Respiratory: Pneumothorax Flashcards
Describe the differing types of pneumothorax [4]
Spontaneous:
- Primary: ‘normal lungs’
- Secondary: ‘Pre-existing lung disease
Non-spontaneous:
- Traumatic
- Iatrogenic
What are the most common causes of iatrogenic pneumothorax? [2]
- Pleural aspiration / chest drain insertion for pleural fluid
- Central venous line insertions
State risk factors for primary pneumothorax [5]
Fit, young people
Tall, thin men
Male sex
Smoking cigarettes and cannabis
Fx
Chest trauma
State causes of secondary pneumothorax:
-Obstructive airway disease [2]
- Infections [2]
- Suppurative lung disease [3]
- Interstitital lung disease [4]
- Genetic [3]
- Other
Obstructive airway disease:
- COPD
- Asthma
Lung and pleural malignancies
Infection:
- TB
- Pneumonia
Suppurative lung disease:
- Cystic fibrosis
- Bronchiectasis
- Lung abscess
Interstitial lung disease:
- Sarcoidosis
- IPF
- Hypersensitivty pneumonitis
- Pneumoconiosis (any lung disease caused by the inhalation of organic or nonorganic airborne dust and fibers)
Genetic:
- CF
- Marfans
- Birt-Hogg-Dube syndrome
Despite the fact that primary pneumothorax is thought to occur in healthy lungs, there are thought to be predisposing factors that contribute to this pathology. Explain what these are [1]
Air bulla (bubbles on surface of pleura) that weaken the visceral pleura and burst
Uncertain why this happens - possibly due to inflammation
What is the clinical significance of primary vs secondary pneumothorax? [1]
Secondary has higher mortality
Describe the clinical features of both primary and secondary pneumothorax [6]
They’re the same
- Acute onset
- Pleuritic chest pain
- SOB
- Cough (late sign)
- Dysopnea (more common in secondary spontaneous
- Ipsilateral reduced breath sounds
- Hypoxia (late sign)
State 3 respiratory and 5 cardiac differential diagnosis
Respiratory:
- PE
- Pneumonia
- Acute exacerbation of respiratory disease
CV:
- MI / ACS
- Pericarditis
- AAA or aortic dissection
- Cardiac tamponade
Describe the clinical signs of pneumothorax [3]
What further signs would indicate that the pneumothorax is severe? [4]
Initial:
* Reduced chest expansion on side of pneumothorax
* Hyper resonant percussion
* Quiet breath sounds
Severe:
* Tachycardia
* hypoxia
* tachypnea
* hypotension
What are the key investigations of pneumothorax? [4]
- PA CXR
- ChestCT (if CXR inconclusive)
- ECG
- Bloods
- Point-of-care ultrasound (POCUS) - useful bedside diagnosis
What does this CXR inidacate? [1]
Giant bulla (not a pneumothorax!)
What are you trying to ID on a CXR to determine if have a pneumothorax? [2]
What is the difference between small and large pneumothorax? [2]
CXR findings:
* No peripheral lung markings
* Visceral pleural line
Size: measure at level of hilum the distance between lung margin and cest wall:
- Small : < 2cm
- Large: > 2cm
What do you need to spefically look at on a blood test prior to treating a pneumothorax with a chest drain? [1]
Correct clotting abnormalities (INR ≥1.5 or platelets ≤50 x 10⁹/L) before inserting a chest drain in patients who are not critically unwell
What is the most common finding of an ABG of pneumothorax patient? [1]
respiratory alkalosis is the most common finding
Describe the general management plan for pneumothoraxes [5]
15 L oxygen
Medical:
- Pleural aspiration
- Chest drain
Surgical
- Open thoracotomy
- Video assisted thoracic surgery (VATS)
Describe the mangement plan for a primary pneumothorax if the patient has no shortness of breath and less than a 2cm rim of air on the chest x-ray [2]
- No treatment is required as it will spontaneously resolve
- Follow-up in 2 – 4 weeks is recommended
Describe the mangement plan for a primary pneumothorax if the patient has shortness of breath or more than a 2cm rim of air on the chest x-ray: [2]
Be specific
Aspiration with 16-18G cannula; aspirate < 2.5L followed by reassessment
When aspiration fails twice, a chest drain is required
Describe the mangement plan for a primary pneumothorax if the patient has bilateral pneumothorax or is haemodynamically unstable [1]
Chest drain
Describe the location of chest drain procedure [4]
Chest drains are inserted in the “triangle of safety”. This triangle is formed by the:
- 5th intercostal space (or the inferior nipple line)
- Midaxillary line (or the lateral edge of the latissimus dorsi)
- Anterior axillary line (or the lateral edge of the pectoralis major)
The needle is inserted just ABOVE the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted, obtain a chest x-ray to check the positioning.
