Pneumothorax

Question 1

What is the difference between a primary and secondary pneumothorax?

Answer 1

A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.

Question 2

True or false: In primary pneumothorax, if the rim of air is <2 then discharge should be considered?

Answer 2

This is true if the patient is not short of breath.

If they are short of breath or the rim of air is greater than 2cm, aspiration should be attempted.

Question 3

How is primary pneumothorax managed?

Answer 3

BTS recommendations include:

• if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
• otherwise, aspiration should be attempted
• if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
• patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Question 4

According to BTS recommendations, how should secondary pneumothorax be managed?

Answer 4

• If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
• Otherwise aspiration should be attempted if the rim of air is between 1-2cm.
• If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
• if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
• regarding scuba diving, the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’

Question 5

What are BTS recommendations for the management of iatrogenic pneumothorax?

Answer 5

• less likelihood of recurrence than spontaneous pneumothorax
• majority will resolve with observation, if treatment is required then aspiration should be used
• ventilated patients need chest drains, as may some patients with COPD