risk factor for pneumothorax?
Smoking
Increases risk 22-fold in M + 9 fold in F
List 5 non-modifiable risk factors for primary pneumothorax
FH
Male
Young
Slim + tall stature
Homocystinuria
Describe 2 symptoms of pneumothorax
Acute onset pleuritic chest pain
SOB
Give 4 signs on examination of pneumothorax on examination
Reduced chest wall movement
Absent breath sounds
Hyper-resonant percussion
Reduced vocal fremitus
Why may symptoms be more severe in secondary pneumothorax?
Pre-existing lung disease means they already have reduced pulmonary reserves
What 4 signs of tension pneumothorax may be found on examination?
Severe acute respiratory distress: cyanosis, restlessness, diaphoresis
Distended neck veins
Haemodynamic instability: Tachycardia, Hypotension, pulses paradoxus
Tracheal deviation AWAY from side of pneumothorax
What additional 3 signs of tension pneumothorax may be found in ventilated patients?
Rapid decrease in SpO2
Reduced air flow
Increased ventilation pressure
What is the primary investigation for pneumothorax?
PA CXR
What is seen on CXR in pneumothorax?
Visible rim between lung margin + chest wall
Absence of lung markings between lung margin + chest wall
What is seen on CXR in tension pneumothorax?
Lung completely compressed
Trachea PUSHED AWAY
Mediastinal shift AWAY
Hemidiaphragm depression
In patients unable to sit upright, what imaging may be considered?
USS
CT
What is an indication to perform an ABG in a patient with pneumothorax?
in patients with SpO2 <92% on RA
Describe the immediate management for a tension pneumothorax
- Cardiac arrest call
Immediate decompression:
Insert large bore cannula into 2nd ICS MCL- hiss of air
High flow O2 - Insert chest drain once decompressed + regular analgesia
How does management of tension pneumothorax secondary to trauma differ?
Decompression with open thoracostomy
What is considered ‘minimally symptomatic’ in primary spontaneous pneumothorax? How should this be managed?
No significant pain
No breathlessness
No physiological compromise
If minimally symptomatic conservative Mx regardless of size
What is conservative management for a minimally symptomatic primary pneumothorax?
Observation 4-6h
Supplemental O2
Regular review as OP every 2-4 days
How should a symptomatic small <2cm primary pneumothorax be managed?
Needle aspiration
How should a large >2cm primary pneumothorax be managed?
Needle aspiration
Observe 4-6h
If unsuccessful; chest drain + admit
How should aspiration be performed?
Aspirate up to 2.5L
Use 16-18G cannula
How should a small secondary pneumothorax be managed?
Admit + observe 24h
High flow O2
How should a moderate secondary pneumothorax be managed?
Needle aspiration
High flow O2
Admit + observe 24h
How should a large/ symptomatic secondary pneumothorax be managed?
Admit
Chest drain
High flow O2
In which 3 situations may a Chest Drain with Underwater Seal be performed for primary pneumothoraces? How?
Aspiration fails
Fluid in the pleural cavity
Post-decompression of a tension pneumothorax
Inserted in 4th-6th ICS MAL
After excluding tension pneumothorax, what is the aim of management? How is this achieved? What influences this decision?
To relieve dyspnoea.
Simple observation, needle aspiration + chest drain
Choice depends upon the severity of the condition
What does the immediate management of pneumothorax involve?
Supplemental Oxygen to relieve hypoxia + accelerate resorption of the pneumothorax
What surgical management can be used for recurrence prevention of Pneumothoraces?
Refer for Video assisted thoracoscopic surgery (VATS) to perform:
Mechanical/ chemical pleurodesis +/- bullectomy
What is a bullectomy?
Large fluid filled spaces in the lung (Bullae) are removed to decrease risk of PTX
Performed during VATS
Give 3 examples of indications for surgical intervention for prevention of pneumothorax recurrence
Severe COPD + significant decompensation with PTX
Tension pneumothorax
High risk occupations: pilots, divers, military
Give 2 pieces of advice to a patient who has had a pneumothorax
Avoid air travel until 1w post CXR check / 2w after successful drainage if no residual air
Avoid diving indefinitely
What is the prognosis for a pneumothorax patient?
After having 1 pneumothorax, >,20% will have another
Frequency increases with repeated pneumothoraces
What complications may arise in a pneumothorax patient?
Recurrent pneumothoraces
Bronchopleural fistula
What is the lifetime risk of pneumothorax in a healthy smoker vs non smoker?
Smoker 10%
Non-smoker 0.1%
What is a complication of rapid decompression pneumothorax?
Re-expansion pulmonary oedema
How does re-expansion pulmonary oedema present?
Asymptomatic radiographic changes to complete cardiopulmonary collapse
Acute onset dyspnoea
Cough
Hypoxaemia
Signs unilateral to PTX (unlike HF)
