Pneumothorax

• What is pneumothorax?

  Pneumothorax occurs when air enters the pleural space, separating the lung from the chest wall.
• How can pneumothorax occur?

  Pneumothorax can occur spontaneously or secondary to trauma, medical interventions, or lung pathology.
• Who is the typical patient presenting with pneumothorax in exams?

  The typical patient is a tall, thin young man presenting with sudden breathlessness and pleuritic chest pain.
• What are the causes of pneumothorax?

  • Spontaneous
  • Trauma
  • Iatrogenic (e.g., lung biopsy, mechanical ventilation, central line insertion)
  • Lung pathologies (e.g., infection, asthma, COPD)
• What is the investigation of choice for diagnosing a simple pneumothorax?

  An erect chest x-ray is the investigation of choice for diagnosing a simple pneumothorax.
• What does an erect chest x-ray show in a pneumothorax diagnosis?

  It shows an area between the lung tissue and the chest wall with no lung markings.
• How is the size of a pneumothorax measured on a chest x-ray?

  It is measured horizontally from the lung edge to the inside of the chest wall at the level of the hilum.
• What can CT thorax detect regarding pneumothorax?

  CT thorax can detect a pneumothorax that is too small to be seen on a chest x-ray.
• What are the acute management steps for pneumothorax according to the 2023 guidelines?

  • Check latest local and national guidelines
  • Consult with seniors when managing patients
  • High-risk patients generally require a chest drain
  • Lower-risk patients with a pneumothorax smaller than 2 cm are managed conservatively
• What characterizes high-risk patients with pneumothorax?

  High-risk patients may have haemodynamic compromise, bilateral pneumothorax, hypoxia, or underlying lung disease.
• How are lower-risk patients with a pneumothorax smaller than 2 cm managed?

  They are generally managed conservatively with regular outpatient reviews.
• What are the management options for lower-risk patients with a pneumothorax greater than 2 cm?

  • 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 or chest drain
• What is a pleural vent ambulatory device?

  A pleural vent involves a catheter inserted into the pleural space attached to a device that allows air to exit but not return.
• Where are chest drains inserted?

  Chest drains are inserted in the "triangle of safety."
• What defines the "triangle of safety" for chest drain insertion?

  • 5th intercostal space (or the inferior nipple line)
  • Midaxillary line (or the lateral edge of the latissimus dorsi)
  • Anterior axillary line (or the lateral edge of the pectoralis major)
• Why is the needle inserted just above the rib during chest drain insertion?

  The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib.
• What should be done after inserting a chest drain?

  Obtain a chest x-ray to check the positioning of the drain.
• How does the chest drain create a seal?

  The external end of the drain is placed underwater, preventing air from flowing back through the drain into the chest.
• What happens to the water in the drain during normal respiration?

  The water in the drain will rise and fall due to changes in pressure in the chest, described as "swinging."
• What indicates successful treatment of pneumothorax with a chest drain?

  Successful treatment is indicated by air bubbling through the fluid in the drain bottle and swinging of the water with respiration.
• What should occur on a repeat chest x-ray after successful treatment of pneumothorax?

  There should be re-inflation of the lung on a repeat chest x-ray.
• What could indicate a problem with the chest drain?

  Problems may be indicated by a blocked or kinked tube, incorrect position in the chest, or not correctly connected to the bottle.
• What are the key complications of chest drains?

  • Air leaks around the drain site (persistent bubbling of fluid, particularly on coughing)
  • Surgical emphysema (subcutaneous emphysema)
• When might patients require surgical interventions for pneumothorax?

  Surgical interventions may be required when a chest drain fails to correct the pneumothorax, there is a persistent air leak, or the pneumothorax recurs.
• What surgical technique can be used to correct a pneumothorax?

  Video-assisted thoracoscopic surgery (VATS) can be used to correct a pneumothorax.
• What are the surgical options for treating pneumothorax?

  • Abrasive pleurodesis (direct physical irritation of the pleura)
  • Chemical pleurodesis (using chemicals like talc powder to irritate the pleura)
  • Pleurectomy (removal of the pleura)
• What is the purpose of pleurodesis?

  Pleurodesis involves creating an inflammatory reaction in the pleural lining so the pleura sticks together and the pleural space becomes sealed.
• What causes tension pneumothorax?

  Tension pneumothorax is caused by trauma to the chest wall that creates a one-way valve allowing air in but not out of the pleural space.
• What happens during inspiration in tension pneumothorax?

  Air is drawn into the pleural space during inspiration, but during expiration, the air is trapped in the pleural space.
• Why is tension pneumothorax dangerous?

  It creates pressure inside the thorax that can push the mediastinum across, kink the big vessels, and cause cardiorespiratory arrest.
• What are the signs of tension pneumothorax?

  • Tracheal deviation away from the side of the pneumothorax
  • Reduced air entry on the affected side
  • Increased resonance to percussion on the affected side
  • Tachycardia
  • Hypotension
• What is a pneumothorax?

  Pneumothorax occurs when air enters the pleural space, separating the lung from the chest wall.
• What are the main causes of pneumothorax?

  Pneumothorax can occur spontaneously, due to trauma, due to medical interventions (iatrogenic), or due to lung pathologies.
• What is the typical patient presentation for pneumothorax?

  The typical patient in exams is a tall, thin young man presenting with sudden breathlessness and pleuritic chest pain, possibly whilst playing sports.
• What is the investigation of choice for diagnosing a simple pneumothorax?

  An erect chest x-ray is the investigation of choice for diagnosing a simple pneumothorax.
• What does a chest x-ray show in a patient with a pneumothorax?

  A chest x-ray shows an area between the lung tissue and the chest wall with no lung markings, and a line demarcating the edge of the lung where the lung markings end and the pneumothorax begins.
• How can the size of a pneumothorax be measured on a chest x-ray?

  The size of the pneumothorax on a chest x-ray can be measured horizontally from the lung edge to the inside of the chest wall at the level of the hilum, according to the BTS guidelines.
• What additional imaging modality can be used to detect small pneumothoraces?

  CT thorax can detect a pneumothorax that is too small to be seen on a chest x-ray.
• What are the key characteristics that determine if a patient with pneumothorax requires a chest drain?

  Patients with high-risk characteristics (e.g., haemodynamic compromise, bilateral pneumothorax, hypoxia or underlying lung disease) generally require a chest drain.
• How are lower-risk patients with a pneumothorax greater than 2 cm managed?

  Lower-risk patients with a pneumothorax greater than 2 cm are categorised based on the patient's main priority - procedure avoidance, rapid symptom relief with ambulatory care, or rapid symptom relief with short-term drainage.