Pneumothorax

Question 1

How does tension pneumothorax arise?

Answer 1

May occur following thoracic trauma when a lung parenchymal flap is created.
This acts as a one way valve and allows pressure to rise in the affected side.
The trachea shifts away from affected side and hyper-resonance is apparent on the affected side.

Question 2

How is tension pneumothorax treated?

Answer 2

wide bore cannula into the second intercostal space, mid-clavicular line to decompress the tension pneumothorax, leading to the formation of a ‘regular’ pneumothorax

Question 3

What are the signs and symptoms of tension pneumothorax?

Answer 3

hyper-resonance to percussion and absent breath sounds on the affected side
trachea is deviated (away from the pneumothorax)
life-threatening respiratory distress and shock

Question 4

What are the risk factors for developing Pneumothorax?

Answer 4

pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
connective tissue disease: Marfan’s syndrome, rheumatoid arthritis
ventilation, including non-invasive ventilation

Question 5

What is catamenial pneumothorax?

Answer 5

3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax

Question 6

What are the features of pneumothorax?

Answer 6

dyspnoea
chest pain: often pleuritic
sweating
tachypnoea
tachycardia

Question 7

How should you manage a primary pneumothorax?

Answer 7

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

Question 8

How should you manage a secondary pneumothorax?

Answer 8

if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours

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.

Question 9

What should you do if aspiration fails in secondary pneumothorax?

Answer 9

If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted.

Question 10

All patients with secondary pneumothorax should be admitted for at least 24 hours

Answer 10

true

Question 11

Iatrogenic pneumothorax has less likelihood of recurrence than spontaneous pneumothorax

Answer 11

true

Question 12

How to manage iatrogenic pneumothorax?

Answer 12

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

Question 13

What is the triangle of safety for inserting a chest drain?

Answer 13

The 5th intercostal space (or the inferior nipple line)
The mid axillary line (or the lateral edge of the latissimus dorsi)
The anterior axillary line (or the lateral edge of the pectoris major)
The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted obtain a chest xray to check the positioning.

Question 14

What is the investigation of choice for a simple pneumothorax?

Answer 14

Erect CXR