Pneumothorax

Question 1

Define

Answer 1

Air in the pleural space

(the potential space between the visceral and parietal pleura)

Variants dependant on substance (haemothorax, chylothorax)

Tension pneumothorax → emergency, functional valve lets air enter during inspiration but not leave during expiration

Question 2

Causes

Answer 2

Spontaneous - previously normal lungs, typically tall thin males, ?rupture of a subpleural bleb

 Secondary - pre-existing lung disease (COPD, asthma, lung carcinoma, CF, diffuse lung disease)

Traumatic - penetrating injury to chest, often iatrogenic (e.g. subclavian/jugular venous cannulation, thoracentesis, biopsy, +ve pressure assisted ventilation

Question 3

Risk factors

Answer 3

Collagen disorders (e.g. Marfan’s, Ehlos-Danlos syndrome)

Question 4

Epidemiology

Answer 4

Annual incidence: 9/100,000

Mainly in 20-40 yr olds

4 x more common in MALES

Question 5

Symptoms

Answer 5

• May be ASYMPTOMATIC if the pneumothorax is small
• Sudden-onset breathlessness
• Pleuritic chest pain

Distress with rapid shallow breathing in tension pneumothorax

Question 6

Signs

Answer 6

• There may be NO signs if the pneumothorax is small
• Signs of respiratory distress
• Reduced expansion
• Hyper-resonance to percussion
• Reduced breath sounds

Tension Pneumothorax

• Severe respiratory distress
• Tachycardia
• Hypotension
• Cyanosis
• Distended neck veins
• Tracheal deviation away from the side of the pneumothorax

Question 7

Investigations

Answer 7

CXR: dark area of film where lung markings do not extend Fluid level may be seen if blood present
ABG: to determine any hypoxaemia

Question 8

Management

Answer 8

Tension Pneumothorax (EMERGENCY)

• Maximum O2
• Insert large bore needle into 2nd intercostal space MCL
• Up to 2.5 L of air can be aspirated
• Stop if patient coughs or resistance is felt
• Put chest drain
• Follow-up CXR 2 hrs and 2 weeks later

Chest Drain with Underwater Seal

Performed if:

• Aspiration fails
• Fluid in the pleural cavity
• After decompression of a tension pneumothorax
• Inserted in the 4th-6th intercostal space midaxillary line

If Small -> analgesia

Recurrent Pneumothoraces

• Chemical pleurodesis (fusing of visceral and parietal pleura with tetracycline or calc)
• Surgical pleurectomy

Advice

• Avoid air travel until follow-up CXR confirms that pneumothorax has resolved
• Avoid diving

Question 9

Complication

Answer 9

Recurrent pneumothoraces

Bronchopleural fistula

Question 10

Prognosis

Answer 10

After having one pneumothorax, at least 20% will have another

Frequency increases with repeated pneumothoraces