Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

When air gains access to, and accumulates in, the pleural space.

Question 2

What is the aetiology of primary spontaneous pneumothorax?

Answer 2

Without preceding trauma/precipitating event, develops in person without significant lung disease. Risk factors: smoking, FHx, Marfan’s, young thin men.

Question 3

What is the aetiology of secondary spontaneous pneumothorax?

Answer 3

Occurs as a complication of an underlying pulmonary disease (COPD most common). Severity of lung pathology increases the risk.

Question 4

What is the aetiology of a tension pneumothorax?

Answer 4

Can complicate primary and secondary. Medical emergency with mediastinal shift and respiratory failure.

Question 5

What is this a presentation of?
Sudden onset dyspnoea, pleuritic chest pain, sudden deterioration in asthma/COPD. Reduced expansion, hyperresonant, diminished breath sounds, decreased vocal fremitus.

Answer 5

Pneumothorax

Question 6

How is a suspected pneumothorax investigated?

Answer 6

1. Clinical diagnosis
2. Incidental finding on CXR - measure rim of air between lung margin and chest wall at the level of hilum.
3. ABG - for those who are hypoxic or with chronic lung disease.

Question 7

What is the management of a pneumothorax?

Answer 7

1. Conservative if small - O2 therapy until it resolves
2. Primary - if >2cm aspirate with 16-18G cannula, if <2cm discharge and follow-up.
3. Secondary - if >2cm chest drain 8-14Fr, if 1-2cm aspirate as above, if <1cm admit with high flow O2 and observe.

Question 8

Where is a chest drain inserted for a pneumothorax?

Answer 8

Square area with 4 borders:

1. Lateral pectoralis major
2. Base of axilla
3. Anterior latissimus dorsi
4. 5th intercostal space

Question 9

Where is an aspirate carried out in a pneumothorax?

Answer 9

2nd intercostal space, midclavicular line (or 5th, mid-axillary line). Can aspirate up to 2.5L.

Question 10

What should you do after treating a pneumothorax and what advice should you give for preventing recurrence?

Answer 10

1. CXR to confirm resolution, avoid air travel for 1 week, permanently avoid diving.
2. Stop smoking to reduce recurrence.

Question 11

What are the indications for surgical management of pneumothorax?

Answer 11

1. Bilateral pneumothoraces
2. Lungs fail to expand within 48hrs of intercostal drain insertion.
3. 2 or more previous pneumothoraces on same side.
4. Hx of pneumothorax on contralateral side.