Pneumothorax

Question 1

What is pneumothorax?

Answer 1

air in the pleural cavity (between lung + chest wall) resulting in collapse of the lung on the affected side

Question 2

Describe the aetiology of spontaneous pneumothorax

Answer 2

Occurs in healthy people
Typically in tall, thin males
Probably caused by rupture of a subpleural bleb

Question 3

What is the epidemiology of pneumothorax?

Answer 3

Mainly in 20-60 yr olds

M > F

Question 4

What are 2 variants of pneumothorax?

Answer 4

Haemothorax: blood
Chylothorax: lymph

Question 5

Describe the aetiology of secondary pneumothorax

Answer 5

Occurs in patients with pre-existing lung disease (e.g. COPD, asthma, TB)

Question 6

Describe the aetiology of traumatic pneumothorax

Answer 6

Caused by penetrating injury to the chest e.g. stab wound
Often iatrogenic (e.g. central line placement, lung biopsy)

Question 7

Which disorders predispose to pneumothorax? Give 2 examples

Answer 7

Collagen disorders
Marfan’s syndrome
Ehlers-Danlos syndrome

Question 8

Which 7 typical clinical situations may a tension pneumothorax arise in?

Answer 8

Ventilated patients.
Trauma patients.
Resuscitation patients (CPR).
Lung disease, esp. acute presentations of asthma + COPD.
Blocked, clamped or displaced chest drains.
Patients receiving non-invasive ventilation.
Patients undergoing hyperbaric oxygen tx

Question 9

List 5 risk factors for pneumothorax

Answer 9

Smoking: 22-fold increase in M + F 9-fold
Tall
Collagen disorders e.g. Marfans, Ehlers-Danlos
Women with endometriosis with pleuritic/ shoulder/ abdomen pain at time of menses
FH

Question 10

How does physical exertion affect onset of pneumothorax?

Answer 10

Not usually associated with physical exertion

Onset is just as likely when sedentary

Question 11

How does primary spontaneous pneumothorax differ to secondary spontaneous pneumothorax?

Answer 11

PSP: minimal or absent

Symptoms are greater in SSP, even if pneumothorax is relatively small in size

Question 12

Describe 2 symptoms of pneumothorax

Answer 12

Sudden onset pleuritic chest pain

SOB

Question 13

What 4 general signs of pneumothorax may be found on examination?

Answer 13

May be NO signs if the pneumothorax is small
Signs of respiratory distress- dyspnoea, sweating, cyanosis
Hypotension
Raised JVP
Tachycardia

Question 14

What 6 signs of tension pneumothorax may be found on examination?

Answer 14

Severe respiratory distress  
Tachycardia  
Hypotension  
Cyanosis  
Distended neck veins  
Tracheal deviation away from side of pneumothorax

Question 15

What 4 signs of pneumothorax may be found on examination of the chest?

Answer 15

Reduced expansion
Hyper-resonance to percussion
Reduced/ absent breath sounds
Tracheal deviation possible

Question 16

Why perform an ABG in a patient with suspected pneumothorax?

Answer 16

Check for hypoxaemia

Question 17

Describe the management for a tension pneumothorax

Answer 17

Maximum O2
Insert large bore needle into 2nd ICS MCL
Up to 2.5 L of air can be aspirated
Stop if patient coughs or resistance is felt
Follow-up CXR 2 hrs + 2 weeks later

Question 18

In which 3 situations may a Chest Drain with Underwater Seal be performed? How?

Answer 18

Aspiration fails
Fluid in the pleural cavity
After decompression of a tension pneumothorax
Inserted in 4th-6th ICS MAL

Question 19

After excluding tension pneumothorax, what is the aim of management? How is this achieved? What influences this decision?

Answer 19

To relieve dyspnoea.
Simple observation, needle aspiration + chest drain
Choice depends upon the severity of the condition

Question 20

What does the immediate management of pneumothorax involve?

Answer 20

Supplying Oxygen to relieve hypoxia + accelerate resorption of the pneumothorax 4-fold

Question 21

What are the management options for recurrent Pneumothoraces?

Answer 21

Chemical pleurodesis (fusing of visceral + parietal pleura with tetracycline or calc) 
Surgical pleurectomy

Question 22

Give 2 pieces of advice to a patient who has had a pneumothorax

Answer 22

Avoid air travel until follow-up CXR confirms that pneumothorax has resolved
Avoid diving

Question 23

What is the prognosis for a pneumothorax patient?

Answer 23

After having 1 pneumothorax, >, 20% will have another

Frequency increases with repeated pneumothoraces

Question 24

What complications may arise in a pneumothorax patient?

Answer 24

Recurrent pneumothoraces

Bronchopleural fistula