Pneumothorax

Question 1

What is a pneumothorax?

Answer 1

Air entering the pleural space

Question 2

Causes of pneumothorax?

Answer 2

Spontaneous
Trauma
Iatrogenic
Lung disease, e.g. asthma, COPD, infection

Question 3

What guidelines are used to assess the size of pneumothorax?

Answer 3

BTS guidelines

Question 3

How is pneumothorax classified?

Answer 3

Either SPONATENOUS or TRAUMATIC

Spontaenous further classified into primary (patient has no underlying lung disease) and secondary (patient has underlying disease)

Question 4

If a pneumothorax is too small to be seen on x ray how else can you visualise it?

Answer 4

CT thorax

Question 5

Management of pneumothorax?

Answer 5

High risk patient (haemodynamic compromise, bilateral pneumothorax, hypoxia, underlying lung disease, 50 or over with significant smoking history) -> chest drain

If smaller than 2cm -> manage conservatively (manage as inpatient if secondary spontaneous pneumothorax)

If bigger than 2cm -> management depends on patient main priority:
- procedure avoidance ->conservative management with regular outpatient review

• rapid symptom relief with ambulatory care -> pleural vent ambulatory device
• rapid symptom relief with short term drainage -> needle aspiration/chest drain

Question 6

What are the borders of the triangle of safety?

Why is chest drain always inserted above the rib rather than below?

What must you do after chest drain insertion

Answer 6

5th intercostal space
Midaxillary line (lateral edge of latissimus dorsi)
Anterior axillary line (lateral edge of pectoralis major

To avoid neurovascular bundle

Confirm position with chest x ray

Question 7

How can you tell when the chest drain is draining air?

Answer 7

Swinging of water with respiration
X ray will show re-inflation of lung

Question 8

What stops a chest drain from working?

Answer 8

Blocked/kinked tube
Inserted in incorrect position
Not correctly connected to the bottle

Question 9

Complications of chest drain?

How do they present?

Answer 9

Air leaks around drain site. Presentation - bubbling at drain site especially on coughing
Surgical emphysema - air bubbles in subcutaneous tissue

Question 10

Indications for surgically treating a pneumothorax?

Answer 10

If failed chest drain
If persistent air leak in drain
Recurrent pneumothoraces

Question 11

What is the surgical treatment for a pneumothorax?

Answer 11

Video assisted thoracoscopic surgery (VATS). 3 forms:

1. Abrasive pleurodesis
2. Chemical pleurodesis
3. Pleurectomy

Question 12

What does chemical pleurodesis involve?

Answer 12

Using talc powder to irritate pleura and cause adhesions

Question 13

What is a tension pneumothorax?

Complication of it?

Answer 13

Emergency where trauma to chest creates a one way valve allowing air in not air out.

Cardiopulmonary arrest as pressure build-up causes mediastinal shift, compressing on the blood vessels in mediastinum

Question 14

Signs of a tension pneumothorax?

Answer 14

Tracheal deviation away from side of the pneumothorax

Reduced air entry on the affected side

Increased resonance to percussion on the affected side

Tachycardia

Hypotension

Question 15

Management of tension pneumothorax

Answer 15

Diagnosed clinically - too urgent for scans

Large bore cannula into 2nd intercostal space mid-clavicular line

Then insert chest drain once pressure relieved

Question 16

What classes a high risk pneumothorax patient and therefore requirement for an immediate chest drain?

Answer 16

Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history
Haemothorax