Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

Air within the pleural space (collapsed lung)

Question 2

What are the causes of a pneumothorax divided into?

Answer 2

Spontaneous

Traumatic

Question 3

What are the spontaneous causes of a pneumothorax divided into?

Answer 3

Primary

Secondary

Question 4

What is a primary pneumothorax due to?

Answer 4

No underlying pathology

Question 5

What is a secondary pneumothorax due to?

Answer 5

Underlying pathology

Question 6

What are the traumatic causes divided into?

Answer 6

Iatrogenic

Non-iatrogenic

Question 7

What do the iatrogenic causes include?

Answer 7

Insertion of a central line
Positive pressure ventilation
Lung biopsy

Question 8

What are the non-iatrogenic causes?

Answer 8

Penetrating trauma

Blunt trauma with rib fracture

Question 9

What are the main presentations of a pneumothorax?

Answer 9

Sudden onset of:
Shortness of breath (dyspnoea)
Chest pain on inspiration

Question 10

What other symptoms of a pneumothorax?

Answer 10

Sweating
tachycardia
tachypnoea

Question 11

What clinical signs would you expect on the affected side?

Answer 11

Reduced chest expansion
Hyper-resonant percussion
Reduced or absent breath sounds
Reduced vocal resonance

Question 12

What additional signs would you expect with a tension pneumothorax?

Answer 12

Tracheal deviation to the contralateral side

Signs of haemodynamic compromise

Question 13

What is the main investigation for a pneumothorax?

Answer 13

Chest x-ray

Erect chest x-ray

Question 14

What is the management of a primary pneumothorax if the patient is not short of breath and the pneumothorax is less than 2cm on chest x-ray?

Answer 14

Conservative management

Patient is discharged and seen at outpatient in 2-4 weeks

Question 15

What is the management of a primary pneumothorax if the patient is short of breath or the pneumothorax is more than 2cm on chest x-ray?

Answer 15

Aspirate under local anaesthetic
If successful-discharge patient

If unsuccessful after 2 attempts - intercostal chest drain

Question 16

What would you do if the aspiration failed to resolve the pneumothorax?

Answer 16

Intercostal drain

Question 17

What is the management of a secondary pneumothorax if the patient is NOT short of breath AND the pneumothorax is <1 cm on the chest x-ray

Answer 17

No further invasive intervention
Admit for observation for 24 hours
Administer oxygen as required.

Question 18

What is the management of a secondary pneumothorax if the patient is NOT short of breath and the pneumothorax is 1-2 cm on the chest x-ray

Answer 18

Aspiration is required
If successful- Patient can be admitted for 24 hours of observation
Unsuccessful- intercostal drain

Question 19

What is the management of a secondary pneumothorax if the patient is short of breath and the pneumothorax is >2 cm on the chest x-ray?

Answer 19

An intercostal drain is necessary (and the patient should be admitted).

Question 20

What is the management for a tension pneumothorax?

Answer 20

High flow oxygen (15 L/min)

Immediate needle decompression- inserted at the second intercostal space, mid-clavicular line, on the affected side.

Question 21

Where should the needle be inserted in the management of a tension pneumothorax?

Answer 21

Needle should be inserted just above the third rib, to avoid damaging the neurovascular bundle

Question 22

What is done after insertion of the needle in the management of a tension pneumothorax?

Answer 22

The needle decompression acts as a bridge before insertion of an intercostal chest drain.

Question 23

What are the possible underlying pathological causes of a pneumothorax?

Answer 23

Marfan’s syndrome
Asthma
COPD
Pneumonia
CF

Question 24

What is classed as the triangle of safety for the insertion of a chest drain?

Answer 24

Base of axilla, lateral pectoralis major, 5th intercostal space, anterior latissimus dorsi

Question 25

What are risk factors for a spontaneous primary pneumothorax?

Answer 25

Tall, thin, male smoker

Question 26

What are risk factors for a spontaneous secondary pneumothorax?

Answer 26

COPD
Asthma
Marfan’s

Question 27

What are risk factors for traumatic pneumothorax?

Answer 27

Recent chest trauma,
Recent invasive medical procedure

Question 28

Who is usually affected by a spontaneous primary pneumothorax?

Answer 28

Tall, young, thin, men who smoke

Question 29

What is usually present in most cases of spontaneous primary pneumothorax?

Answer 29

Subpleural blebs and bullae

Question 30

What is a tension pneumothorax due to?

Answer 30

Air leaks into pleural space during inspiration, can’t escape during expiration

Question 31

What does a tension pneumothorax cause?

Answer 31

Increased intrapleural pressure resulting in mediastinal shift and impaired cardiac function

Question 32

Which way will the trachea deviate in a tension pneumothorax?

Answer 32

To the unaffected side

Question 33

What is the initial management of a tension pneumothorax?

Answer 33

ABCDE
High flow oxygen
Needle decompression using a 16-gauge cannula

Question 34

Where should the needle be inserted in a tension pneumothorax?

Answer 34

Second intercostal space, mid-clavicular line, on the affected side- just above the 3rd rib (avoid neurovascular)

Question 35

When can a tension pneumothorax occur?

Answer 35

May occur following thoracic trauma when a lung parenchymal flap is created.