Pneumothorax

Question 1

Answer 1

Deep sulcus sign

Due to air in front of, and under, the lungs

PTx on a SUPINE FILM
- Deep sulcus
- Lucency over upper abdo (gas underneath lung)
- Depressed hemidiaphragm
- Sharply outlined pericardial fat pad
- Double diaphragm sign
- Subcut emphysema

Question 2

PTx size classification:

Answer 2

Britain and Australia:
Measure interpleural distance at the hilum.

SMALL = < 2cm

LARGE = > 2cm
=50% collapse

US: distance at apex, >/< 3cm

Question 3

What is the spontaneous rate of absorption of a PTx?

Answer 3

2% hemithorax volume, per day

Question 4

Causes of secondary PTx:

Answer 4

Trauma
–> Rib #, penetrating,
COPD/ asthma
LRTI
–> PJP, TB, necrotising
CF
Connective Tissue Disease
–> Marfans, Ehler’s Danlos
Stimulants
THC/ smoking (blebs)
Tumours
Pleural endometriosis

Question 5

Management options for PTx:

Answer 5

Based on clinical symptoms more than PTx size

1- Conservative
- Suitable if small and asymptomatic, or even large, PRIMARY and asymptomatic (and low risk)
- Less recurrence
- Either straight home, or 100% O2 overnight if risk factors

Anyone Sx or O2 requirement needs the air OUT

2- Aspiration
- Poor success in secondary PTx
- Best if young, primary, smaller volume
- Needle OR chest drain ‘in/out’
–> Drain advantage= can keep in if asp fails
- Aim to get to ‘small’ size (<2cm) without reaccumulation

3-Chest drain
3A- Small bore
3B- Large bore
- Mandatory if traumatic (risk of blood)
- Strong evidence that small-bore adequate- 12-14F
- If haemothorax, 32F+
—> Underwater seal or Heimlich

4- OT/VATS
- Unresolving air leak after days
—> pleura not healing, bronchopleural fistula
- Recurrent
- Need to fly or dive (eg. occupational)

Question 6

Standard follow up after DC for PTx:

Answer 6

CXR
- 24 hours
- Weekly until resolved

Do not fly until resolved at least 1 week

Do not dive EVER
–> Unless VATS.

Counsel re recurrence:
- Up to 50%
- After 1 year, this drops.
- 70% risk recurrence after 2

Avoid smoking, bongs, stimulants

Question 7

USS findings in PTx:

Answer 7

Any probe works

Loss of slide/ ‘ants marching’
In M mode: ‘barcode’ (not seashore)
Loss of comet tails
’Lung Point Sign’—> 100% specific/ diagnostic