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Popular Search heart failurehypertensionpneumothoraxhypernatrehypernat

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Pneumothorax

Table of Contents
  • Overview
  • Triage
  • Causes
  • Clinical features
  • Investigations
  • Classification
  • Management
    • Management - small asymptomatic pneumothorax
  • Diagnosis
  • References

Overview #

Definitions

A pneumothorax refers to gas in the pleural space. This can be classified by aetiology [1]:

  • Primary spontaneous pneumothorax: no precipitating event, no pre-existing lung disease
  • Secondary spontaneous pneumothorax: complication of pre-existing lung disease such as COPD
  • Traumatic pneumothorax: due to blunt or penetrating trauma

The severity of pneumothorax can also be classified:

  • Simple
  • Tension: air accumulates progressively in the pleural cavity with haemodynamic compromise [2]

Prioritisation

URGENT: A tension pneumothorax can progress to cardiac arrest and death within minutes [2]

Triage #

Emergency requiring immediate attention. If tension pneumothorax is suspected, immediate escalation is required.

Causes #

Risk factors: [1]

Primary spontaneous pneumothorax

  • Tall thin males between 10 to 30 years old
  • Smoking
  • Marfan syndrome

Secondary spontaneous pneumothorax

  • COPD
  • Cystic fibrosis
  • Lung malignancy

Differentials: [3]

  • Acute pulmonary embolism
  • Pleuritis
  • Pneumonia
  • Myocardial ischaemia or infarction
  • Pericarditis
  • Musculoskeletal pain

Clinical features #

History:

  • Sudden onset
  • Typically unilateral chest pain, often pleuritic
  • Dyspnoea
  • Recent exercise, air travel, scuba diving or illicit drug use
  • Recent invasive procedure or trauma to chest, neck, gut or abdomen

Examination:

  • Increased work of breathing
  • Decreased chest expansion
  • Decreased breath sounds
  • Hyperresonance to percussion
  • Contralateral tracheal deviation: Indicates tension pneumothorax

Look out for vitals as a guide to the severity:

  • Hypoxia
  • Tachycardia
  • Tachypnoea
  • Hypotension

Investigations #

Initial investigations [3]

InvestigationSignificance
Chest x-ray [4]Visceral pleural edge – sharp white lineAbsent lung markingsRadiolucent compared to normal lungMediastinal shift – indicates tension pneumothorax
ECGRule out acute coronary syndrome
COVID 19 swabTo confirm COVID 19 status

Further investigations to consider

InvestigationIndication
TroponinRule out acute coronary syndrome
D-dimerRule out pulmonary embolism
ABGPneumothorax typically causes acute respiratory alkalosis
CT chest *If uncertain after CXR findings

* Consult with senior before ordering

Classification #

Consider size [5]:

  • Small pneumothorax – visible rim < 2cm between lung margin and chest wall
  • Large pneumothorax – visible rim ≥ 2cm between lung margin and chest wall

Consider clinical features:

  • Asymptomatic
  • Symptomatic

Consider severity:

  • Simple
  • Tension
  • Bilateral

Management #

Management – symptomatic pneumothorax

!! URGENT – notify senior clinician immediately !!

Initial management:

  • COVID 19 status should be confirmed – if unsure, manage as presumed COVID 19 positive. 
  • DRSABCD
  • MET call – if signs of shock
  • Code blue – if airway compromise (eg. tension pneumothorax)
  • Analgesia
  • Refer to respiratory, cardiothoracics or trauma team as appropriate

Further management (requiring senior clinician):

  • Observation 
  • Supplemental oxygen 
  • Needle aspiration or chest drain insertion
Management – small asymptomatic pneumothorax #

Management

  • COVID 19 status should be confirmed – if unsure, manage as presumed COVID 19 positive. 
  • Analgesia if required
  • Consider conservative management (including supplemental oxygen) after discussion with senior
  • Repeat CXR after 4 hours

Diagnosis #

Clinical diagnosis or imaging features (see investigations section)

References #

  1. Lee YC. Pneumothorax in adults: Epidemiology and etiology. In: Broaddus V, ed. by. UpToDate [Internet]. Waltham, MA: UpToDate Inc.; 2020 [cited 31 August 2021]. Available from: https://www.uptodate.com 
  2. ​​Qureshi P, Gaillard F. Tension pneumothorax [Internet]. Radiopaedia.org. 2021 [cited 31 August 2021]. Available from: https://radiopaedia.org/articles/tension-pneumothorax?lang=us 
  3. Lee YC. Clinical presentation and diagnosis of pneumothorax. In: Broaddus V, ed. by. UpToDate [Internet]. Waltham, MA: UpToDate Inc.; 2020 [cited 31 August 2021]. Available from: https://www.uptodate.com 
  4. Luhar M, Gorrochategui M. Pneumothorax [Internet]. Radiopaedia.org. 2021 [cited 31 August 2021]. Available from: https://radiopaedia.org/articles/pneumothorax 
  5. MacDuff A, Arnold A, Harvey JManagement of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010Thorax 2010;65:ii18-ii31.
  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr Norine Ma

Dr Asha Bonney

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Updated on May 1, 2023
Table of Contents
  • Overview
  • Triage
  • Causes
  • Clinical features
  • Investigations
  • Classification
  • Management
    • Management - small asymptomatic pneumothorax
  • Diagnosis
  • References

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