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Year 3 > Pneumothorax (RESP) > Flashcards

Pneumothorax (RESP) Flashcards

1
Q

Define pneumothorax.

A

Collection of air within the pleural space between the lung (visceral pleura) and chest wall (parietal pleura)

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2
Q

What are the different types of pneumothorax? (4)

A
  • primary spontaneous - in patients without underlying lung disease, in the absence of trauma or medical intervention
  • secondary spontaneous - complication of underlying lung disease (e.g. COPD, asthma, TB)
  • traumatic - caused by penetrating injury to chest (e.g. stabbing, gunshot)
  • tension - medical emergency requiring immediate decompression
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3
Q

Who do primary spontaneous pneumothoraxes typically affect?

A

Tall, thin males

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4
Q

What is a primary spontaneous pneumothorax caused by?

A

Rupture of a sub-pleural bleb (bulla)

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5
Q

What is important about tension pneumothorax?

A
  • life-threatening variant, complication of one of the other types (primary/secondary spontaneous, traumatic)
  • one-way valve, air can enter pleural space but cannot leave hence shifts trachea and can press on heart
  • usually due to trauma
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6
Q

What are the signs of tensioning in pneumothorax? (2)

A
  • tracheal deviation away from pneumothorax
  • sudden hypoxia and increased ventilation
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7
Q

How does tension pneumothorax cause hypotension?

A

Mediastinal shift –> cardiac outflow obstruction –> hypotension

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8
Q

How can tension pneumothorax cause death?

A

Severe hypotension

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9
Q

When should you suspect tension pneumothorax in a hospital setting?

A

Sudden deterioration following intubation

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10
Q

Describe the epidemiology of primary spontaneous pneumothorax. (2)

A
  • M>F (tall, thin males)
  • 16-25 year olds
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11
Q

What are the clinical features of pneumothorax? (3)

A
  • sudden, severe, pleuritic chest pain
  • dyspnoea/breathlessness (sudden)
  • rapid shallow breathing
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12
Q

How might a tension pneumothorax present differently to another pneumothorax?

A
  • general: dyspnoea and chest pain
  • tension pneumothorax: respiratory distress, rapid laboured respirations, cyanosis, excessive diaphoresis (sweating), tachycardia, hypotension
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13
Q

What might you see on examination in pneumothorax? (4 + 2)

A
  • unilateral reduced chest expansion
  • unilateral reduced breath sounds
  • hyper-resonant percussion
  • ipsilateral reduced tactile vocal fremitus

Tension pneumothorax:

  • tracheal deviation AWAY from pneumothorax
  • haemodynamic instability - tachycardia, hypotension, tachypnoea, cyanosis
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14
Q

What are some risk factors for pneumothorax? (10)

A
  • smoking
  • tall & slender body
  • male sex
  • <40 years
  • Fx
  • pre-existing lung disease (e.g. COPD, asthma, TB) –> secondary pneumothorax
  • recent invasive medical procedure (chest drain)
  • chest trauma (rib can puncture lung)
  • collagen disorders - Marfan’s syndrome, EDS
  • cystic fibrosis
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15
Q

What is the first-line investigation for pneumothorax?

A

Chest x-ray (order an erect PA CXR in inspiration)

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16
Q

What would you see on CXR in pneumothorax? (3)

A
  • absent lung markings
  • collapsed lung - visible rim between lung margin and chest wall
  • visible pleura
17
Q

What investigation is used for patients with pneumothorax who are immobilised following trauma?

A

Chest ultrasound - requires specialist expertise

18
Q

When is CT thorax used in pneumothorax?

A

To identify small pneumothoraces missed by CXR

19
Q

What might you see on ABG in pneumothorax?

A

Respiratory alkalosis secondary to hyperventilation (low PaCO2 and PaO2 - done if O2 sats are low)

20
Q

What are some differential diagnoses for pneumothorax? (9)

A
  • asthma exacerbation
  • COPD exacerbation
  • pulmonary embolism
  • myocardial ischaemia
  • pleural effusion
  • bronchopleural fistula
  • fibrosing lung disease
  • oesophageal perforation
  • giant bullae
21
Q

What is the clinical difference between a small and large pneumothorax?

A
  • small: a visible rim of </=2cm between the lung margin and chest wall at the level of the hilum on PA CXR
  • large: a visible rim of >2cm between the lung margin and chest wall at the level of the hilum on PA CXR
22
Q

How do we manage a primary pneumothorax without SOB and <2cm?

A

Discharge and review as outpatient in 2-4 weeks

23
Q

How do we manage a primary pneumothorax with SOB or >2cm?

A

Aspiration (16-18G cannula, aspirate <2.5L)

If unsuccessful –> chest drain

24
Q

How do we manage a secondary pneumothorax without SOB and <1cm?

A
  • admit for 24h and observe
  • high flow oxygen
25
Q

How do we manage a secondary pneumothorax without SOB and 1-2cm?

A

Aspiration (16-18G, <2.5L)

If unsuccessful –> chest drain

26
Q

How do we manage a secondary pneumothorax with SOB or >2cm?

A

Chest drain

27
Q

Where do we do a chest drain in pneumothorax?

A

Safety triangle: (avoids long thoracic artery and nerve)

  • 5th ICS
  • latissimus dorsi
  • pectoralis major
  • base of axilla
28
Q

What complication may occur after chest drain in pneumothorax?

A

Re-expansion pulmonary oedema

29
Q

Where do we aspirate in pneumothorax?

A

Large bore cannula (16-18G) into 2nd ICS MCL - up to 2.5L air can be aspirated, stop if patient coughs/resistance felt, follow-up CXR in 2h and 2 weeks

30
Q

How do we manage a tension pneumothorax?

A

Immediate needle decompression on ipsilateral side - insert large-bore cannula (14-16G) into 2nd ICS MCL

Insert a chest drain immediately after decompression

Do not wait for imaging if tension pneumothorax suspected

31
Q

How do we manage recurrent pneumothorax? (2)

A
  • chemical pleurodesis (fusing of visceral and parietal pleura with tetracycline)
  • surgical pleurectomy / video-assisted thoracoscopy (VATS) / thoracostomy
32
Q

What advice do we give to patients to prevent recurrent pneumothoraces? (3)

A
  • avoid air travel until follow-up CXR confirms pneumothorax has resolved
  • avoid diving
  • smoking cessation advice
33
Q

What are some complications of pneumothorax? (5)

A
  • respiratory failure
  • cardiac failure - tension pneumothorax is a cause of pulseless electrical activity
  • recurrent pneumothoraces (>20%)
  • bronchopleural fistula
  • chest drain –> re-expansion pulmonary oedema (fluffy shadowing on CXR)
34
Q

Describe the prognosis of pneumothorax.

A

Recurrence rate 30-50% in primary spontaneous pneumothorax, higher rate for secondary

Year 3 (80 decks)

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