Pneumothorax (PTX)

Question 1

What is a pneumothorax and what types are there?

Answer 1

A breach in the pleura leadin to air fillin the cavity and the lung collapsing on elastic recoil.

Spontaneous - Primary & secondary
Traumatic - Iatrogenic & non-iatrogenic

Any can be tension PTX, where the hole acts like a valve and air can enter but not leave so progressive worsening of symptoms, mediastinal shift and crushing of other lung/heart/trachea

Question 2

How does a primary spontaneous PTX most often occur?

Answer 2

Due to the wieght of the lung causing apical blebs which eventually burst
Mainly in young, tall, thin men

Question 3

What lung disease most often causes a secondary spontaneous PTX?

Answer 3

COPD causes 30-50% of them

Question 4

What procedures can cause an iatrogenic traumatic PTX?

Answer 4

Subclavian Vein Cannulation
Lung,Liver,Renal & breast biopsies
Pleural Aspiration or Biopsy
Acupuncture

Question 5

What causes a non-iatrogenic traumatic PTX?

Answer 5

A penetrating injury such as stab or gunshot

A blunt injury that either breaks ribs or ruptures bronchi

Question 6

What are the symptoms of a PTX?

Answer 6

If small & the persons lungs are healthy can be asymptomatic
Otherwise acute SOB & pleuritic Pain
Extreme SOB suggests a tension PTX or existing lung disease

Question 7

What are the signs of PTX?

Answer 7

Affected Side:

• Lower breath sounds & expansion
• Hyperresonance
• Trachea deviates to affected side

Tension:

• Haemodynamic compromise
• Raised JVP
• Mediastinal shift
• Trachea deviates away from affected side

Surgical Emphysema if large (bubble wrap like air tracking in subcutaneous fat)

Question 8

How do you asses a PTX?

Answer 8

Give that man a CXR

need to decide if its primary or secondary, how big, how Short of breath and if its tension.

Question 9

How do we treat a tension PTX?

Answer 9

Needle aspiration and follow with an intercostal chest drain

Question 10

How do we treat a small primary PTX, i.e. when theres no SOB?

Answer 10

Observe overnight then re CXR.
If no change then the holes sealed
Send home, no vigourous activity and re-CXR in 2 weeks
HEals super slow

Question 11

How do we treat a breathless primary PTX?

Answer 11

Needle Aspiration
If successful overnight -> re-CXR -> send home.
If fails -> Chest drain

Question 12

How do we treat a secondary PTX?

Answer 12

Can try to aspirate if small but almost always need a chest drain

Question 13

How do we do needle aspiration?

Answer 13

Put a needle then a cannula in the 2nd intercostal space in mid clavicular line.
Success -> Lung surface expands to touch cannula
Failure -> Aspirate over 3 litres (leak is persitant) -> Chest Drain

Question 14

How do we perform a Chest Drain and what do we do if its successful/fails?

Answer 14

Drain in 5th intercostal space in mid-axillary line.
Ideal:
-> Lung inflates in 1-2 days & drain stops bubbling.
-> Confirm on a CXR
-> Clamp for 24 hours, Re-CXR, Send home

Non-Ideal:

• > Fails to ifnlate >48hrs
• > Apply suction for 24 hours
• > Call thoracic surgeon for thorascopic inspection
• > Clip any blebs or tears and maybe talc poudrage pleurodhesis

Question 15

In what cicumstance would we perform surgical or talc poudrage pleurodhesis in order to prevent future PTX?

Answer 15

If:

• Second ipsilateral PTX
• First Contraleral PTX
• First PTX in high risk job (diver, pilot etc)
• Bilateral Spontaneous PTX

Question 16

What surgical techniques are there for PTX?

Answer 16

• Surgical or Talc Poudrage pleurodhesis

- Pleurectomy