Pneumothorax

Question 1

What is a pneumothorax?

What is the difference between primary & secodary pneumothorax?

What is a tension pneumothorax?

Answer 1

Abnormal collection of air or gas in the pleural space that separates the lung from the chest wall.

Primary - no apparent cause & absence of significant lung disease

Secondary - presence of existing lung pathology

Tension - Air drawn into plrual space with each inspiration has no route of excape during expiration. Mediastinum is pushed over into contralateral hemithorax, kinking & compressing great veins. Causing cardiorespiratory arrest if not treated.

Question 2

What can cause a pneumothorax?

Answer 2

Primary spontaneous;

• Young thin men
• Due to rupture of sub-pleural bulla (air-filled lesions under pleural surface)

Secondary;

• Asthma, COPD, Lung/ cystic fibrosis
• TB, Pneumonia, Sarcoidosis
• Lung abscess, Carcinoma

Any pneumothorax can cause a Tension pneumothorax

Question 3

What are the sympyomts & signs of a pneumothorax?

Answer 3

Symptoms;

• None (fit, young ppl or small pneumothorax)
• Or sudden onset;
  
  • Dyspnoea
  • Pleuritic chest pain
• Sudden deterioration in asthma, COPD

Signs;

• ↓ expansion & breath sounds
• ↑ per-resonance to percussion
• Tension pneumothorax also has;
  
  • Trachia deviated away from pneumothorax
  • Respiratory distress
  • ↓BP, ↑HR, ↑JVP (distended neck veins)

Question 4

How would you investigate a pneumothorax?

Answer 4

• PA CXR
  
  • Measure interplerual (rim) distance at level of hilum
  • If unclear, do lateral (decubitus)
  • If obscured by surgical emphysema/ complex bulla disease CT may help

Question 5

How would you treat a pneumothorax?

Answer 5

Primary pneumothorax;

1. Rim >=2cm or breathless?
   
   • Yes - aspirate
   • No - observe for 4hr & follow-up
2. Rim <=1cm, breathing better?
   
   • No - intercostal tube drainage
   • Yes - observe for 4hr & follow-up

Secondary pneumothorax;

1. Rim >=2cm or breathless?
   
   • Yes - intercostal tube drainage
   • No - → 2
2. Rim of air >1cm?
   
   • Yes - aspirate and (→3)
   • No - in-patient observation (→3)
3. Rim <1cm?
   
   • No - Intercostal tube drainage
   • Yes - in-patient observation

If bilateral or haemodynamically unstable proceed to chest drain.