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    TBL - Pneumothorax

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    ÁýáFáŕőúg
    The document discusses guidelines for managing pneumothorax and different types including primary, secondary, and iatrogenic pneumothorax. It recommends treatments such as observation, aspiration, or chest drain insertion depending on the size and symptoms of the pneumothorax. Tension pneumothorax requires immediate treatment and chest drain insertion as it can lead to reduced venous return and death if not addressed promptly.

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    TBL - Pneumothorax

    Uploaded by

    ÁýáFáŕőúg
    59 views26 pages
    The document discusses guidelines for managing pneumothorax and different types including primary, secondary, and iatrogenic pneumothorax. It recommends treatments such as observation, aspiration, or chest drain insertion depending on the size and symptoms of the pneumothorax. Tension pneumothorax requires immediate treatment and chest drain insertion as it can lead to reduced venous return and death if not addressed promptly.

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    The document discusses guidelines for managing pneumothorax and different types including primary, secondary, and iatrogenic pneumothorax. It recommends treatments such as observation, aspiration, or chest drain insertion depending on the size and symptoms of the pneumothorax. Tension pneumothorax requires immediate treatment and chest drain insertion as it can lead to reduced venous return and death if not addressed promptly.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    59 views26 pages

    TBL - Pneumothorax

    Uploaded by

    ÁýáFáŕőúg
    The document discusses guidelines for managing pneumothorax and different types including primary, secondary, and iatrogenic pneumothorax. It recommends treatments such as observation, aspiration, or chest drain insertion depending on the size and symptoms of the pneumothorax. Tension pneumothorax requires immediate treatment and chest drain insertion as it can lead to reduced venous return and death if not addressed promptly.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 26

    Pneumothorax

    TBL session
    2023
    LIMU
    Department of Emergency
    Medicine

    Aboubakr O. Aldhib
    Question 1

    A 25 year old male is admitted to hospital with acute right sided chest pain and
    SOB. He has no significant past medical history, but is a smoker of 20 cigarettes/day
    and smokes cannabis twice/week.
    A CXR confirms a large right sided pneumothorax. He undergoes needle aspiration
    of 2L and a subsequent plain film shows a small apical pneumothorax.
    His symptoms have resolves and he is clinically stable so is discharged with pleural
    clinic follow up booked the following week.
    He informs you that he has booked to fly to Spain for a short break next month. For
    how long after radiological resolution of a primary spontaneous pneumothorax
    should a patient refrain from air travel?

    A) 1 week
    B) 2 week
    C) 6 week
    D) 1 year
    E) Permanently
    Question 2

    A man came into the ED with SOB and anterior chest pain. CXR showed a
    50% pneumothorax on the right side, with midline shift away from the side
    of the pneumothorax.
    His pulse was 95 bpm and BP was 95/70 mmHg. What should be done next?

    A) wide bore cannula inserted through second ICS mid- clavicular line.
    B) Needle aspiration in mid-axillary line
    C) Chest drain insertion
    D) Repeat chest X- ray after a few hours
    E) Chest drain insertion under radiographic control
    Question 3

    A 60-year-old female with a history of COPD presents to the Emergency


    Department with shortness of breath. Blood pressure is 120/80 mmHg and
    he pulse is 90 bpm. The chest x-ray shows a pneumothorax with a 2.5 cm
    rim of air and no mediastinal shift. What is the most appropriate
    management?

    A) Intercostal drain insertion


    B) Discharge
    C) Admit for 48 hours observation and repeat chest x-ray
    D) Immediate 14G cannula into 2nd intercostal space, mid-clavicular line
    E) Aspiration
    Question 4

    A 22-year-old man presents with sudden onset breathlessness. His oxygen


    saturations are 97% on air. A chest x-ray shows a right-sided
    pneumothorax. You decide to measure the size of the pneumothorax to
    determine your further management.
    At what point on the x-ray do you measure?

    A) Apex
    B) Costophrenic angle
    C) Hilum
    D) Largest point
    E) Second rib
    Question 5

    A 25-year-old smoker presents to the Emergency Department with a 3-


    day history of pleuritic chest pain and mild exertional dyspnoea. A chest
    radiograph confirms a left sided pneumothorax that measures 3 cm at the
    hilum. What would be the correct course of action?

