Pneumothorax

Question 1

How does a traumatic pneumothorax occur?

Answer 1

problem with parietal pleura (eg. pierced during surgery/stabbed)
obliterates negative pressure in pleural space
therefore lung deflates

Question 2

Pneumothorax acute onset symptoms

Answer 2

pleuritic chest pain
breathlessness

Question 3

Examination features of a pneumothorax

Answer 3

trachea/mediastinum pushed
reduced/absent expansion
hyper-resonant percussion
reduced/absent breath sounds
hypoxemia (especially if underlying lung disease present)

Question 4

Difference between primary and secondary spontaneous pneumothoraces

Answer 4

primary = no underlying lung pathology
secondary = lung disease or significant smoking history

Question 5

Secondary spontaneous pneumothorax causes

Answer 5

connective tissue disease (eg. Marfan’s, Ehlers-Danlos)
obstructive lung disease (eg. asthma, COPD)
infective lung disease (eg. TB, pneumonia)
fibrotic lung disease (eg. CF, IPF)
neoplastic disease (eg. bronchial carcinoma)

Question 6

How can you sub-classify traumatic pneumothoraces?

Answer 6

iatrogenic (eg. pacemaker insertion, central line insertion, CPAP)
non-iatrogenic (eg. penetrating trauma, blunt trauma with rib fracture)

Question 7

Define pneumothorax

Answer 7

air within the pleural space

Question 8

How does a pneumothorax show on a CXR?

Answer 8

absence of lung markings at periphery
pleural separation line

Question 9

Where is the size of a pneumothorax measured?

Answer 9

horizontally at the hilar level from the pleural separation line top the wall of the thorax

Question 10

Define tension pneumothorax

Answer 10

not a mechanism
pneumothorax so large it’s causing haemodynamic compromise

Question 11

Tension pneumothorax signs

Answer 11

low BP
low HR
tachypnoea
tracheal deviation

Question 12

How is a tension pneumothorax treated?

Answer 12

large bore needle decompression
2nd intercostal space (just above 3rd rib)
mid-clavicular line

Question 13

What are the borders of the safe triangle?

Answer 13

anterior = lateral border of pectoralis major
superior = base of axilla
inferior = line of 5th intercostal space
lateral = lateral edge of latissimus dorsi

Question 14

Why should a needle be inserted above the rib and not below it with a needle decompression?

Answer 14

go above rib to avoid neurovascular bundle

Question 15

Where should a chest drain be inserted?

Answer 15

safe triangle

Question 16

Chest drain complications

Answer 16

pain/infection
drain dislodgement
drain blockage
visceral injury
death

Question 17

When can someone who has had a pneumothorax fly?

Answer 17

at least 1 week after pneumothorax has resolved

Question 18

When can someone who has had a pneumothorax scuba dive?

Answer 18

never
increases risk of pneumothorax recurrence

Question 19

What can be done for recurrent or non-resolving pneumothoraces?

Answer 19

medical chemical pleurodesis

Question 20

What should be done if a pneumothorax has not settled after 5 days with a drain?

Answer 20

VATS (video-assisted thoracoscopic surgery)

Question 21

Treatment for:
primary pneumothorax, >2cm/breathless

Answer 21

aspirate
16-18G cannula
aspirate <2.5L

Question 22

Treatment for:
primary pneumothorax, <2cm/asymptomatic

Answer 22

consider discharge
review in outpatients in 2-4 weeks

Question 23

Treatment for:
unresolved primary pneumothorax after aspiration

Answer 23

chest drain

Question 24

Treatment for:
secondary pneumothorax, >2cm/breathless

Answer 24

chest drain

Question 25

Treatment for:
secondary pneumothorax, 1-2cm + not breathless

Answer 25

aspirate
16-18G cannula
aspirate <2.5L

Question 26

Treatment for:
secondary pneumothorax <1cm + not breathless

Answer 26

admit
high flow oxygen (unless expected oxygen-sensitive)
observe for 24 hours

Question 27

Treatment for:
unresolved 1-2cm secondary pneumothorax after aspiration

Answer 27

chest drain

Question 28

Further management if aspiration of a 1-2cm secondary pneumothorax is successful and size is now <1cm?

Answer 28

admit
high flow oxygen (unless expected oxygen-sensitive)
observe for 24 hours
chance of recurrence high