Pneumothorax - Simple Pneumothorax

Question 1

What is a Pneumothorax?

Answer 1

When air gets into the pleural space (that separates the lung from the chest wall).

Question 2

Risk Factors of Pneumothorax (4).

Answer 2

1. Connective Tissue Disease.
2. Pre-Existing Lung Disease.
3. Ventilation e.g. NIV.
4. Catamenial - Endometriosis in Thorax.

Question 3

Aetiology of Pneumothorax (2).

Answer 3

1. Primary - Spontaneous.

2. Secondary - Trauma, Iatrogenic, Lung Pathology.

Question 4

Give 3 Iatrogenic Causes of Pneumothorax.

Answer 4

1. Lung Biopsy.
2. Mechanical Ventilation.
3. Central Line Insertion.

Question 5

Give 3 Lung Pathology Causes of Pneumothorax.

Answer 5

1. Infection.
2. Asthma.
3. COPD.

Question 6

What may be the pathophysiology of a primary pneumothorax?

Answer 6

Alveoli in the apex of the lung are subjected to greater mean distending pressures, leading to the development of sub-pleural blebs.

Question 7

Stereotypical Patient in Pneumothorax.

Answer 7

Young thin tall man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports.

Question 8

Clinical Features of Pneumothorax (3).

Answer 8

1. Dyspnoea.
2. Pleuritic Chest Pain.
3. Sudden Tachycardia, Tachypnoea and Sweating.

Question 9

Examination Findings of Pneumothorax (3).

Answer 9

1. Reduced Expansion of Affected Side.
2. Percussion : Hyper-Resonance of Affected Side.
3. Auscultation : Reduced/Absent Breathing Sounds + Vocal Resonance of Affected Side.

Question 10

Investigations of a Pneumothorax (2).

Answer 10

1. Erect CXR - area with no lung markings + measure size (horizontally from lung edge to inside of chest wall).
2. CT Thorax - Small Pneumothorax.

Question 11

Management of Primary Pneumothorax (4).

Answer 11

BTS 2010 Guidelines :

1. No SOB + < 2cm rim = No Treatment (Spontaneous Resolution) + Follow-Up in 2-4 Weeks.
2. SOB +/- >2cm rim = Aspiration using 16-18G Cannula under LA and Reassessment.
3. Aspiration Fails 2x = Chest Drain.
4. Unstable, Bilateral, Secondary = Chest Drain.

Question 12

Management of Secondary Pneumothorax (3).

Answer 12

BTS 2010 Guidelines :

1. Age > 50 + Rim > 2cm or SOB = Chest Drain.
2. 1cm < Rim < 2cm + No SOB = Aspiration + Admission for 24 hours.
3. Rim < 1cm + No SOB : Oxygen + Admit for 24 hours.

Question 13

Chest Drain Insertion (3).

Answer 13

1. Insert into Triangle of Safety (5th Intercostal Space + Mid Axillary Line + Anterior Axillary Line) + use US and Local Anaesthetic using Sledinger Technique.
2. Above Rib to avoid Neurovascular Bundle - position patient supine or 45 Degrees.
3. Use CXR to check positioning + secure tubing using straight ditch or adhesive dressing.

Question 14

Chest Drain Results (5).

Answer 14

1. External End of Drain is placed underwater to create a seal to prevent air from flowing back through the drain into the chest.
2. Air exits chest and bubbles through water and water prevents re-entry of air.
3. Normal - Swinging (Water rises and falls due to pressure in chest).
4. Repeat CXR - Re-inflation of lung.
5. No Bubbling after Resolution.

Question 15

Why may a Chest Drain not succeed? (3)

Answer 15

1. Blocked/Kinked Tube.
2. Incorrect positioning.
3. Not properly connected.

Question 16

Complications of Chest Drains (3).

Answer 16

1. Air Leaks around Drain Site (persistent bubbling of fluid, especially when coughing).
2. Surgical/Subcutaneous Emphysema (air collects in subcutaneous tissue).
3. Re-Expansion Pulmonary Oedema (Clamp Drain (never clump if bubbling) if output exceeds 1L in less than 6 hours + Urgent CXR)

Question 17

Contraindications of Chest Drain (4).

Answer 17

1. INR > 1.33.
2. Platelet Count < 75.
3. Pulmonary Bullae.
4. Pleural Adhesions.

Question 18

Indications of Chest Drain (3).

Answer 18

1. Pleural Effusion.
2. Pneumothorax, Haemothorax, Haemopneumothorax, Chylothorax.
3. Empyema.

Question 19

Removal of Chest Drain (2).

Answer 19

1. Fluid Drainage : No Output for > 24 Hours and Imaging shows Resolution.
2. Pneumothorax : No Longer Bubbling

Question 20

Indications of Surgical Management in Pneumothorax (3).

Answer 20

1. Chest Drain Fails (Bubbling still 5 days later).
2. Persistent Air Leak in Drain (call respiratory team).
3. Recurrent Pneumothorax.
4. Multiple/Bilateral.

Question 21

Surgical Management of Pneumothorax (4).

Answer 21

1. VATS (Video-Assisted Thoracoscopic Surgery).
2. Abrasive Pleurodesis (Direct Physical Irritation of Pleura).
3. Chemical Pleurodesis (Chemical Irritation using Talc Powder).
4. Pleurectomy (Removal of Pleura).

Question 22

What is Pleurodesis?

Answer 22

Create an inflammatory reaction in the pleural lining so that the pleurae stick together and pleural space becomes sealed.

Question 23

Lifestyle Advice after Pneumothorax (3).

Answer 23

1. Avoid Smoking.
2. BTS - Travel by air after 1 week post CXR.
3. Scuba Diving (Permanently Avoid).