What should you do to check positioning of chest drain? [1]
Once the chest drain is inserted, obtain a chest x-ray to check the positioning.
Desribe the mechanism of a chest drain treating pneumothorax
The external end of the drain is placed underwater: creating a seal and one way valve to prevent air from flowing back through the drain into the chest.
Air can exit the chest cavity and bubble through the water
But the water prevents air from re-entering the drain and chest.
During normal respiration, the water in the drain will rise and fall due to changes in pressure in the chest (described as “swinging”).
How do you know if a chest drain has been successful in its treatment? [1]
During the procedure:
- When the chest drain successfully treats the pneumothorax, air will bubble through the fluid in the drain bottle
- There will be swinging of the water with respiration.
After the procedure:
- Once the pneumothorax resolves, there should be no further bubbling in the drain bottle. The swinging of the water with respiration will also reduce.
Name three causes of chest drain not working properly [3]
Blocked or kinked tube
Incorrect position in the chest
Not correctly connected to the bottle
Describe two complications of a chest drain
Air leaks around the drain site (indicated by persistent bubbling of fluid, particularly on coughing)
Surgical emphysema (also known as subcutaneous emphysema) is when air collects in the subcutaneous tissue
Label A-C of treatment of primary pneumothorax
What size cannula do you use to manage a primary pneumothorax with rim > 2 cm and / or breathless? [2]
16-18G
State [1] and explain [2] how much air you can aspirate during the managment of a primary pneumothorax with rim > 2 cm and / or breathless?
< 2.5L:
- reduces the risk of re-expansion pulmonary oedema;
- if needs more than 2.5L needs a chest drain anyway
Describe the mangement plan for a secondary pneumothorax if the patient has shortness of breath and 1-2cm rim of air on the chest x-ray [2]
Aspiration with 16-18G cannula; aspirate < 2.5L followed by reassessment
When aspiration fails twice, a chest drain is required
Describe the mangement plan for a secondary pneumothorax if the patient has shortness of breath and / or > 2cm rim of air on the chest x-ray [1]
Chest drain and admit
Describe the mangement plan for a secondary pneumothorax if the patient has no shortness of breath and < 1-2cm rim of air on the chest x-ray [2]
Admit
High flow O2 (15 L)
Observe for 24 hrs (important difference between primary pneumothorax!)
Label A-C for secondary pneumothorax
Label A-D of triangle of safety [4]
A: lateral edge of pec major
B: Base of axilla
C: 5th intercostal space
D: Lateral edge of latissimus dorsi
What would a non-swinging chest drain indicate? [2]
Chest tube blocked
Tube fallen out
How long do most pneumothoraces resolve with a chest drain? [1]
What would you call it if after two days there was no resolution? [1]
Should resolve in 2-3 days
If not: called a persistent air leak - call the thoracic surgeons
Describe the procedure of a surgical pleurodesis [1]
creating an inflammatory reaction in the pleural lining so the pleura sticks together and the pleural space becomes sealed. This prevents further pneumothoraces from developing.
Surgically apply talc between the pleural linings of the lungs
How do you manage secondary pneumothorax persistent leak? [1]
Risk of surgery is greater: need to consider risk benefit:
- medical pleurodesis: put talc through chest drain (not as effective as surgical pleurodesis & painful)
- Abrasive / surgical pleurodesis (using direct physical irritation of the pleura)
- Open thoracotomy
Describe the signs of tension pneumothorax [4]
- Tracheal deviation away from the side of the pneumothorax
- Reduced air entry on the affected side
- Increased resonance to percussion on the affected side
- Tachycardia
- Hypotension
- Distended jugular veins
Describe the pathophysiology of tension pneumothorax [3]
The pleural injury acts as a one-way valve.
As a result, the air can enter the pleural space during inspiration, but is unable to escape during expiration.
