Pneumothorax: Primary, Tension, and Traumatic

Question 1

What is the definition of pneumothorax?

Answer 1

The presence of air in the pleural space with varying degrees of secondary lung collapse.

Question 2

What are the types of pneumothorax ?

Answer 2

-Primary spontaneous pneumothorax
– Secondary spontaneous pneumothorax
– Traumatic pneumothorax
– Tension pneumothorax

Question 3

What is the definition of Primary spontaneous pneumothorax?

Answer 3

Defined as a pneumothorax which presents without a precipitating external event in the absence of clinical lung disease. It is common in males than in females.

Question 4

What is the etiology of Primary spontaneous pneumothorax?

Answer 4

Primary spontaneous pneumothorax is mainly caused by the rupture of a small subpleural emphysematous vesicle (designated a bleb) or of a subpleural paraseptal emphysematous lesion (designated a bulla).

Question 5

What are the risk factors for Primary spontaneous pneumothorax?

Answer 5

• Development of subpleural blebs
• Tall thin males b/t 10-30yoa
• Smokers
• Genetics
• Changes in transpulmonary pressure
  – Valsalva, Divers

Question 6

What is the definition of secondary spontaneous pneumothorax ?

Answer 6

Defined as pneumothorax that presents as acomplication of underlying lung disease. It is common in men over the age of 55 than in woman.

Question 7

What is the most common etiology of secondary spontaneous pneumothorax ?

Answer 7

COPD in 80% of cases.

Question 8

What are the risk factors for secondary spontaneous pneumothorax ?

Answer 8

• Chronic airway disease such as COPD, Severe Asthma, Cystic Fibrosis,
  Emphysema.
• Connective tissue disorders such as RA, Marfan syndrome, and ankylosing spondylitis.
• Malignant lung and chest diseases such as Bronchial Cancer, and Sarcoma.

Question 9

What is the definition of traumatic pneumothorax?

Answer 9

Air in the pleural space resulting from trauma causing partial or complete lung collapse.

Question 10

What is the definition of tension pneumothorax?

Answer 10

It develops when a lung or chest wall injury allows air into the pleural space by forming a one way valve and can occur in any type of pneumothorax.

Question 11

What are the consequences of tension pneumothorax ?

Answer 11

The one way valve system allows Accumulation of positive air pressure within the pleural cavity which pushes the mediastinum trachea,
great vessels and heart to the contralateral side. It can eventually lead to Decreases venous return to the heart leading to shock.

Question 12

What are the iatrogenic causes of tension pneumothorax ?

Answer 12

procedures such as thoracentesis, central line placement, pacemaker insertion and tracheostomies.

Question 13

What are the non-iatrogenic causes of tension pneumothorax?

Answer 13

Trauma can cause minor or severe type of TP.

Question 14

What are the signs and symptoms of tension pneumothorax ?

Answer 14

• Dyspnoea
• Chest pain
• Tachypnoea
• Hyperresonance on
  percussion
• Absent breath sounds
  on side of
  pneumothorax

Question 15

What are the investigations in pneumothorax ?

Answer 15

• If the patient is stable C-XR.
• CT can be used to accurately estimate the size of pneumothorax.

Question 16

What is the management of Primary Pneumothorax OR small asymptomatic secondary
pneumothorax of <2cm?

Answer 16

Give 100% oxygen, observe and monitor.

Question 17

What is the Primary or secondary pneumothorax >2cm OR
symptomatic?

Answer 17

Insert a chest drain in the safety triangle on the side of
the pneumothorax.

Question 18

What is the location of the safety triangle for inserting chest drain ?

Answer 18

4th or 5th intercostal space, mid-axillary line

Question 19

What is the procedure for Needle Thoracentesis in tension pneumothorax ?

Answer 19

2nd intercostal space in the
mid-clavicular line with a 14g cannula .

Question 20

What is a heamothroax and its causes ?

Answer 20

It is a collection of blood within the pleural cavity due to blunt trauma such as car accident. Lung and chest wall cancers, malignant pleural effusion and Catheter insertion into vein can also causes it.

Question 21

What are the symptoms of heamothroax ?

Answer 21

• Chest pain
• Dyspnoea
• Tachypnoea
• Tachycardia
• Shock
• Fever

Question 22

What are the work ups in hemothorax ?

Answer 22

*Hx and Px to determine the mechanism of injury.
* X-Ray and or US
* CT is the highest sensitivity test for detecting blood in the pleural space.

Question 23

What is the management of heamothorax?

Answer 23

*Fluid resuscitation +/- RBC transfusion.
* Intercostal drainage using chest tube, Video-assisted thoracoscopic surgery, open thoracotomy ( VATS is preferred over OT nowadays).
* Intrapleural fibrinolysis maybe considered. ( not routine only with pulmonology consult).

Question 24

what are the Indications for emergency or urgent thoracotomy in haemothorax ?

Answer 24

• Haemodynamic instability despite adequate resuscitation.
• Initial drainage >1500 mL.
• Continued bleeding >200 mL/hour for 3 consecutive hrs.
• Continued bleeding >1500 mL/day.
• Radiographic evidence of retained clot of >1/3of pleural space.

Question 25

What is the Tx of HAEMOPNEUMOTHORAX ?

Answer 25

Combination of pneumothorax and haemothorax. Treatment is the same as Haemothorax
– Chest tube drainage (1st Line)
– VATS
– Open Thoracotomy