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Definition of a pneumothorax

  • Air in the pleural space leading to lung deflation. Pneumothoraces can be divided into:
    • Primary: otherwise “normal” lung
    • Secondary: underlying lung disease e.g. COPD
    • Tension: mediastinal shift and respiratory compromise


Epidemiology of pneumothoraces

  •  Approximately 10 per 100,000
  • Male>Female (6:1)
  • > 40 years often associated with COPD
  • Smoking increases the risk of pneumothorax


Causes of pneumothoraces

  • Spontaneous/ Primary
    • Thought to be due to congenital weakness of a pleural bleb
  • Secondary
    • COPD, Asthma, Lung cancer, Pulmonary Fibrosis, TB, Sarcoid, CF, PCP
    • Marfans, Ehlers Danlos, Psuedoxanthoma elasticum
  • Iatrogenic
    • Pleural aspiration or biopsy
    • CVP or pacemaker insertion
    • CPR
  • Chest trauma
    • Penetrating chest injury
      • Tension pneumothorax is more likely in this group
  • Intubation and ventilation
    • Especially with high pressures used


Presentation of a pneumothorax

  • Pleuritic chest pain and shortness of breath
    • (but note may be asymptomatic)
  • Signs:
    • Tachycardia and tachypnoea
    • Cyanosis
    • Tracheal deviation
    • Hyper-resonance to percussion
    • Decreased breath sounds
    • In tension pneumothorax:
      • Raised JVP, pulsus paradoxus, marked tracheal deviation, Tachycardia >135, hypotension, distended neck veins


Differential diagnosis of a pneumothorax

  • Pleural effusion
  • PE
  • Pneumonia
  • Pericarditis


Investigation of a pneumothorax

  • ABG
    • Hypoxia, severity dependent on size of pneumothorax and respiratory reserve
  • CXR
    • Will show characteristic rim around outside of lung
    • Size can be estimated by depth of rim at hilum
      • 2cm is approximately equal to 50% lung volume lost
    • In supine films, look for deep costophrenic sulci, darkened lung field and prominent heart border.
  • USS Chest
    • Can be helpful to look for iatrogenic pneumothorax following US guided drain insertion/ pleural biopsy
  • CT
    • Can detect occult pneumothoraces
    • Can be useful to differentiate bullae from pneumothorax
    • To look for causes of persistent leak in patients with non-resolving pneumothorax


Staging of pneumothorax

  • Small vs Large
    • > 2cm rim between lung margin and chest wall at the level of the hilum


Management of a pneumothorax

  • Observation In small primary pneumothorax without significant shortness of breath.
  • Patients with primary or secondary pneumothorax and significant breathlessness should undergo active intervention


Further management of a pneumothorax

  • Surgical
    • Those with persistent air leak at 48 hours should be discussed with thoracic surgeons.
    • Surgical management options include:
      • Open thoracotomy and pleurectomy (give lowest recurrence rates)
      • VATs with pleurectomy and pleural abrasion (better tolerated)
      • Surgical chemical pleurodesis
  • Medical pleurodesis
    • Considered for patients refusing/ not fit enough for surgery
  • Ambulatory management with Heimlich valve
  • Smoking cessation


Treatment of tension pneumothorax (a medical emergency):

  • High-flow oxygen
  • Emergency needle decompression
    • Large cannula, second intercostal space (just above third rib), mid-clavicular line
    • Converts tension to a simple pneumothorax
  • Followed by chest drain insertion for definitive management



Complications of pneumothoraces

  • Respiratory failure
  • Conversion to tension pneumothorax
  • Bronchopleural fistula
  • Recurrence


Prognosis in pneumothorax

  • Good if treated but recurrence is common: up to 30% overall.
  • Mortality low, but increased in secondary versus primary pneumothorax


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