Reduces venous return and stops you breathing
Can lead to cardiac arrest
Describe treatment for tension pneumothorax [1]
Insert a large bore cannula into the second intercostal space in the midclavicular line
If a tension pneumothorax is suspected, do not wait for any investigations. A chest drain is required for definitive management once the pressure is relieved with a cannula.
Describe the lifestyle advice you would give to someone after a pneumothorax [4]
Avoid smoking
Fitness to fly: leave 2-6 weeks
Scuba diving
the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
Monitor pregnant populations closely
What is crucial to remember with a chest drain? [1]
Never clamp a bubbling chest drain
Describe what is meant by swinging and bubbling in a chest drain [2]
If a chest drain is inserted, look out for:
Swinging:
- the fluid in the chest drain tubing moves towards the patient during inspiration (due to reduced intrathoracic pressure during inspiration when the diaphragm descends).
Bubbling:
- the fluid in the chest drain bottle bubbles when the pneumothorax is initially drained (this should stop eventually). The persistence of bubbling for >48 hours may indicate an air leak, which is a connection between the bronchial tree and pleural space (also known as a bronchopleural fistula).21 This may need to be discussed with a thoracic surgeon.
Describe the position of the CXR needed for investigating a pneumothorax? [1]
An erect chest x-ray PA is the investigation of choice for diagnosing a simple pneumothorax.
Which drug is contraindicated in pneumothorax? [1]
Nitrous oxide
Why is nitrous oxide contraindicated in pneumothorax? [1]
May diffuse into gas-filled body compartments → increase in pressure.
Other than findings on respiratory examination, which observation makes the diagnosis of tension pneumothorax more likely than simple pneumothorax?
Blood pressure
Oxygen saturations
Pain score
Respiratory rate
Temperature
Blood pressure
Hypotension will occur in tension pneumothoraces as a result of cardiac outflow obstruction
A 26-year-old male is admitted to the Emergency Department due to sudden onset dyspnoea and pleuritic chest pain. On examination:
Investigation Result Normal value
Respiratory rate (RR) 24 breaths/min 12–18 breaths/min
Sats 96% on air 94–98%
Blood pressure 120/81 mmHg < 120/80 mmHg
Heart rate (HR) 90 beats/min 60–100 beats/min
Chest clear, some reduced air-entry on right upper zone. His chest X-ray shows a 1-cm pneumothorax on the apex of the right lung.
Which is the next most appropriate treatment for this patient?
Oxygen
Admit the patient for observation
Discharge the patient home
Aspiration
Chest drain
Admit the patient for observation
This young patient with primary pneumothorax requires careful management. According to BTS guidelines, discharge may be considered if the air rim is < 2 cm and the patient is not breathless. For breathless patients, aspiration is attempted. If unsuccessful (> 2 cm or persistent breathlessness), a chest drain is inserted. Close monitoring and reassessment are necessary to prevent complications and ensure prompt intervention.
What are the two criteria need to have when deciding if primary spontaneous pneumothorax can be discharged? [2]
< 2 cm from rim
AND
Not SOB
Explain the character
You are a junior doctor on A+E and your patient has become acutely short of breath. On examination, you become convinced that this patient has a left tension pneumothorax.
Which clinical signs would best support this diagnosis?
Left hyper-resonance, left trachial deviation, absent JVP
Left hyper-resonance, left trachial deviation, raised JVP
Left hyper-resonance, right trachial deviation, raised JVP
Left hypo-resonance, left trachial deviation, absent JVP
Left hyper-resonance, right trachial deviation, absent JVP
You are a junior doctor on A+E and your patient has become acutely short of breath. On examination, you become convinced that this patient has a left tension pneumothorax.
Which clinical signs would best support this diagnosis?
Left hyper-resonance, right trachial deviation, raised JVP
Which conditions would you not perform a needle aspiration and go straight to a chest drain to manage a pneumothorax? [6]
- Haemodynamic compromise (suggesting a tension pneumothorax)
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- ≥ 50 years of age with significant smoking history
- Haemothorax
If a patient has persistent pneumothoraces, how do you treat them? [1]
If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
How long should you get a primary spontaneous pneumothorax patient to come to outpatients after letting them go? [1]
How long should you get a secondary spontaneous pneumothorax patient to come to outpatients after letting them go? [1]
Primary spontaneous pneumothorax that is managed conservatively should be reviewed:
- every 2-4 days as an outpatient
Secondary spontaneous pneumothorax:
- follow-up in the outpatients department in 2-4 weeks
