Pleural Disease - Pneumothorax

Question 1

What is a pneumothorax

Answer 1

The presence of air within the pleural cavity

Question 2

What causes a pneumothorax

Answer 2

A breach of the visceral or parietal pleura with the entry of air causing the lung to collapse away from the chest wall because of the elastic recoil of the lung

Question 3

What are the two ways pneumothorax can come about

Answer 3

Spontaneously

Traumatically

Question 4

What types of spontaneous pneumothorax are there

Answer 4

Primary spontaneous

Secondary spontaneous

Question 5

What types of traumatic pneumothorax are there

Answer 5

Non-iatrogenic

Iatrogenic

Question 6

What is a tension pneumothorax

Answer 6

The build-up of air within the pleural space, usually due to a lung laceration which allows air to escape into the pleural space

Question 7

Is primary spontaneous pneumothorax a clinically apparent disease

Answer 7

No

Question 8

Who does primary spontaneous pneumothorax tend to affect

Answer 8

Tall thin individuals

People under age of 45 (accounts for 81% of pneumothorax)

Question 9

What is the cause of primary spontaneous pneumothorax

Answer 9

It is believed to be due to the weight of the lung which induces the development of apical blebs that rupture

Question 10

How many men and women suffer from primary spontaneous pneumothorax

Answer 10

18-28 per 100,000 men per year

1.2-6 per 100,000 women per year

Question 11

What is the peak incidence of primary spontaneous pneumothorax

Answer 11

It has a young peak incidence (20-30 years)

Question 12

What is the cause of secondary spontaneous pneumothorax

Answer 12

Tends to occur due to a pre-existing lung disease (almost any lung disease)

Question 13

What types of pre-existing lung diseases can cause secondary spontaneous pneumothorax

Answer 13

COPD
Asthma
Pneumonia
TB 
Cystic fibrosis
Fibrosing alveolitis
Sarcoidosis
Histiocytosis X

Question 14

How many cases of secondary spontaneous pneumothorax are due to COPD

Answer 14

30-50%

Question 15

How many asthmatics get secondary spontaneous pneumothorax

Answer 15

0.8%

Question 16

How many TB patients get secondary spontaneous pneumothorax

Answer 16

1.4%

Question 17

Name 2 causes of traumatic non-iatrogenic pneumothorax

Answer 17

Penetrating chest injury (stab, gunshot)

Blunt chest injury (rib fractures, bronchial rupture)

Question 18

Name 4 causes of traumatic iatrogenic pneumothorax

Answer 18

Pleural aspiration/biopsy
Sub-clavian vein cannulation
Lung, liver, breast, renal biopsy
Acupuncture

Question 19

What are the symptoms are of a pneumothorax

Answer 19

Small pneumothorax in a patient with a good respiratory reserve is normally asymptomatic

Acute breathlessness, worsening breathlessness and pleuritic chest can occur

Question 20

What does extreme dyspnoea in a previously fit individual indicate

Answer 20

Tension pneumothorax

Question 21

What does extreme dyspnoea in a person with chest disease indicate

Answer 21

Tension pneumothorax or severe lung disease

Question 22

What are the signs of of a small pneumothorax

Answer 22

Normally no signs

Question 23

What are the signs of a non-tension pneumothorax

Answer 23

Decreased expansion
Hyper resonant
Absent or decreased breath sounds

Question 24

What are the signs of a tension pneumothorax

Answer 24

Trachea deviates away from the affected side
Haemodynamic compromise
Increased JVP

Question 25

What type of investigation can be conducted for a pneumothorax

Answer 25

Chest X-Ray

Question 26

What is considered a large or small pneumothorax

Answer 26

Large - over 2cm | Small - under 2cm

Question 27

What are the 4 questions which should be asked when deciding treatment

Answer 27

1) Is it a tension pneumothorax? 2) Is the pneumothorax small or large? 3) Is the patient breathless? 4) Is the pneumothorax likely to be primary or secondary?

Question 28

How is a tension pneumothorax treated

Answer 28

Cannula (large grey venflon) in the 2nd intercostal space min-clavicular line then insert an intercostal chest drain

Question 29

How is a small primary pneumothorax (non-breathless) treated

Answer 29

Observed overnight Repeat chest X-Ray If no change then hole has sealed Discharged

Question 30

What should the patient be advised

Answer 30

Avoid vigorous activity | Return if they become breathless

Question 31

How does a small primary pneumothorax resolve

Answer 31

1.25% per day | Should be reviewed in a chest X-Ray clinic 2 weeks

Question 32

How is a breathless primary pneumothorax treated

Answer 32

Aspiration while the patient is at at 45˚ and lignocaine placed into the second intercostal space in the midclavicular line using a 50 ml syringe, venflon, 3 way tap and tube to water

Question 33

How long is a breathless primary pneumothorax treated

Answer 33

Aspirated until the surface of the lung can be felt on the tip of the venflon just beneath the surface of the chest wall

Question 34

What does it mean is over 3L is aspirated

Answer 34

Persistent air leak

Question 35

If the aspiration is successful in a breathless primary pneumothorax what are the next steps

Answer 35

A chest X-Ray should be conducted after 24 hours

Question 36

If the aspiration is unsuccessful in a breathless primary pneumothorax what are the next steps

Answer 36

Chest drain

Question 37

Can a small breathless secondary pneumothorax be aspirated

Answer 37

Yes but it is less successful

Question 38

What is the recommended treatment for breathless secondary pneumothorax

Answer 38

An intercostal chest drain should be inserted into the 4th intercostal space in the mid-axillary line using a small bore 10-14F

Question 39

What three things should occur upon the successful insertion of an intercostal chest drain

Answer 39

Lungs should inflate within 1-2 days Drain should stop bubbling CXR should confirm that the lung has inflated

Question 40

After inserting an intercostal chest drain what are the two next steps available

Answer 40

The drain can be clamped for 24 hours, repeat CXR done, if there is no change then the drain can be removed A repeat CXR can be conducted after 24 hours and if there is no change then the drain can be removes

Question 41

Why is clamping the intercostal chest drain for 24 hours a better choice

Answer 41

Allows the detection of small air leaks and avoids the re-insertion of chest drains

Question 42

If the lungs fail to re-inflate and the drain continues to bubble 48 hours after inserting an intercostal chest drain what should be done

Answer 42

A suction should be applied to the drain (high volume, low pressure -10 to -20 cm H2O)

Question 43

What should be done if the lungs still fail to re-inflate after applying suction

Answer 43

Thoracic surgeons should be contacted at 3 days for a thoracoscopic inspection of the visceral pleura, identification of blebs, tears, clipping and talc poudrage pleurodesis

Question 44

What is the risk of a subsequent pneumothorax

Answer 44

High risk 54% recurrence within 4 years 10-25% in first 4 months 10-15% contralateral pneumothorax

Question 45

Which 4 categories of patients should be referred for a surgical pleurodesis

Answer 45

Second ipsilateral pneumothorax First contralateral pneumothorax Bilateral spontaneous pneumothoraxes First pneumothorax in high risk professions (pilots, divers)

Question 46

What other types of management are there

Answer 46

Talc poudrage | Pleurectomy