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==[[Spontaneous pneumothorax]]==
==Types==
===Background===
*[[Spontaneous pneumothorax]]
*Primary Pneumothorax
**Spontaneous ptx in pt w/o underlying pulm disease
*Secondary Pneumothorax
**Spontaneous ptx in pt w/ underlying pulm disease
**Worse prognosis
 
===Causes===
#Smoking
#[[COPD]]
#[[Asthma]]
#Cystic fibrosis
#Necrotizing pneumonia
#Lung abscess
#[[PCP]] PNA
#[[TB]]
#Neoplasm
#Interstitial lung disease
#Connective tissue disease
#Pulmonary infarct
 
===Clinical Features===
*Sudden onset pleuritic chest pain evolving to dull constant ache over days
*Most often occurs at rest, not during exertion
*Tachypnea, hypoxemia, increased work of breathing
*Reduced ipsilateral lung excursion
*Hypotension -> tension pneumothorax
 
===Diagnosis===
*[[Ultrasound: Lungs]]
**NO comet tail artifact
**No sliding lung sign
**Bar Code (instead of waves on the beach) appearance on M-mode
*CXR
[[File:Pneumothorax.jpeg|thumbnail]]
[[File:Pneumothorax.jpeg|thumbnail]]
**Displaced visceral pleural line w/o lung markings between pleural line and chest wall
**Air fluid level with [[Pleural Effusion]] = ptx
**Supine CXR view shows deep sulcus sign
*CT Chest
**Very sensitive and specific
*Size
**Large >3cm lung apex to cupola (chest wall)
**Small <3cm apex to cupola (chest wall)
===Differential Diagnosis===
{{Thoracic trauma DDX}}
===Management===
*Important considerations are:
#Stability
##RR<24, O2 Sat >90%, HR between 60-120, nl BP
##Can speak in full sentences
##Absence of hemothorax
#Size of ptx
#Primary or secondary pneumothorax
===Special Instructions===
'''Flying'''
*Patients can consider flying 1 week after resolution of pneumothorax <ref name="BTC">British Thoracic Society Guidelines [https://www.brit-thoracic.org.uk/Portals/0/Guidelines/PleuralDiseaseGuidelines/Pleural%20Guideline%202010/Pleural%20disease%202010%20pneumothorax.pdf PDF]</ref>
==General Treatment Options==
#Observation alone
#Observation + oxygen,
##Oxygen (3L/min nasal cannula to 10L/min mask) increases pleural air resorption by 3-4x
#Needle or catheter aspiration
##Needle/catheter aspiration is as effective as chest tube for small ptxs
###Place in 2nd IC space in midclavicular line or 4th/5th IC space in ant axillary line
###If lung fails to expand can try 2nd aspiration attempt, Heimlich valve, or chest tube
#Tube thoracostomy
##Use for large, recurrent, or b/l ptxs, abnormal vitals, or large air leak anticipated
##Underwater seal drainage is adequate (suction only necessary if persistent air leak)
===Primary Spontaneous Pneumothorax===
#Small size, clinically stable
##Option 1: Observe for 6hr; d/c if no sx and have pt return in 24hr for recheck
##Option 2: Small-size catheter (<14F) or needle aspiration with immediate catheter removal
###Then observe for 6h; d/c if no sx and have pt return in 24hr for recheck
##Option 3: Small-size catheter or chest tube (10-14F), Heimlich valve or water-seal, admit
#Large size or bilateral
##Mod-size chest tube (16-22) and admit; large-size chest tube (24-36) if hemothorax
===Secondary Pneumothorax===
#Small size, clinically stable
##Small-size catheter or chest tube, Heimlich valve or water-seal drainage, and admit
##Observation alone associated with some mortality
#Large size or bilateral
##Mod-size chest tube (16-22) and admission; large-size chest tube (24-36) if hemothorax


==[[Tension pneumothorax]]==
==[[Tension pneumothorax]]==

Revision as of 18:12, 4 December 2014

Types

Pneumothorax.jpeg

Tension pneumothorax

  • Death occurs from hypoxic respiratory arrest (V-Q mismatch), not circulatory arrest

Diagnosis

  • Diminished or absent breath sounds
  • Hypotension or e/o hypoperfusion
  • Distended neck veins
    • May not occur if pt is hypovolemic
  • Tracheal deviation
    • Late sign

Treatment

  • Immediate needle decompression if unstable
    • 14ga IV in midclavicular line just above the rib at the second intercostal space
  • Always followed by Chest Tube placement


Traumatic pneumothorax

Background

  • Present in 25% of pts w/ chest trauma
  • Rib fx and penetrating trauma most common causes
  • Isolated ptx does not cause severe symptoms until >40% of hemithorax is occupied

Types

  • Can be open, closed, or occult
    • Open
      • Communication between pleural space and atmospheric pressure (sucking chest wound)
    • Occult
      • PPV can convert an occult ptx to a tension ptx

Diagnosis

  • Ptx after a stab wound may be delayed for up to 6 hr
    • If pt decompensates obtain repeat imaging
  • CXR
    • Upright is best (esp expiratory film)
      • Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
      • No lung markings distal to white line
    • Supine
      • Look for deep sulcus sign
  • US
    • Absence of lung sliding; absence of seashore (M-mode)

Treatment

  • Tension ptx
    • Immediate needle thoracostomy
  • Open ptx
    • Cover wound with three-sided dressing
      • Make sure to avoid complete occlusion (may convert injury to a tension ptx)
  • Tube thoracostomy indicated if:
    • Pt cannot be observed closely
    • Pt requires intubation
    • Pt will be transported by air or over a long distance
  • Observation alone ok if:
    • Small ptx (<1cm wide, confined to upper 1/3 of chest) is unchanged on two CXR 6hr apart
    • Occult ptx (seen only on CT) unless pt requires mechanical ventilation

Special Instructions

Flying

  • Can consider flying 2 weeks after full resolution of traumatic pneumothroax[1]

See Also

Source

  • Roberts and Hedges Clinical Procedures in Emergency Medicine
  • Rosen's
  • American College of Chest Physicians Consensus Statement
  1. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named BTC
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