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Pneumothorax

Background knowledge ๐Ÿง 

Definition

  • An accumulation of air or gas in the pleural space, leading to lung collapse

Classification/Types

  • Spontaneous pneumothorax: occurs without trauma or an obvious trigger
    • High-risk characteristics: haemodynamic compromise, significant hypoxia, bilateral pneumothorax, underlying lung disease, โ‰ฅ50 years with significant smoking history, haemopneumothorax
    • No high-risk characteristics
  • Traumatic pneumothorax: result of blunt or penetrating injury
  • Tension pneumothorax: air enters but cannot exit the pleural space, leading to increasing intrathoracic pressure (medical emergency)
  • Iatrogenic pneumothorax: result of medical procedures, e.g. central line insertion, lung biopsy

Clinical Features ๐ŸŒก๏ธ

Symptoms

  • Sudden onset of pleuritic chest pain
  • Dyspnoea

Signs

  • On affected side
    • Reduced chest expansion
    • Hyperresonance to percussion
    • Decreased breath sounds
  • In tension pneumothorax: severe respiratory distress, tracheal deviation away from affected side, distended neck veins, hypotension

Investigations ๐Ÿงช

Imaging

  • Chest X-ray: shows absence of lung markings peripherally and a visible pleural line
  • CT scan: useful if it is unclear whether it is safe to intervene, it is a complicated pneumothorax, the diagnosis is uncertain, or to evaluate for underlying lung disease

Management ๐Ÿฅผ

Management options

  • High risk characteristics present โ†’ chest drain (a tension pneumothorax will require needle thoracostomy to stabilise the patient first)
  • No high risk characteristics present โ†’ multiple options depending on patient priories
    • Observation with serial CXRs
    • Ambulatory pleural device
    • Needle aspiration
    • Chest drain

Surgical intervention: may be required in recurrent cases or persistent cases, most commonly by video-assisted thoracoscopic surgery (VATS)

Prognosis

  • Air travel must be avoided for at least 2 weeks after successful full lung re-expansion

Complications

  • Recurrent pneumothorax
  • Respiratory failure: in cases of bilateral pneumothoraces or in patients with compromised lung function
  • Haemothorax: If blood vessels are damaged or iatrogenic related to chest drain insertion

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