Pneumothorax

Question 1

What are 4 risk factors for pneumothorax?

Answer 1

1. Pre-existing lung disease
2. Connective tissue disease: Marfan’s syndrome, rheumatoid arthritis
3. Ventilation, including non-invasive ventilation
4. Catamenial pneumothorax

Question 2

What are 5 pre-existing lung disease causes of pneumothorax?

Answer 2

1. COPD
2. Asthma
3. Cystic fibrosis
4. Lung cancer
5. Pneumocystis pneumonia

Question 3

What are 2 connective tissue disease causes of pneumothorax?

Answer 3

1. Marfan’s syndrome
2. Rheumatoid arthritis

Question 4

What are 2 connective tissue diseases which are risk factors for pneumothorax?

Answer 4

1. Marfan’s syndrome
2. Rheumatoid arthritis

Question 5

What is catamenial pneumothorax?

Answer 5

air leaking into th epleural space occurring in conjunction with menstrual periods and/or during ovulation, believed to be caused primary by endometriosis of the pleura

Question 6

What is thought to cause catamenial pneumothorax?

Answer 6

endometriosis within the thorax

Question 7

What are 5 symptoms of pneumothorax?

Answer 7

1. Dyspnoea
2. Chest pain: often pleuritic
3. Sweating
4. Tachypnoea
5. Tachycardia

Question 8

What are 5 signs on examination of pneumothorax?

Answer 8

1. On general inspection - tachypnoeic, respiratory distress
2. Reduced chest expansion of affected side
3. Hyper-resonant percussion note
4. Reduced or absent breath sounds on affected side, no added sounds
5. Vocal resonance/fremitus reduced on affected side

Question 9

What is the most important investigation for a pneumothorax (non-tension)?

Answer 9

CXR - helps guide treatment options

Question 10

What are the 2 broad groups that simple pneumothoraces can be grouped into that determine management?

Answer 10

primary and secondary

primary=no underlying lung disease

Question 11

What is the algorithm for primary pneumothorax management?

Answer 11

• if <2cm at level of hilum on CXR / not breathless
  
  • discharge and review in outpatient department in 2-4 weeks
• if >2cm at level of hilum on CXR / breathless:
  
  • aspirate with 16-18G (grey/green) cannula under local anaesthetic
    
    • if successful discharge
    • if unsuccessful, intercostal drain + admit

Question 12

What is the management of a primary pneumothorax if there is no breathlessness / less than 2cm at level of hilum on CXR?

Answer 12

discharge and review as outpatient in 2-4 weeks

Question 13

What is the management of a primary pneumothorax if there is breathlessness / greater than 2cm at level of hilum on CXR?

Answer 13

aspiration indicated with 16G (grey) or 18G (green) cannula in midclavicular line, 2nd intercostal space (or anterior axillary line, 4th ICS)

if successful, discharge. if not, admit and chest drain

Question 14

Why might the usual 2nd ICS mid-clavicular line be the best site of aspiration for a pneumothorax and what is the recommended alternative?

Answer 14

• in patients with obesity/ reasonable pectoral muscle mass - too much at this location to get through to thoracic cavity
• 5th ICS mid-axillary line should be second port of call/first line in some

Question 15

Where in relation to the ribs should aspiration/ drainage be performed?

Answer 15

just above the rib to avoid the neurovascular bundle

Question 16

Where should chest drains be inserted if indicated?

Answer 16

5th ICS in mid-clavicular line

within triangle of safety (axilla border, lateral border of pectoralis major, lateral border of latissimus dorsi, 5th ICS), just above rib

Question 17

In which direction should a chest drain for pneumothorax be angled?

Answer 17

upwards - air likely to be at apex of lung

Question 18

What are the borders of the triangle of safety?

Answer 18

• lateral edge of pectoralis major
• lateral edge of latissimus dorsi
• base of axilla
• 5th intercostal space

Question 19

What is the algorithm for the management of secondary pneumothoraces?

Answer 19

• <1cm / not SOB - admit and observe for 24 hours, give oxygen as required
• 1-2cm / not SOB - aspirate
  
  • if successful, admit for 24h of observation
  • if unsuccessful, intercostal drain necessary
• >2 cm or short of breath - drain
  
  • intercostal drain necessary + admit

Question 20

What is the management of a secondary pneumothorax that is <1cm on CXR at level of hilum and no shortness of breath?

Answer 20

admit and observe for 24hours

Question 21

What is the management of a secondary pneumothorax that is 1-2cm on CXR at level of hilum and no shortness of breath?

Answer 21

aspirate

if successful, admit and observe for 24h

if unsuccessful, intercostal drain

Question 22

What is the management of a secondary pneumothorax that is >2cm on CXR at level of hilum OR the patient is breathless OR the patient is >50 years?

Answer 22

admit and intercostal drain inserted

Question 23

What are 3 indications for going straight to intercostal chest drain as the management of secondary pneumothorax?

Answer 23

1. Patient short of breath
2. Size >2cm
3. Patient >50 years

Question 24

What key risk factor should patients be advised to avoid to reduce the pneumothorax risk?

Answer 24

stop smoking - lifetime risk in smoking men 10% vs 0.1% in non-smoking men

Question 25

What is the advice regarding pneumothoraces and diving?

Answer 25

patients should permanently avoid scuba diving unless the patient has undergone surgical pleurectomy, and has normal lung function and chest CT scan postoperative

Question 26

What is the usual outcome of iatrogenic pneumothorax?

Answer 26

most will resolve with observation, if treatment required aspiration should be used