Pneumothorax Flashcards
What is pneumothorax?
Air in the pleural space
What are the 3 main causes of pneumothorax?
List some examples of secondary pneumothorax and iatrogenic causes.
Primary spontaneous pneumothorax esp in young, thin men
Secondary pneumothorax occurs with pre-existing lung disease:
i. Chronic lung disease i.e COPD Asthma Cystic fibrosis Lung fibrosis Sarcoidosis
ii. Infections i.e.
TB
Pneumonia
Lung abscess
iii. Carcinoma
iv. Connective tissue disorders i.e. Marfan’s, Ehlers-Danlos
v. Trauma including iatrogenic: Subclavian central venous line insertion Pleural aspiration / biopsy Transbronchial biopsy Percutaneous liver biopsy Positive pressure ventilation
What is the underlying pathology in primary spontaneous pneumothorax?
Who does it affect most commonly?
- Primary spontaneous pneumothorax occurs due to sub pleural bulla rupture
- Commonly affects thin, young men
What are the signs and symptoms of pneumothorax?
Small pneumothorax in fit, young person = asymptomatic
Symptoms:
Sudden onset of dyspnoea
Pleuritic chest pain
Sudden deterioration in patients with COPD/Asthma
Shock (tension pneumothorax)
Hypoxia in mechanically ventilated patients => increase in ventilation pressures
Signs:
Reduced expansion
Hyper-resonance on percussion
Diminished breath sounds on the affected side
Trachea deviation away from affected side (tension pneumothorax)
Which investigations are carried out for pneumothorax?
What should you not do in a tension pneumothorax?
A plain expiratory chest x-ray => look for devoid lung markings peripheral to lung collapse
DO NOT request a chest x-ray in tension pneumothorax as it is an emergency — do not delay!!
ABG in dyspneic/hypoxic patients and in chronic lung disease patients
Which 5 factors does the management of pneumothorax depend on?
Whether it is a:
Primary pneumothorax
Secondary pneumothorax (underlying lung disease)
Smoker >50 years old
Size of pneumothorax
Symptoms
How is the size of a pneumothorax measured?
From the visible lung margins to the chest wall at level of hilum
How is a pneumothorax due to trauma or mechanical ventilation treated?
Chest drain
Primary pneumothorax management:
SOB ± >2cm air on CXR => No => Discharge + outpatients review in 2-4 weeks
SOB ± >2cm air on CXR => Yes => Aspiration = Aspiration successful => Yes => Discharge + outpatient review
Aspiration not successful => Chest drain
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Secondary pneumothorax management:
SOB ± >2cm air on CXR => No => Size 1-2cm => No => Admit for 24h under observation and O2
SOB ± >2cm air on CXR => No => Size 1-2cm => Yes => Aspiration => Aspiration successful => Admit for 24h under observation and O2
SOB ± >2cm air on CXR => No => Size 1-2cm => Yes => Aspiration => Aspiration not successful => chest drain
SOB ± >2cm air on CXR => Yes => Chest drain
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Where do you aspirate on the chest?
Describe briefly the aspiration procedure?
2nd intercostal space in the mid-clavicular line or 4-6th intercostal space in the mid-axillary line (safe triangle).
Procedure:
1% lidocaine down to the pleura overlying the pneumothorax
Insert 16G canal into pleural space => remove the needle and connect cannula to a 3-way tap and a 50mL syringe.
Aspirate 2.5L of air - stop if resistance felt or patient coughs excessively
Request CXR to confirm resolution of pneumothorax => can discharge
Repeat CXR in 24h and again in 7-10 days to exclude reoccurrence
What do you advice the patient after a successful aspiration?
Avoid air travel for 6 weeks after a normal CXR.
Driving permanently avoided
What is the next step if the aspiration fails?
Chest drain
What are the indications for a chest drain in a pneumothorax?
Tension pneumothorax
Recurrent/persistent pneumothorax despite aspiration
Ventilated patient with pneumothorax
What is the “safe triangle” to insert a chest drain?
Line along lateral border of pectorals major,
Line along the anterior border of latissimus doors
Line horizontally to the superior level of the nipple
What are the complications with a chest drain?
Thoracic/abdominal injury
Lymphatic damage
Chylothorax
Damage to long thoracic nerve of Bell => wing scapula
When do you know to remove a chest drain?
When the drain is no longer bubbling and CXR shows re-inflation.
Give analgesia before removal - withdraw drain on expiration or Valsalva (forceful expiration on closed airway i.e. pinched nose)
What happens in a tension pneumothorax?
Air is drawn into the pleural space with each inspiration but has no route to escape during expiration due to a valve-like effect of the parietal pleura.
Mediastinum is pushed away from the pneumothorax, compressing the great veins.
Why is treating a tension pneumothorax an emergency?
!!! Removal of air is an emergency otherwise cardiorespiratory arrest will occur !!!
What are the signs and symptoms of tension pneumothorax?
Symptoms:
Acute respiratory distress
Chest pain
Respiratory arrest
Signs: Respiratory distress Tachycardia Hypotension Distended neck veins Trachea deviation Asymmetrical lung expansion Hyper-resonance on percussion Reduced air entry/breath sounds on affected side
How do you treat a tension pneumothorax?
Insert a large bore IV cannula through the 2nd intercostal space, mid-clavicular line (or less common 4-6th intercostal space in the mi-axillary line for chest drain) => air will hiss out => don’t remove cannula a tension will re-occur => insert a chest drain after aspiration
Advised to stop smoking because smoking can cause marked emphysematous changes leading to subcutaneous bullae.
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