Pneumothorax workbook and lecture

Question 1

Types of pneumothorax (4)

Answer 1

• Spontaneous –> primary or secondary
• Traumatic
• Tension - emergency
• Iatrogenic - eg post central line, pacemaker insertion

Question 2

RF or pneumothorax

Answer 2

• Pre-existing lung disease
• Height
• Smoking/cannabis
• Diving
• Trauma/chest procedure
• Association with other conditions eg Marfan’s syndrome, Ehlers Danlos

Question 3

Management of PRIMARY pneumothorax

Answer 3

• If no symptoms and <2cm - consider discharge and f/u CXR
• If symptomatic or rim of air >2cm on CXR –> aspirate and give O2
• If unsuccessful –> chest drain or re-aspirate
• If successful and <2cm and breathing good –> discharge
• Remove drain after full re-expansion / cessation of air leak

Question 4

Management of SECONDARY pneumothorax

Answer 4

• If breathless and >2cm air rim –> chest drain
• If 1-2cm and no breathlessness aspirate, if unscuccessful to <1cm –> chest drain
• If <1cm - admit, high flow O2, observe 24hrs

Question 5

Aspiration equiptment and amount

Answer 5

• 16-18G cannula
• Aspirate <2.5L of air

Question 6

Management of persistent pneumothorax >5 days

Answer 6

Could be bronchopleural fistula –> refer to thoracic surgeons for VATs (video assisted thoracoscopic surgery)

Question 7

Discharge advice for pneumothorax

Answer 7

• No flying - can fly 2 weeks after drainage if no residual air shown on CXR
• Avoid scuba diving permanently unless bilateral pleurectomy and normal lung function and CT scan post op

Question 8

Management tension pneumothorax

Answer 8

• Large bore IV cannula into 2nd ICS mid clavicular line
• Chest drain into affected side

Question 8

Tension pneumothorax presentation - signs

Answer 8

• Hypotension
• Tachycardia
• Deviation of trachea away from side of pneumothorax
• Mediastinal shift away from pneumothroax

Question 9

Presentation of pneumothroax - signs

Answer 9

• 20s
• Decreased breath sounds
• Shallow breathes
• Hyperresonance to percussion

Question 10

CXR sign of pneumothroax

Answer 10

Visceral pleural line come away from ribs
Blackness around this

Question 11

What is done before all procedures of lungs now?

Answer 11

USS - assess layers and fluid etc

Question 12

What is present on USS when pneumothorax present?

Answer 12

Barcode sign

Question 13

Investigations for pneumothorax

Answer 13

• CXR
• FBC, CRP, U&Es, Troponins, D-dimer, Clotting
• Sputum sample - culture

Question 14

How to measure size of pneumothroax

Answer 14

Level if hilum
Distance from ribs to visceral pleural line

Question 15

Other option to aspiration using syringe

Answer 15

Pleural vent - one way valve allowing air out but not in
Keep valve in and monitor with CXR every 48hrs

Question 16

Procedures to prevent recurrence of pneumothroax

Answer 16

• Pleurectomy using VATs - remove layers of pleura and also therapeutic as remove bullae
• Chemical pleurodesis using talc, bleomycin etc -causes inflammation and then adhesion

Question 17

New pneumothorax management 2023 BTS guidelines

Answer 17

• Safe size is 2cm or more apically or laterally OR any size on CT
• Resolution is improved symptoms and sustained improvement on CXR
• If reviewing conservative and pleurovent and enlarging or worse symptoms, consider chest drain