Pneumothorax and Tension pneumothorax

• What is a pneumothorax?

  When air gets into the pleural space separating the lung from the chest wall
• What is the typical patient to present with a pneumothorax?

  Tall, thin young man with sudden breathlessness, pleuritic chest pain following playing sports.
• Give 4 causes of pneumothorax

  Spontaneous

  Trauma

  Iatrogenic

  Lung pathologies such as asthma, COPD or infection
• What investigations are needed for suspected pneumothorax?

  Erect chest x-ray

  CT thorax
• What would you see on X-ray of pneumothorax

  No lung markings

  Line demarking the edge of the lung
• Why is imaging needed in suspected pneumothorax?

  So that the size of it can be measured
• Why would a CT thorax be done after a CXR for pneumothorax?

  If the pneumothorax is too small to see on CXR and to assess the size more accurately.
• What determines the management of pneumothorax?

  The size of it and also presence of shortness of breath.
• How would you manage a patient with a pneumothorax <2cm and asymptomatic (no SOB)?

  No treatment required, just follow up in 2-4 weeks.
• How would you manage a patient with shortness of breath and a pneumothorax of 2cm or greater?

  Aspiration

  If aspiration fails twice then insert a chest drain.
• What are the requirements for managing pneumothorax with a chest drain?

  Unstable patients

  Bilateral pneumothorax

  Secondary pneumothorax
• Where would you insert a chest drain?

  In the triangle of safety
• What are the borders of the triangle of safety?

  5th intercostal space

  Anterior axillary line which is the border of pectoralis major

  Midaxillary line which is the border of latissimus dorsi
• Where is the needle specifically inserted for chest drain?

  Above the rib to avoid the neurovascular bundle that runs below the rib.
• How do you know that the chest drain is working and in the right place?

  Swinging of the water with respiration
• What are 2 complications of chest drains?

  Air leaks around drain site

  Surgical emphysema - air collects in subcutaneous tissue
• When would surgical management be indicated in pneumothorax?

  Recurrent pneumothorax
• Give 3 surgical options for pneumothorax

  Abrasive pleurodesis

  Chemical pleurodesis

  Pleurectomy
• What is pleurodesis?

  When the pleura sticks together and seals the pleural space
• What is tension pneumothorax?

  Trauma to the chest wall that creates a one way valve that lets air in but not out of the pleural space.
• Why is tension pneumothorax dangerous?

  Pressure inside the thorax that will push the mediastinum across, kink the big vessels and cause cardiopulmonary arrest.
• Give 5 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
• How do you manage tension pneumothorax?

  Insert a large bore cannula into the second intercostal space in the midclavicular line.

  OR

  Fourth or fifth intercostal space, anterior to the midaxillary line
• Once the pressure is relieved after insertion of cannula for tension pneumothorax what should be done next?

  Insert chest drain