Pneumothorax

Original article by Tom Leach | Last updated on 2/3/2015
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Introduction

A pneumothorax is a collection of air in the pleural space. They can be:
  • Primary – no underlying lung disease. Typically, tall thin young men might have a spontaneous pneumothorax
  • Secondary – to underlying lung disease - such as COPD
 
They can be divided into:

Standard or simple pneumothorax

  • Air in the pleural space, but the volume is not increasing.
  • On CXR: trachea is not deviated. Lung collapse may be visible (sometimes subtle – decreased vascular markings around the outer lung field)
  • spontanous pneumothroax typically occurs in THIN + TALL YOUNG men due to rupture of pleural bleb - the bleb is from congenital defect in the CT tissue of the alveolar wall.

Tension pneumothorax – LIFE THREATENING

  • Air in the pleural space, and the volume continuing to increase. Typically due to the formation of a one-way valve, allowing air into the pleural space on inspiration, but not out again on expiration.
  • On CXRthe trachea may be deviated away from the side of the pneumothorax. Lung collapse likely to be more obvious.
clinical features tension pneumothorax:
!) Plueritic chest pain
2)Breathlessness
3)large pneomothroax = reduced breath sounds affected area and hyper-resonant on percussion.

comlication:
1) it can compress the mediastinum = Decrease Cardiac Output (compressed heart) , increase Heart Rate, Jagular vien distension

INVESTIGATION:

1) Its a clinical Diagnosis
2) if on the X-ray there is LARGE bleb or not sure if its a pheomothorax....then Get CT scan to make sure its not BLEB to save the patient a pontentially dangerous needle aspiration. (BLEB needs surgical resection)

 

Emergency Treatment

Standard Pneumothorax – must do CXR first before attempting to treat!

Rim of air <2cmconsider alternate diagnosis, OR small pneumothorax that will resolve with conservative management.

  • discharge on advice - dont do strenuous exercise - and return if Breathless.
  • oberserve at 2 weekly until air is reasorped

Primary Pneumothorax - SOB + rim of air >2cm on CXR:

  • Attempt aspiration – 2ND INTERCOSTAL SPACE, MIDCLAVICULAR LINE!
  • If unsuccessful, repeat
  • If unsuccessful, consider chest drain

Secondary Pneumothorax  - SOB + rim of air >2cm on CXR

 
Tension Pneumothorax
  • If suspected, attempt to aspirate before CXR. Use a large bore needle with syringe, filled with saline, to act as a water seal, when entering the pleural space.

if pneumothorax remains at 48 hours or patient has reccurent episodes then do >>> Pleurectomy.