pneumothorax

Question 1

what are the causes of a pneumothorax? (7)

Answer 1

1. Spontaneous – (Primary): typically young, tall men, due to pleural bleb bursting
2. Traumatic
3. Iatrogenic: mechanical ventilation, non invasive ventilation, subclavian cvp line insertion, biopsy
4. Lung pathology (secondary pneumothorax): COPD, Asthma, CF, lung cancer, Pneumocystis pneumonia
5. Connective tissue disease: Marfan’s, Rheumatoid arthritis
6. Catamenial pneumothorax: endometriosis within thorax causing pneumothorax in menstruating women
7. Smoking history

Question 2

What are the symptoms of a pneumothorax? (5)

Answer 2

1. Dyspnoea
2. Chest pain – often pleuritic
3. Sweating
4. Tachypnoea
5. Tachycardia

Question 3

What investigations would you do?

Answer 3

1. Erect chest X-ray - PA (for simple pneumothorax), measure size of pneumothorax
2. CT thorax - can detect smaller ones

Question 4

How do you manage a primary pneumothorax?

Answer 4

o Less than <2cm and not breathless – consider discharge
o >2cm and/or breathless – aspirate
o If this fails (>2cm or still SOB) chest drain should be inserted
o Advised to stop smoking to reduce risk of further episodes

Question 5

How do you manage a secondary pneumothorax?

Answer 5

o >50 years old and >2cm in size and/or short of breath - chest drain should be inserted
o Otherwise: 1-2cm –> aspirate. If fails (still >1cm) –> chest drain
o Less than 1cm –> give oxygen + admit for 24 hours
o Diving should be avoided unless - bilateral pleurectomy+ normal lung function + Post op CT

Question 6

How do you manage iatrogenic pneumothorax?

Answer 6

o Less likely to reoccur than spontaneous pneumothorax
o Majority resolve with observation, otherwise aspirate
o Ventilated patients and some COPD need chest drains

Question 7

What can cause a tension pneumothorax?

Answer 7

• May occur following thoracic trauma when lung parenchymal flap is created
• Acts as a one way valve that allows the pressure to rise (inspiration air enters, expiration gets trapped)

Question 8

what are the signs of a tension pneumothorax?

Answer 8

o	Tracheal deviation away from side of pneumothorax
o	Reduced air entry to affected side
o	Increased resonant to percussion 
o	Tachycardia
o	Hypotension

Question 9

How do you manage a tension pneumothorax?

Answer 9

o Large bore cannula (14G) , second intercostal space, mid clavicular line - immediately dont wait for cxr
o Once pressure relieved with cannula, chest drain required for definitive management

Question 10

where do you insert a chest drain?

Answer 10

in the triangle of safety:

• 5th intercostal space
• mid axillary line (lateral edge of lattimus dorsi)
• anterior axillary line (lateral edge of pectoris major)