Pneumothorax

• Pneumothorax


  Occurs when air enters the pleural space, separating the lung from the chest wall
• Causes of Pneumothorax


  • Spontaneous
  • Trauma
  • Iatrogenic (e.g., due to lung biopsy, mechanical ventilation, central line insertion)
  • Lung pathologies such as infection, asthma, COPD
• Investigations for Pneumothorax


  1. Erect chest x-ray is the investigation of choice for diagnosing a simple pneumothorax

  2. Measuring the size of the pneumothorax on a chest x-ray according to BTS guidelines (2010)

  3. CT thorax can detect a pneumothorax that is too small to be seen on a chest x-ray and assess the size accurately
• Management of Pneumothorax


  Acute management based on the 2010 guidelines from the British Thoracic Society. Always check the latest local and national guidelines, and consult with healthcare professionals
• Management


  1. Based on the 2010 guidelines from the British Thoracic Society

  2. Always check the latest local and national guidelines, and consult with seniors when managing patients
• No shortness of breath and less than a 2cm rim of air on the chest x-ray


  1. No treatment is required as it will spontaneously resolve

  2. Follow-up in 2 – 4 weeks is recommended
• Shortness of breath or more than a 2cm rim of air on the chest x-ray

  1. Aspiration followed by reassessment

  2. When aspiration fails twice, a chest drain is required
• Unstable patients, bilateral or secondary pneumothoraces

  Generally require a chest drain
• Chest Drain


  1. Chest drains are inserted in the “triangle of safety” formed by the 5th intercostal space, Midaxillary line, and Anterior axillary line

  2. The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib

  3. Once the chest drain is inserted, obtain a chest x-ray to check the positioning

  4. The external end of the drain is placed underwater to create a seal to prevent air from flowing back through the drain into the chest

  5. During normal respiration, the water in the drain will rise and fall due to changes in pressure in the chest (described as “swinging”)
• Successful treatment of pneumothorax with chest drain

  1. Air will bubble through the fluid in the drain bottle

  2. There will be swinging of the water with respiration

  3. On a repeat chest x-ray, there will be re-inflation of the lung
• Problems with the chest drain

  1. Blocked or kinked tube

  2. Incorrect position in the chest

  3. Not correctly connected to the bottle
• Resolution of pneumothorax


  1. No further bubbling in the drain bottle

  2. Swinging of the water with respiration will reduce
• Complications of chest drains

  • Air leaks around the drain site
  • Surgical emphysema (subcutaneous emphysema)
• Surgical Management


  1. Patients may require surgical interventions when a chest drain fails to correct the pneumothorax, there is a persistent air leak in the drain, or the pneumothorax reoccurs (recurrent pneumothorax)

  2. Video-assisted thoracoscopic surgery (VATS) can be used to correct a pneumothorax
• Surgical options for pneumothorax

  • Abrasive pleurodesis (using direct physical irritation of the pleura)
  • Chemical pleurodesis (using chemicals, such as talc powder, to irritate the pleura)
  • Pleurectomy (removal of the pleura)
• Pleurodesis


  Involves creating an inflammatory reaction in the pleural lining so the pleura sticks together and the pleural space becomes sealed to prevent further pneumothoraces from developing
• Tension pneumothorax is caused by trauma to the chest wall that creates a one-way valve
• Inflammatory reaction in the pleural lining


  Pleura sticks together and the pleural space becomes sealed
• Tension pneumothorax is caused by trauma to the chest wall creating a one-way valve that lets air in but not out of the pleural space
• Tension pneumothorax


  Air is drawn into the pleural space during inspiration and trapped during expiration, creating pressure inside the thorax
• Tension pneumothorax


  Creates pressure inside the thorax to push the mediastinum across, kink the big vessels in the mediastinum, and cause cardiorespiratory arrest
• 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
• Management of Tension Pneumothorax: 'Insert a large bore cannula into the second intercostal space in the midclavicular line'
• Advanced Traumatic Life Support (ATLS) recommends using the fourth or fifth intercostal space, anterior to the midaxillary line for adults due to smaller chest wall thickness
• If a tension pneumothorax is suspected, do not wait for any investigations. A chest drain is required for definitive management once the pressure is relieved with a cannula