Session 10: Pneumothorax & Pleural Effusion

Question 1

What is a pneumothorax?

Answer 1

The presence of air between the visceral and parietal pleura.

Question 2

Where does the air come from in a pneumothorax?

Answer 2

The lung (most common)

Thorugh the chest wall (rare)

Both lung and through chest wall (rare)

Question 3

Who commonly gets a primary spontaneous pneumothorax?

Answer 3

Most commonly happens in young, tall thin males with no predisposing lung disease or history of trauma.

Question 4

What is commonly thought to be the cause of primary spontaneous pneumothorax?

Answer 4

Small sub-pleural bleb or bulla rupture.

Question 5

What increases that risk of primary spontaneous pneumothorax?

Answer 5

Smoking

Question 6

Give examples of what secondary pneumothorax can be secondary to.

Answer 6

Underlying lung disease

Trauma

Iatrogenic

Question 7

Give examples of underlying lung disease that can cause secondary pneumothorax.

Answer 7

COPD, Asthma

Bronchiectasis

Lung cancer

Pneumonia

TB

Question 8

Give causes of secondary pneumothorax secondary to trauma.

Answer 8

Fractured rib puncturing the visceral pleura

Blunt chest trauma

Penetrating chest injury

Question 9

Give causes of secondary pneumothorax due to iatrogeny.

Answer 9

High pressure ventilation

Insertion of central lines

Question 10

Symptoms and signs of simple pneumothorax.

Answer 10

Sudden onset of pleuritic chest pain

Breathlessness

Question 11

Findings on examinations of simple pneumothorax

Answer 11

Reduced chest movement on affected side

Hyper-resonance on affected side

Breath sounds reduced on affected side

Vocal resonance is reduced

Question 12

CXR findings of simple pneumothorax.

Answer 12

Hyperlucent on affected side (darker)

Absent lung markings on affected side

Edge of collapsed lung

Question 13

Treatment of pneumothorax.

Answer 13

Needle aspiration may be sufficient if there is a small pneumothorax

If there is a large pneumothorax then insertion of chest drainage might be needed.

Question 14

Where is a chest drain inserted in case of a simple pneumothorax?

Answer 14

In the safe triangle.

In the 5th intercostal space in the mid-axillary line

Just above the 6th rib to avoid the neurovascular bundle.

Question 15

Borders of the safe triangle.

Answer 15

Anteriorly the pectoralis major

Inferiorly the nipple line

Posteriorly the latissimus dorsi.

Question 16

What is a tension pneumothorax?

Answer 16

Can occur due to any aetiology and is defined as any size of pneumothorax causing a mediastinal shift and cardiovascular collapse.

Question 17

Why does the mediastinal shift and cardiovascular collapse happen?

Answer 17

There is compression of the normal lung as air cannot escape the affected side on epxiration.

The intrapleural pressure becomes higher than the atmospheric pressure which causes venous return to be impaired and cardiac output to drop.

This leads to hypoxaemia and haemodynamic compromise.

Question 18

Symptoms and signs of a tension pneumothorax.

Answer 18

Severe resp distress and dyspnoea

Pleuritic chest pain

Fatigue

Tachycardia and hypotension

Raised JVP

Deviated trachea

Displaced apex beat

Hyper-resonance

Absent breath sounds

Question 19

Treatment of tension pneumothorax.

Answer 19

Emergency needle decompression of the chest where a plastic cannula is inserted.

Question 20

Where is the emergency plastic cannula inserted?

Answer 20

Into the 2nd intercostal space in the mid-clavicular line

The cannula is then left in place until the chest drain is inserted in the 4th ICS in the mid-axillary line.

Question 21

Why is an underwater seal used in treatment of pneumothorax?

Answer 21

Question 22

What is a pleural effusion?

Answer 22

Excess of fluid in the pleural cavity.

Question 23

What is pleural fluid secreted by and drained by?

Answer 23

Secreted by parietal pleura and drained through the lympathics of the parietal pleura.

This means that an imbalance in the normal rate of pleural fluid production and drainage will cause a pleural effusion.

Question 24

In a pleural effusion, what can the pleural fluid be?

Answer 24

Transudate or exudate from blood.

Question 25

What is a haemothorax?

Answer 25

When the fluid is blood (trauma e.g.)

Question 26

What is a chylothorax?

Answer 26

When the fluid is lymph (leak from lympathic duct e.g.)

Question 27

What is an empyema?

Answer 27

When the fluid is pus.

Question 28

How is characterisation of the effusion established?

Answer 28

By removal and analysis of some of the fluid.

Question 29

What is a simple pleural effusion?

Answer 29

An effusion which is not a haemothorax, chylothorax, or an empyema.

Question 30

What is a simple pleural effusion categorised by?

Answer 30

According to their protein content

(High protein content - exudate)

(Low protein content - Transudate)

Question 31

Give causes of pleural effusion where transudate is found.

Answer 31

Congestive heart failure leading to increased pressure in venous end of the capillaries.

Hypoproteinaemia like in nephrotic syndrome (increased loss) or liver failure (reduced protein synthesis in cirrhosis).

Question 32

What causes exudate to be found in the pleural space?

Answer 32

An increased capillary permeability due to inflammation.

Question 33

Give causes of pleural effusion due to exudate.

Answer 33

Infection like pneumonia or TB

Cancer like bronchial carcinoma that can block the lymphatic drainage.

Pulmonary infarction due to pulmonary embolism.

Question 34

How can whether the fluid is transudate or exudate be assessed?

Answer 34

Question 35

Symptoms and signs of pleural effusion.

Answer 35

Breathlessness (gradual onset)

Pleuritic chest pain

Features of causative disease

Question 36

Findings on examination of pleural effusion.

Answer 36

Reduced chest movement on affected side

Stony dull sound on percussion on affected side

Reduced breath sounds

Vocal resonance is reduced.

Question 37

Clinical presentation on CXR of pleural effusion.

Answer 37

Question 38

What is the aspirate tested for in a pleural effusion?

Answer 38

Protein content

LDH levels

Bacterial examination including gram stain and culture.

Cytology

Question 39

Treatment of pleural effusion.

Answer 39

Treat underlying condition

In case of severe symptoms drainage may be needed to relieve symptoms.

In very severe cases pleurodesis can be done.