Pneumothorax

Question 1

What happens in a tension pneumothorax?

Answer 1

In a tension pneumothorax the tissue forms a one
way valve allowing air to enter the pleural space
and preventing its escape

Question 2

Why does a tension pneumothorax usually occur?

Answer 2

Due to trauma

Question 3

How does the tension pneumothorax affect the heart?

Answer 3

The trapped air compresses the heart and reduces venous return by pushing the mediastinum to the opposite side

This compromises circulation

Question 4

What are the symptoms of pneumothorax?

Answer 4

sharp pain in the chest
tachypnoea
fast respiratory rate
low oxygen saturation
low blood pressure

Question 5

How does the trachea change position in a pneumothorax?

Answer 5

It deviates away from the pneumothorax

Question 6

What clinical signs can be elicited in a pneumothorax patient?

Answer 6

decreased expansion of the chest
increased percussion note
decreased breath sounds

crunching due to surgical emphysema

Question 7

How is venous pressure changed in a patient with a pneumothorax?

Answer 7

Raised central venous blood pressure

Question 8

What is surgical emphysema?

Answer 8

Accumulation of air in subcutaneous tissue due to trauma or surgical procedure

Question 9

How can surgical emphysema be identified clinically?

Answer 9

touching the skin makes a crackling sound due to the movement of air

Question 10

How can a pneumothorax be identified on a chest X-ray?

Answer 10

Follow the lung markings and look for the places where they do not reach the periphery

Question 11

How is a pneumothorax treated?

Answer 11

Aspiration

Using a catheter which has a valve to let air escape and an underwater seal

Air moves from the chest cavity, into the water and then escapes

Question 12

Why is a water-tight seal important when treating a pneumothorax?

Answer 12

Air escaping in the right direction requires a pressure gradient

water prevents air from re-entering the thorax

Question 13

If a pneumothorax is bilateral or haemodynamically unstable, how is it treated?

Answer 13

Chest drain

Question 14

What is the difference between a primary and secondary pneumothorax?

Answer 14

Secondary occurs if the patient is over 50 and has a significant smoking history

Or they have evidence of underlying lung disease on exam or chest X ray

Question 15

How is a primary pneumothorax treated?

Answer 15

If it is >2cm and the patient is breathless, it is aspirated

Otherwise discharge is considered and it is reviewed in OPD in 2-4 weeks

Question 16

How is a secondary pneumothorax treated?

Answer 16

If it is >2 cm and the patient is breathless, a chest drain is used and patient admitted

If it is 1 - 2 cm, it is aspirated with a 16-18G cannula

Question 17

How is a secondary pneumothorax treated if it is less than 1 cm?

Answer 17

Patient admitted and given high flow oxygen

They are observed for 24 hours

Question 18

How is the “size” of the pneumothorax measured?

Answer 18

It is the interpleural distance at the level of the hilum

Question 19

Can someone with a non-traumatic pneumothorax fly?

Answer 19

CXR must confirm resolution before flight

Wait 7 days until flight

Question 20

Can someone with a traumatic pneumothorax fly?

Answer 20

The time period following a full radiographic resolution should be at least 2 weeks

Question 21

In which types of patients is the risk of pneumothorax recurrence higher?

Answer 21

Those with co-existing lung disease

The risk doesn’t decline significantly for at least a year

Question 22

Can patients who have had a surgical intervention via thoracotomy fly?

Answer 22

This procedure is likely to be entirely successful so patients can fly once they have recovered from the effects of surgery

Question 23

What are the 2 types of pneumothorax that can occur without trauma?

Answer 23

Primary spontaneous pneumothorax

Secondary spontaneous pneumothorax

Question 24

What causes a primary and secondary spontaneous pneumothorax?

Answer 24

Primary - smoking, family history

Secondary - many diseases including COPD/CF

Question 25

What is the chance of recurrence after a spontaneous pneumothorax?

Answer 25

After the first, there is a 10% chance of recurrence

After a second pneumothorax, the risk increases to 40%

Question 26

How do spontaneous pneumothoraces usually arise?

Answer 26

From the rupture of small subpleural blebs

Question 27

What is meant by the safe triangle when inserting a needle into the thorax?

Answer 27

Area of the chest with less chance of complication

The needle must be inserted over a rib to avoid arteries/veins/nerves