pneumothorax + PE

Question 1

iatrogenic causes of pneumothoraxes

Answer 1

thoracentesis
ventilation - non-invasive ventilation
long biopsy
central venous catheter placement

Question 2

management of pneumothorax and important factor when deciding

Answer 2

symptomatic
minimal symptoms = no significant pain or breathlessness + no physiological compromise

no/minimal sx = conservative, regardless of pneumothorax size

symptomatic = assess for high risk characteristics
- no high risk = conserv, ambulatory or needle aspiration
- high risk = chest drain

Question 3

high risk characteristic in context of pneumothorax management

Answer 3

• haemodynamic compromise (suggesting tension pneumo)
• significant hypoxia
• bilateral pneumothorax
• underlying lung disease
• > =50y/o + smoker
• haemothorax

Question 4

conservative management of pneumothorax

Answer 4

primary spontaneous = outpatient, reviewed every 2-4days

secondary spontaneous (underlying condition) = monitored as inpatient

Question 5

management of persistent / recurrent pneumothorax

Answer 5

video-assisted thorascopic surgery (VATS)

• allow for mechanical/chemical pleurodesis +/- bullectomy

Question 6

fitness to fly + scuba diving after pneumothorax

Answer 6

may fly 2wks after successful drainage if no residual air

scuba diving = permanently avoided, unless bilateral surgical pleurectomy

Question 7

management of tension pneuomothorax

Answer 7

needle thoracostomy in 5th intercostal space mid-axillary line
- with large bore cannula

followed by placement of chest drain

Question 8

common sx of PE

Answer 8

tachypneoea
crackles heard
tachycardia
fever >37.8

textbook;
pleuritic pain
haemoptysis
clear chest

Question 9

PE rule out criteria (PERC)

Answer 9

done when theres a low pre-test probability of PE <15%

all must be absent to rule out
- age >=50
- HR >=100
- O2 sats <=94%
- previous DVT or PE
- recent surgery or trauma in past 4wks
- haemoptysis
- unilateral leg swelling
- oestrogen use - HRT, contraceptive

if all absent, post-test probability <2%

Question 10

what scoring system should you use if you suspect a PE

Answer 10

2-level Wells score

> 4 = PE likely
<=4 = unlikely

Question 11

investigations when Wells >4 for PE

Answer 11

immediate CTPA
- if delay then therapeutic anticoag (DOAC) until scan is performed

if CTPA neg - proximal leg vein US if DVT is suspected

DOAC = apixaban, rivaroxaban

Question 12

investigations when Wells <=4 for PE

Answer 12

arrange a D-dimer
- if pos -> immediate CTPA (doac while wait)
- if neg - stop anticoag, alternative dx

Question 13

when is a V/Q scan the investigation of choice for PE

Answer 13

if renal impairment
- doesnt require use of contrast, unlike CTPA

Question 14

ECG changes in PE

Answer 14

large S wave in lead I
Q wave in lead III
inverted T wave in lead III
–> S1Q3T3

RBBB + R axis deviation
sinus tachycardia

Question 15

Chest X-ray for PE

Answer 15

recommended for all patients to exclude other pathology
typically normal in PE

sometimes - wedge-shaped opacification

Question 16

tool used to decide whether PE can be treated as an outpatient

Answer 16

Pulmonary Embolism Severity Index (PESI)

• NICE recommends using a ‘validated risk stratification tool’ to determine the suitability of outpatient treatment.

Question 17

management of PE

Answer 17

DOAC! - apixaban, rivaroxaban

if severe renal impairement (<15/min) or antiphospholipid –> LMWH

massive PE where hypotension –> thrombolysis

Question 18

length of anticoag in PE

Answer 18

provoked = 3 months
- (3-6months if active cancer)

unprovoked = 6 months

Question 19

manangement of repeat PEs even on anticoag

Answer 19

consider inferior vena cava (IVC) filters