Pneumothorax

• Spontaneous pneumothorax occurs without any apparent cause, often in young, tall, thin individuals.
• Primary pneumothorax = in a patient without known respiratory disease

  Secondary pneumothorax = in a patient with pre existing respiratory disease

  Tension pneumothorax = severe pneumothorax with displacement of trachea / mediastinum and haemodynamic instability
• Causes of secondary pneumothorax include:

  • Chronic obstructive pulmonary disease
  • Asthma
  • Cystic fibrosis
  • Marfan syndrome
• Causes of tension pneumothorax include:

  • Penetrating/blunt trauma
  • Mechanical ventilation or non-invasive ventilation
  • Conversion of simple pneumothorax to tension pneumothorax
• Risk factors for pneumothorax include:

  • Smoking
  • Tall and thin build
  • Male sex
  • Young age (in primary pneumothorax)
• A small pneumothorax may be asymptomatic.

  Typical symptoms of pneumothorax include:

  • Ipsilateral pleuritic chest pain
  • Dyspnoea
  • Cough
• Other important areas to cover in the history include:

  • Recent trauma to the chest wall
  • Smoking history: quantify in pack-years (1 pack-year equates to smoking 20 cigarettes a day for a whole year)
  • Family history of pneumothorax
• Typical clinical findings in pneumothorax include (on the same side as the pneumothorax):

  • Hyper-resonant lung percussion
  • Reduced breath sounds
  • Reduced lung expansion
• In addition, typical clinical findings in tension pneumothorax include:

  • Tracheal deviation away from the pneumothorax
  • Severe tachycardia
  • Hypotension
• Investigations for pneumothorax:

  • FBC in trauma patients
  • ABG
  • Pulse oximetry
  • Lung ultrasound in trauma patients - absence of lung sliding sound
  • CXR - rim between lung margin and chest wall
  • Margin >2cm is a large pneumothorax
• Management of a tension pneumothorax is emergency decompression with a large bore cannula and then chest drain insertion
• Management of primary pneumothorax:

  • > 2 cm or SOB - aspirate
  • Can be discharged if successful and repeat CXR in 2-4 weeks
  • Chest drain if unsuccessful
• Management of secondary pneumothorax:

  • 1-2 cm margin - aspirate
  • > 2 cm or SOB - chest drain
  • Admit and observe
  • High flow oxygen (caution in COPD)
• patients should not fly until full resolution of pneumothorax