    A) Insert Seldinger chest drain


    B) Aspirate with cannula up to 2.5L and repeat chest X-Ray
    C) Discharge with follow up in 2-4 weeks
    D) Admit for 24 hours observation with conservative treatment
    E) Discharge without follow up
    Question 6
    An emergency room nurse assesses a female client who has sustained a
    blunt injury in the chest wall. Which of the following signs would
    indicate the presence of a pneumothorax in this patient?

    A. A low respiration
    B. Diminished breathing sounds
    C. The presence of a barrel chest
    D. A sucking sound on the site of injury
    Question 7
    A male client was admitted with chest trauma after a motorbike accident
    and has undergone subsequent intubation. The nurse checks the client
    when the high-pressure alarm on the ventilator makes sounds and notes
    down that the client has an absence of breathing sounds in the right upper
    lobe of his lung. What other signs does the nurse immediately assess?

    A. Right pneumothorax
    B. Pulmonary embolism
    C. Displaced endotracheal tube
    D. Acute respiratory distress syndrome
    All of the abo

    Question 8
    When a person is suffering from pneumothorax, which of the following
    are the anatomic alterations that occur?

    A) The lung on the affected side collapses.


    B) The visceral and parietal pleura separate
    C) The chest wall moves outward
    D) All of the above
    Question 9
    What is the primary cause of hypotension in a patient with a
    large pneumothorax?

    Pain
    Decreased venous return to the heart
    Tracheal compression
    Atelectasis
    Question 10
    The following statements about spontaneous pneumothorax are
    true except?

    A) SOB and pleuritic chest pain may be present


    B) Bronchial breathing is audible over the affected hemithorax
    C) Surgical referral is required if there is bronchopleural fistula
    D) Pleurodesis should be considered for recurrent pneumothoraces
    PNEUMOTHORAX: MANAGEMENT

     The British Thoracic Society (BTS) published


    updated guidelines for the management of
    spontaneous pneumothorax in 2010. A
    pneumothorax is termed primary if there is no
    underlying lung disease and secondary if there
    is.
    Primary pneumothorax
    Recommendations include:
    •if the rim of air is < 2cm and the patient is not short of breath then

    discharge should be considered


    •otherwise aspiration should be attempted

    •if this fails (defined as > 2 cm or still short of breath) then a chest

    drain should be inserted


    •patients should be advised to avoid smoking to reduce the risk of

    further episodes - the lifetime risk of developing a pneumothorax in


    healthy smoking men is around 10% compared with around 0.1% in
    non-smoking men
    Secondary pneumothorax

    Recommendations include:
    if the patient is > 50 years old and the rim of air is > 2cm and/or the

    patient is short of breath then a chest drain should be inserted.


    otherwise aspiration should be attempted if the rim of air is between 1-

    2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest
    drain should be inserted. All patients should be admitted for at least 24
    hours
    if the pneumothorax is less the 1cm then the BTS guidelines suggest

    giving oxygen and admitting for 24 hours


    regarding scuba diving, the BTS guidelines state: 'Diving should be

    permanently avoided unless the patient has undergone bilateral surgical


    pleurectomy and has normal lung function and chest CT scan
    postoperatively.'
    Iatrogenic pneumothorax
    Recommendations include:
    •less likelihood of recurrence than spontaneous pneumothorax

    •majority will resolve with observation, if treatment is required then

    aspiration should be used


    •ventilated patients need chest drains, as may some patients with COPD
    Tension pneumothorax
    This is the one not to miss. If you cannot diagnose a tension pneumothorax at
    medical finals you won't find an examiner who will defend you.
    The left hemithorax is black due to air in the pleural cavity.
    Signs of tension
    The left lung is completely compressed (arrowheads).
    The trachea is pushed to the right (arrow)
    The heart is shifted to the contralateral side - note right heart border is pushed to
    the right (red line)
    The left hemidiaphragm is depressed (orange line)
    Important note
    If you diagnose a tension pneumothorax clinically - do not request an X-ray - TREAT
    THE PATIENT!
    Large pneumothorax - early tension

    A large pneumothorax is usually easy to recognise, but always check for


    signs of tension.
    Rising pressure within a hemithorax reduces venous flow to the heart,
    potentially leading to rapid death.
    Signs of tension
    Right heart border (white arrows) and left heart border (black arrows)
    shifted to the left
    Right hemidiaphragm slightly depressed - should be higher than the left
    Minor shift of the trachea - unlikely to be clinically detectable
    Don't waste time discussing the exact definition of a tension
    pneumothorax - this patient needs attention - NOW! Start with ABC and
    get help

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