Pneumothorax

Background/Epidemiology/Aetiology

  • Air in the pleural space
  • Primary disease is more common in younger individuals (typically tall, thin males).  Almost all cases in elderly patients will be secondary e.g. rib fracture, TB, mesothelioma etc
  • Can be spontaneous – primary or secondary to underlying cause
    • Spontaneous
      • Primary
        • No evidence of lung disease.  Air escapes from the lung through a ruptured pleural bleb or pleural adhesion
      • Secondary
        • e.g. in COPD, TB, asthma, lung abscess, lung Ca, fibrotic disease, cystic disease
    • Traumatic/Iatrogenic
      • Following surgery/biopsy/procedure etc
      • Chest wall injury
  • Can also be classified as open or closed (or tension)
    • Closed pneumothoraces close off as the lung deflates.  Reabsorption/re-inflation can therefore occur over days/weeks
    • Open disease does not close off.  Common causes include ruptured bullous diseases (including TB cavity/lung abscess)
    • Tension pneumothorax occurs when the communication acts as a one-way valve (letting air out but not in).  This is an emergency- it can quickly deteriorate, causing pressure and displacement of the other organs

Clinical Features

  • Commonly sudden-onset unilateral pleuritic chest pain and/or breathlessness
  • Reduced sounds on auscultation and hyperresonant percussion may be signs in patients with significant disease (small pneumothorax may have normal examination)
  • Tension pneumothorax
    • Rapidly progressive shortness of breath with
      • tachycardia
      • hypotension
      • cyanosis
      • tracheal displacement
      • silent hemithorax
  • Other signs may include asymmetrical breathing; pulsus paradoxicus (slowed pulse on inspiration)

Investigation

  • CXR
  • chest0018a
  • CT can also be used

Management

  • Spontaneous pneumothorax
    • Age >50 and significant smoking history or evidence of underlying lung disease on examination or CXR?  (I.e. primary vs secondary)
    • Primary
      • >2cm (or >1/3 of lung) (NB some centres use 20% lung volume as a cut off) and/or breathless
        • Aspirate 16-18G cannula (<2.5l) (2nd (or 3rd) IC space, midclavicular line)
          • If successful, consider discharge and review in 2-4 weeks
          • If unsuccessful, chest drain (5th IC space- mid-axillary line)
      • <2cm with no breathlessness
        • Consider discharge and review in 2-4 weeks
    • Secondary (all patients admit, O2 therapy and observe for 24 hours)
      • >2cm and/or breathless
        • chest drain (5th IC space, mid-axillary line)
      • 1-2cm
        • Aspirate then drain if unsuccessful
      • <1cm
        • Admit for 24 hours with O2 therapy
      • NB If the pneumothorax is secondary to an open (i.e. puncture) wound-
        • Seal off the wound
        • Chest drain
        • Then close wound
  • Recurrent pneumothorax
    • Consider surgical pleurodesis for patients after 2nd event
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

w

Connecting to %s