7/11 (Afif Mansor)
1) Causes of acute shortness of breath
a) Cardiac origin
Heart failure
Heart arrhythmias
Heart attack
b) Respi causes
Asthma
Pneumonthorax
Pulmonary embolism
c) Non cardio respi
Anxiety disorder
Chocking
Anemia
2) The Algorithm of Management for Pneumothorax
Management of Primary spontaneous pneumothorax (PSP)
Minimal symptoms
Observation is the treatment of choice for small PSP without significant breathlessness
Patients with a small PSP without breathlessness should be considered for discharge with
early outpatient review. These patients should also receive clear written advice to return in
the event of worsening breathlessness.
Selected asymptomatic patients with a large PSP may be managed by observation alone
Symptomatic pneumothorax
For breathless patients require active intervention (needle aspiration or chest drain insertion)
Needle aspiration or chest drain?
Needle (14–16 G) aspiration (NA) is as effective as large-bore (>20 F) chest drains and may
be associated with reduced hospitalisation and length of stay.
NA should not be repeated unless there were technical difficulties.
Following failed NA, small-bore (<14 F) chest drain insertion is recommended.
Large-bore chest drains are not needed for pneumothorax.
Suction
Suction should not be routinely employed.
Caution is required because of the risk of Re-expansion pulmonary oedema (RPO).
High-volume low-pressure suction such as Vernon-Thompson pumps or wall suction with
low pressure adaptors systems are recommended.
Specialist referral
Failure of a pneumothorax to re-expand or a persistent air leak should prompt early referral
to a respiratory physician preferably within the first 24 hr.
May require prolonged chest drainage with complex drain management (suction, chest drain
repositioning) and liaison with thoracic surgeons
Complex drain management is best effected in areas where specialist medical and nursing
expertise is available.
Management of Secondary Spontaneous Pneumothorax (SSP)
All patients with SSP should be admitted to hospital for at least 24 h and receive
supplemental oxygen (caution is required for patients with carbon dioxide retention)
Most patients will require the insertion of a small-bore chest drain.
All patients will require early referral to a chest physician for management of the
pneumothorax and also of the underlying lung disease
Those with a persistent air leak should be discussed with a thoracic surgeon at 48 h.
Patients with SSP but unfit for surgery
Medical pleurodesis may be appropriate for inoperable patients.
Patients with SSP can be considered for ambulatory management with a Heimlich valve.
Discharge and follow-up
Patients should be advised to return to hospital if increasing breathlessness develops.
All patients should be followed up by respiratory physicians until full resolution.
Air travel should be avoided until full resolution.
Diving should be permanently avoided unless the patient has undergone bilateral surgical
pleurectomy and has normal lung function and chest CT scan postoperatively.
Tension pneumothorax
Tension pneumothorax is a medical emergency that requires heightened awareness in a
specific range of clinical situations.
Treatment is with high concentration oxygen and emergency needle decompression, a
cannula usually being introduced in the second anterior intercostal space in the mid-
clavicular line.
chest drain may need to be inserted if there is an initial treatment failure
chest drain should be inserted immediately after needle decompression and the cannula left
in place until bubbling is confirmed in the underwater seal system to confirm proper
function of the chest drain
