Pneumothorax

Question 1

What is the typical cause of primary spontaneous pneumothorax (PSP)?

Answer 1

a rupture of a bulla, which is an air pocket in the lung

Question 2

What are the risk factors for primary spontaneous pneumothorax (PSP)?

Answer 2

1. tall and thin
2. smoking (especially cannabis)
3. There is usually no underlying lung disease or triggering event.

Question 3

What distinguishes secondary spontaneous pneumothorax (SSP) from primary spontaneous pneumothorax (PSP)?

Answer 3

SSP occurs in the presence of underlying lung disease, whereas PSP occurs without any underlying lung disease.

Question 4

What are some other causes of pneumothorax besides primary and secondary spontaneous pneumothorax?

Answer 4

1. Iatrogenic factors (related to medical procedures)
2. Trauma.

Question 5

What is the pathophysiological mechanism behind pneumothorax?

Answer 5

Pneumothorax abolishes the transmural pressure gradient, leading to increased intrathoracic pressure and subsequent collapse of the lung.

Question 6

What are the typical symptoms of pneumothorax?

Answer 6

Shortness of breath, acute onset pleuritic chest pain, and dyspnea.

Question 7

What signs may be present on examination of a patient with pneumothorax?

Answer 7

Hypoxia
Tachycardia
Decreased cardiac output
Reduced breath sounds
Chest expansion on the affected side
Hyper-resonance on percussion (hollow, drum-like sounds).

Question 8

What imaging modality is typically used for diagnosing pneumothorax?

Answer 8

CXR

Question 9

What is the management approach for when pneumothorax is small and asymptomatic?

Answer 9

none

Question 10

What is the management approach for pneumothorax if acutely unwell?

Answer 10

aspiration (5th intercostal space, midaxillary line, safe triangle)

Question 11

Describe the procedure for pneumothorax aspiration

Answer 11

Procedure for pneumothorax aspiration (needle thoracocentesis)Insert lignocaine 5-10ml initially under the skin and then into subcutaneous tissues and pleural space

Question 12

What is the management approach for pneumothorax if aspiration fails?

Answer 12

Insert chest drain (5th intercostal space, midaxillary line)

Question 13

What is the life-threatening variant of pneumothorax?

Answer 13

Tension pneumothorax

Question 14

What are the common causes of tension pneumothorax?

Answer 14

Punctured lung from broken rib or during CPR

Question 15

What is the pathophysiological mechanism of underlying tension pneumothorax?

Answer 15

One-way valve allows air in but not out, leading to increased pressure in pleural space, mediastinal shift, and cardiorespiratory compromise.

Question 16

How does tension pneumothorax present clinically?

Answer 16

Hypertension, tachycardia, increased resp. rate, tracheal deviation away from the affected side, decreased CO, elevated JVP, and distended neck veins

Question 17

What is the management approach for tension pneumothorax?

Answer 17

Needle aspiration until chest drain can be inserted; emergency needle decompression in 5th intercostal space in midaxillary line.

(used to be 2nd midclavicular)

Question 18

A 20-year-old male patient presents to the emergency department with sudden onset shortness of breath and right-sided pleuritic chest pain.

On physical examination the trachea is central, and there is reduced chest expansion on the right with associated hyper-resonant percussion and reduced breath sounds. Of note, the patient is tall with a wide arm span and arachnodactyly.

Given the most likely diagnosis, what is the patient at increased risk of developing?

Answer 18

Acute aortic dissection

Question 19

A 25-year-old male patient presents to the emergency department with sudden onset shortness of breath and left-sided pleuritic chest pain. This came on while he was playing football.

Chest X-ray reveals a visible pleura and absent lung markings at the left base.

What clinical signs are consistent with the most likely diagnosis?

Answer 19

Hyper-resonant percussion note at the left base

Question 20

A 34-year-old man presents to the emergency department with sudden-onset shortness of breath and sharp chest pain on inspiration following a road traffic accident.

On examination, his trachea is displaced to the left, chest expansion is reduced on the right-hand side, there is hyper-resonance to percussion on the right-hand side and absent breath sounds on the right-hand side. His vital signs show a heart rate of 123, blood pressure of 86/60, respiratory rate of 26 and saturation of 86%.

What does this patient have? and what is the best management option for this patient?

Answer 20

Tension pneumothorax

Needle decompression

Question 21

A 64-year-old has been admitted with a 3cm pneumothorax. He has COPD and smokes. An underwater seal chest drain is inserted. In the first minute after drain insertion, there is bubbling in the water of the drain. This abruptly stops and there is concern that the chest drain tube is blocked. What is the most appropriate initial step to take?

Answer 21

Check the drain tube to see if the fluid is ‘swinging’

Question 22

A 52 year old man with COPD presents to the Emergency Department with shortness of breath and left-sided chest pain. He denies trauma. He has a good functional baseline.

Chest x-ray confirms a 5cm pneumothorax.

A 24 Fr chest drain is inserted. 5 days later, air continues to escape through the chest drain and chest x-ray confirms pneumothorax remains present.

What is the most appropriate management for the patient’s pneumothorax?

Answer 22

thoracic surgery

Question 23

A 23-year-old male developed sudden onset right-sided pleuritic chest pain and shortness of breath. He does not have any significant past medical history. On exam, there are decreased breath sounds throughout the right lung as well as a hyperresonant percussion note. In what anatomical space is the abnormality located?

Answer 23

Between the visceral and parietal pleura

Question 24

A 77-year-old female is being mechanically ventilated in the ICU following admission for a very severe exacerbation of COPD. Her mechanical ventilation pressures have increased acutely but her observations are stable. On examination, the right lung has reduced air entry and is hyper-resonant to percussion. There is no tracheal deviation. What is the next most appropriate action for the doctor to take?

Answer 24

CXR

Question 25

A patient comes in who is symptomatic - shortness of breath and we know it’s not tension pneumothorax. What is the next step?

Answer 25

Chest drain

Question 26

A 17 year old male with a background of Marfan syndrome presents with generalised pleuritic chest pain. Observations are: HR 100, RR 28, oxygen saturations 93% on air, BP 122/76, afebrile. Chest x-ray demonstrates bilateral pneumothoraces of approximately 1.5cm. Why your answer?

Answer 26

Proceed to chest drain insertion

= bilateral pneumothoraces or are haemodyamically unstable with a spontaneous pneumothorax should proceed straight to chest drain (regardless of the size or whether the pneumothorax is primary or secondary to lung disease)

Question 27

Patient is not breathless, but has pleutic chest pain

Answer 27

Discharge

Question 28

A 37-year-old male presents to the A&E department with pleuritic chest pain and dyspnoea. He has recently returned from a diving holiday in Thailand. The patient is frightened of hospitals and is incredibly distressed by needles.

On examination, his trachea is central, percussion note is hyper-resonant and there is silent auscultation on the left-side.

Observations: HR 98bpm, SpO2 99% on air, RR 19 breaths per minute, temperature 37.7 degrees Celsius.

A chest x-ray confirms the presence of a pneumothorax 3cm lateral to left lung margin.

Given the patient’s clinical findings and wishes, what is the likely management of his condition

Answer 28

Discharge home with regular review as an outpatient