Pneumothorax

Question 1

What is a primary pneumothorax?

Answer 1

if there is no underlying lung disease and secondary if there is

Question 2

Management of primary pneumothorax?

Answer 2

• if the rim of air is < 2cm and the patient is not short of breaththen discharge should be considered
• otherwise, aspiration should be attempted
• if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted

Question 3

Management of secondary pneumothorax?

Answer 3

• if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then achest drainshould be inserted.
• otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
• if thepneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours

Question 4

If a secondary pneumothorax > 2cm and/or the patient is short of breath then patient should be treated with?

Answer 4

chest drain (not aspiration) as first-line

Question 5

Management of iatrogenic pneumothorax?

Answer 5

• less likelihood of recurrence than spontaneous pneumothorax
• majority will resolve with observation, if treatment is required then aspiration should be used
• ventilated patients need chest drains, as may some patients with COPD

Question 6

management of recurrent pneumothorax?

Answer 6

If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.

Question 7

Discharge advice after a pneumothorax?

Answer 7

Smoking

• patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Fitness to fly

• absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to1 week post check x-ray

Scuba diving

• the BTS guidelines state:*‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’

Question 8

What is seen on a chest x ray with a pneumothorax?

Answer 8

Absent lung markings

Question 9

Key points of tension pneumothorax

Answer 9

May occur following thoracic trauma when a lung parenchymal flap is created.

This acts as a one way valve and allows pressure to rise.

The trachea shifts and hyper-resonance is apparent on the affected side.

Treatment is with needle decompression and chest tube insertion.

Question 10

Causes of a pneumothorax?

Answer 10

Spontaneous
Trauma
Iatrogenic such as due to lung biopsy, mechanical ventilation or central line insertion
Lung pathology such as infection, asthma or COPD

Question 11

Signs of tension pneumothorax

Answer 11

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

Question 12

Management of Tension Pneumothorax

Answer 12

The management sentence you need to learn and recite in your exams is: “Insert a large bore cannula into the second intercostal space in the midclavicular line.”

If a tension pneumothorax is suspected do not wait for any investigations. Once the pressure is relieved with a cannula then a chest drain is required for definitive management.

Question 13

Where are chest drains inserted?

Answer 13

Chest drains are inserted into the “triangle of safety”. This triangle is formed by:

• The 5th intercostal space (or the inferior nipple line)
• The mid axillary line (or the lateral edge of the latissimus dorsi)
• The anterior axillary line (or the lateral edge of the pectoris major)

The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted obtain a chest xray to check the positioning.

Question 14

Why do tension pneumothorax occur

Answer 14

Tension pneumothorax is caused by trauma to chest wall that creates a one-way valve that lets air in but not out of the pleural space. The one-way valve means that during inspiration air is drawn into the pleural space and during expiration, the air is trapped in the pleural space. Therefore more air keeps getting drawn into the pleural space with each breath and cannot escape. This is dangerous as it creates pressure inside the thorax that will push the mediastinum across, kink the big vessels in the mediastinum and cause cardiorespiratory arrest.