Pneumothorax and Pleural Effusion

Question 1

Define pneumothorax

Answer 1

The presence of air between the visceral and parietal pleura of the lungs

Question 2

Where does the air in a pneumothorax come from?

Answer 2

The Lung (most common)

• primary to spontaneous pneumothorax
• Secondary to underlying disease/ trauma
• Iatrogenic- high pressure ventilation, central line placement

Through the chest wall (rare)

• trauma

Both the lung and through chest wall (rare)

• Trauma e.g. penetrating chest injury

Question 3

What is a primary pneumothorax?

Answer 3

Pneumothorax commonly caused by rupture of a small sub pleural bleb or bulla

Question 4

What is the usual demographic of a patient with primary pneumothorax?

Answer 4

Young, tall, thin males

No lung disesse or thoracic trauma but smoking increases risk x9

Question 5

What is secondary pneumothorax?

Answer 5

Occurs secondary to an underlying lung problem

(COPD, asthma, bronchiectasis, cancer, pulmonary infection)

Or, secondary to trauma

Question 6

What symptoms would you get from the history of someone with a simple pneumothorax?

Answer 6

• sudden onset
• pleuritc chest pain
• breathlessness
• +/- history or lung disease (if secondary)

Question 7

What signs would you find on examination of a patient with a simple pneumothorax?

Answer 7

• Chest movement reduced on affected side
• Percussion note hyper-resonant on affected side
• Breath sounds reduced/ absent on affected side
• Vocal Resonance reduced

Question 8

What features of this CXR suggest a pneumothorax?

Answer 8

• Right side is hyperlucent (darker than normal side)
• Absent lung markings on right side (beyond edge of collapsed lung)
• Edge of collapse is seen

Question 9

What can you see on this CT scan to suggest pneumthorax?

Answer 9

Dark area on the left shows air

Question 10

How do you treat a pneumothorax (small and large)

Answer 10

Small: needle aspiration

Large: insert chest drain

Question 11

Where do you place a chest drain if someone has a pneumothorax?

Answer 11

In the safe triangle

• 5th intercostal space
• midaxillary line
• Above 6th rib to avoid neurovascular bundle

Question 12

What is a tension pneumothorax?

Answer 12

Any size of pneumothorax that causes mediastinal shift and cardiovascular collapse

Question 13

Explain the pathophysiology of a tension pneumothorax

Answer 13

Occurs when air can enter the pleural cavity on inspiration but cannot escape on expiration

The flap that closes on expiration acts as a one way valve

Question 14

Why is a tension pneumothorax life threatening?

Answer 14

• Mediastinal shift compresses normal lung
• Increased intrapleural pressure is higher than atmospheric pressure
• Venous return is impaired and cardiac output drops
• Causes hypoxaemia and haemodynamic compromise

Question 15

What signs and symptoms would indicate a tension penumothorax?

Answer 15

• Severe distress and dyspnoea
• Pleuritic Chest pain
• Fatigue
• Tachycardia and Hypotension
• Raised JVP
• Deviated trachea
• Displaced Apex Beat
• Hyper-resonant percussion
• Absent breath sounds

Question 16

What features of this CXR suggest tension pneumothorax?

Answer 16

• Trachea deviated to the left
• Heart displaced to left
• Right lung is hyperlucent with absent lung markings
• Edge of collpsed lung visible

Question 17

How do you treat a tension pneumothorax?

Answer 17

Emergency needle decompression of the chest

Plastic cannula inserted into 2nd ICS, midclavicular line

Question 18

What is a pleural effusion?

Answer 18

An exess of fluid within the pleural cavity

Question 19

What is a haemothorax, chylothorax and empyema?

Answer 19

Haemothorax: fluid is blood

Chylothorax: fluid is lymph

Empyema: fluid is pus

Question 20

How does pleural effusion occur?

Answer 20

When there is an imbalance between the amount of pleural fluid and the absorption via the lymphatics

Question 21

What is the difference between a pleural effusion transudate and exudate?

Answer 21

Transudate= low protein content

Exudate= high protein content

Question 22

What are some of the common caues of Pleural effusion Transudate?

Answer 22

• Congestive Heart Failure (most common)- due to increased capillary hydrostatic pressure
• Hypoproteinaemia (reduced colloid oncotic pressure) either by nephrotic syndrome or liver failure

Question 23

What are some of the common causes of a pleural effusion exudate?

Answer 23

Anything that causes increased capillary permeability due to inflammation:

• Infection: Pneumonia/ TB
• Cancer (primary or secondary or blocks lymphatic drainage
• Pulmonary infarction due to PE

Question 24

What are the symptoms you would find in the history of someone with pleural effusion?

Answer 24

• Breathlessness (gradual onset over days)
• Chest pain (pleuritic)
• +/- causative disease (congestive heart failure/ lung malignancy)

Question 25

What signs would you find on physical examination of someone with pleural effusion?

Answer 25

• Chest movement reduced on affected side
• Percussion note sounds stony/ dull on affected side
• Breath sounds reduced/ absent on affected side
• Vocal ressonance reduced

Question 26

How do you treat pleural effusion?

Answer 26

Usually by treating the underlying cause

Theraputic drainage of large effusions may be required to relieve symptoms