Pneumothorax (Medicine practical examination)

  •  Sudden onset or rapidly progressive dyspnoea.
  • Ipsilateral acute pleuritic pain – the pain is either sharp or a steady ache.
  • A small pneumothorax may be asymptomatic.
  •  Obtain history of recent pleural aspiration or insertion of subclavian line (J R Soc Med 1997: 90: 319-21), recent surgery to head and neck, abdominal procedures using bowel or peritoneal distension.
  •  History of asthma, COAD, ARDS, pneumonia, trauma to chest.
  • History of Marfan’s syndrome.
  • History of HIV
  •  History of positive pressure ventilation.
  • Decreased movement of the affected side.
  • Increased percussion note.
  • Trachea may be central (small pneumothorax) or deviated to the affected side (underlying collapse of lung) or the opposite side (large pneumothorax).
  •  Increased vocal resonance with diminished breath sounds.
    Proceed as follows:
  • Look for clues regarding aetiology: Pleural aspiration site, Infraclavicular region for a bruise from the central line.
  • Comment if the patient is thin or has marfanoid features.
  • Inhaler or peak flow meter by the bedside (asthma, COAD).
  • Tell the examiner that you would suspect tension pneumothorax when there is tachycardia (>135 beats/minute), hypotension and pulsus paradoxus.

This patient has diminished breath sounds and hyper-resonant note on R/L side of the chest (lesion) due to pneumothorax secondary to Marfan’s syndrome (aetiology), and is not breathless at rest (functional status).

-CXR, both inspiratory and expiratory phases. In critically ill patients pneumo-thorax is suspected when

(a) the costophrenic angle extends more inferiorly than usual due to air- the ‘deep sulcus sign’ (Radiology 1980; 136: 25-7),

(b) liver appears more radiolucent due to air in the CP angle, or on the left side, when the air will outline the medial aspect of the hemidiaphragm under the heart.

-Blood gases if the patient is breathless: hypoxaemia depending on the shunting, whereas hypercapnia does not develop.

· Spontaneous (usually in thin males).
· Trauma.
· Bronchial asthma.
· COAD – emphysematous bulla (JAMA 1975; 234: 389-93).
· Carcinoma of the lung.
· Cystic fibrosis.
· TB (the original descriptions of pneumothorax were commonly associated with TB.                                                  

  • Small pneumothoraxes (less than 20% in size) spontaneously resolve within weeks.
  • Larger ones (irrespective of size) with normal lungs are managed by simple aspiration rather than an intercostal tube as the initial drainage procedure. Aspiration is less painful than intercostal drainage, leads to a shorter admission and reduces the need for pleurectomy with no increase in recurrence rate at 1 year.
  •  When there is rapid re-expansion following simple aspiration, an intercostal tube with underwater seal drainage is used. The tube should be left in for at least 24 hours. When the lung re-expands, clamp the tube for 24 hours. If repeat radiography shows that the lung remains expanded, the tube can be removed. If not, suction should be applied to the tube. If it fails to resolve within 1 week, surgical pleurodesis should be considered. Video-assisted thoracoscopic surgery with several chest ports allows clear visualization of the pleural cavity for resection of bullae and pleurodesis.

Tension pneumothorax should be suspected in the presence of any of the following:
· Severe progressive dyspnoea.
· Severe tachycardia.
· Hypotension.
· Marked mediastinal shift

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