Pneumothorax

Causes

• Can be spontaneous is young thin men due to rupture of subpleural bulla
• Other causes;
  • Asthma
  • COPD
  • TB
  • Pneumonia
  • Lung abscess
  • Carcinoma
  • CF
  • Lung fibrosis
  • Sarcoidosis
  • CT disorders – Marfan’s, Ehlers-Danlos
  • Trauma
  • Iatrogenic

Clinical features

• May be none
• Sudden dyspnoea
• Pleuritis chest pain
• Sudden deterioration of asthma or COPD
• Signs
  • Reduced expansion
  • Hyper-resonance
  • Diminished breath sounds on affected side

Management of a tension pneumothorax

• Mediastium is pushed over onto the contralateral side, kinking and compressing the great veins
• Unless air is rapidly removed cardiopulmonary arrest will occur

Signs

• Respiratory distress
• Tachycardia
• Hypotension
• Distended neck veins
• Trachea deviated from the side of the pneumothorax
• Increased percussion note
• Reduced air entry/breath sounds on affected side

Treatment

• Insert a large bore (14-16G) needle with a syringe partially filled with saline into 2^nd IC space midclavicular line on the side of the suspected pneumothorax
• Alternatively insert a wide bore cannule into the same space
• Do this before requesting a CXR
• Then insert a chest drain

Management of a non-tension pneumothorax

• This depends on whether it is primary or secondary due to underlying lung disease
• Primary pneumothorax
• Is patient SOB and/or rim of air >2cm on CXR? If no consider discharge, if yes
• Aspirate
• If this doesn’t work try and aspirate again and if this doesn’t work insert a chest drain
• Secondary pneumothorax
• Is patient SOB and age >50 with a rim >2cm of air on the CXR? If not aspirate, if yes put in a chest drain
• If the aspirate doesn’t work put in a chest drains

Surgery

• Consider if;
  • Bilateral pneumothoraces
  • Lungs fail to expand after intercostals drain insertion
  • 2 or more pneumothoraces on the same side
  • History of pneumothorax on the opposite side