Topic = Pneumothorax

( Most important topic 2-3 question will be

surely from it in exam)


 What is pneumothorax ...?
Ans. The term pneumothorax describes air in the pleural
Space.
( OR )
A collection of air within the pleural space between
the lung (visceral pleura) and the chest wall (parietal pleura) that
can lead to partial or complete pulmonary collapse.

 Now question arises from where this air comes...?

Ans. Air enter the pleural space from two ways I -e either it will
enter from outside or will come from alveoli.

 Normally there is no air present between pleural space . Just

pleural fluid is present .
Clear upto This.??

 How is pneumothorax divided ...?

Ans. There are various ways by which we can classify the
pneumothorax but the most acceptable is as follow :-

1. Spontaneous pneumothorax ( primary & secondary )

2. Traumatic pneumothorax
3. Tension pneumothorax

 What is spontaneous Pneumothorax ...?

Ans. It is type of pneumothorax that occur without any precipitate
event.

✓ spontaneous pneumothorax is further divided into primary and

secondary spontaneous pneumothorax.

• ✓✓ Primary spontaneous pneumothorax: occurs in patients without

clinically apparent underlying lung disease
 • ✓✓ Secondary spontaneous pneumothorax: occurs as a complication of
underlying lung disease

 What is traumatic pneumothorax ...?

Ans. Traumatic pneumothorax: a type of pneumothorax caused by a trauma
(e.g., penetrating injury, iatrogenic trauma.

 Now this traumatic pneumothorax is further divided into open

and closed pneumothorax.

1. Open pneumothorax: The entry of air into the pleural cavity

through an unsealed defect in the thoracic wall (e.g.,
following penetrating trauma).

2. Closed pneumothorax: The entry of air into the pleural

cavity through a breach in the visceral pleura (e.g., ruptured
pulmonary bulla).
1. Primary sponataneous pneumothorax occurs in people without
underlying lung disease and in the absence of an inciting event.

2. Air enters into the intrapleural space without preceding trauma

and without an underlying history of clinical lung disease.

Q- Now here question arises if there is no any precipitating

factor for Primary spontaneous Pneumothorax then how
does it occur...?

Ans. Primary spontaneous pneumothoraxes are thought to

result from rupture of apical pleural blebs beneath the
visceral pleura.

 What are the risk factors for PSP.?

ANS.
1. Tall thin males
2. Marfan Syndrome
3. Ehler’s Syndrome
4. Alpha one anti-trypsin deficiency
5. Smoking ( Smoking is associated with a 12% increased risk of
developing pneumothorax in otherwise healthy men)
 ✓✓ Secondary spontaneous pneumothoraces are less common
and account for approximately 10-20% of all spontaneous
pneumothoraces.

✓✓ The classic presentation would be that of a patient with COPD

aged 60–70 years old.

 Ok now please tell what is tension pneumothorax...?

Ans. Any type of pneumothorax can develop into tension

pneumothorax.

 What happens in tension pneumothorax .?

Ans. One-way valve mechanism, in which air enters the pleural
space on inspiration but cannot exit

✓✓ Progressive accumulation of air in the pleural space and

increasing positive pressure within the chest.
 ✓✓ Collapse of ipsilateral lung; compression
of contralateral lung, trachea, heart, and superior vena cava;
angulation of inferior vena cava
Impaired respiratory function, reduced venous return to the heart
Reduced cardiac output

✓✓ Hypoxia and hemodynamic instability

Ok now please tell what will be the classic

findings on physical examination in
pneumothorax .?

Ans. Pleuritic Chest Pain

O Due to injury or inflammation at or near the pleural tissue

Lining

3. ↓Tactile Fremitus on the Affected Side

O This occurs due to air in the pleural space dampening the

Sound vibrations → Thus, “99” would not be felt well on the

 Hypothenar eminence

4. Hyper-Resonance to Percussion on the Affected Side

O The air in the pleural cavity provides a significantly decreased

Density → Thus, it appears hyper-resonant when percussed

5. ↓Breath Sounds on the Affected Side

O The presence of a large pneumothorax may dampen breath

Sounds as there is a large barrier between the chest wall,

Bronchi, and alveoli due to the Pneumothorax.

 How to diagnose the Pneumothorax ....?

Ans. Obtain a CXR (should be an Expiratory CXR)

✓✓Purpose:

O Assess for suggestive findings of pneumothorax in a patient

Presenting with dyspnoea and pleuritic chest pain

O Rule out other lung pathologies (e.g., PNA, Pneumothorax,

Pulmonary edema, etc.)

✓✓ Abnormal Findings on x-ray :-

O Absent lung markings on the affected side

O Visualization of the pleural line detached away from the chest

wall

CLEAR UPTO THIS .?

Ok so now let’s discuss the final part of the lecture
I -e treatment of pneumothorax. It is the most
confusing part, but we will make it easy so be relax
,

 So let’s start with some basics concepts and

terms :-

1. Chest tube placement or tube thoracostomy is a procedure in

which a flexible tube is inserted between the ribs into
the thoracic cavity to drain intrathoracic air, blood, or other
fluid (e.g., pleural effusion, empyema), allowing
for lung reexpansion.

2. Simple Needle aspiration :- Needle aspiration is a technique

that allows aspiration of air via the chest wall without insertion
of a chest drain (thoracotomy tube).
  Please keep remember the difference between needle aspiration
& needle decompression ....?

Ans. Needle decompression is a emergency procedure which is done in

tension Pneumothorax only. While needle aspiration is done in
sponataneous pneumothorax .

 What are the sites of needle decompression...?

( Asked multiple times)

Ans. Updated guidelines.

1. Needle decompression adult= 5th intercostal space anterior to

mid axillary line.

2. Needle decompression children= second intercostal space mid

clavicular line.

 Ok now let’s discus the actual part of ALGORITHIM, BTS guideline

have been changed in July 2023 for treatment of spontaneous
Pneumothorax , so we will stuck to these new guidelines, u have
to solve the S BCQ in exam according to this new guideline.
 So now u have seen this algorithm , let’s make it easy how to
remember it,

 In this algorithm Safe to intervene means simply saying about

pneumothorax size. If its safe intervene means it is
pneumothorax of sufficient size means it is either 2 cm or greater
than 2 cm.

 The first thing We will check whether patient is symptomatic or

asymptomatic.

✓✓ If a-symptomatic then We will do just conservative care and

will call them for follow-up

(PSP: regular review as outpatient

(every 2-4 days)

SSP: inpatient review

If stable, follow up in OPD in 2-4 Weeks

 But if the patient is symptomatic then we will check for high risk
characteristic are present or not. If they are present then Simply
check size of pneumothorax if 2 or greater than 2 then go for
CHEST DRAIN.

IF SIZE is less than 2 cm then go for CT SCAN and then reassess.

 What are high risk characteristics....?

Ans. Mnemonic to remember them is HBL -50- HH

H= HEMODYNAMIC COMPROMISE

H= hypoxia

B = Bilateral pneumothorax

L= lung disease

H = hemopneumothorax

50= age greater than 50 with significant smoking.

 If No any high risk characteristic present then again look for size
of pneumothorax, if less than 2 cm then just conservative care.

If size greater than 2 cm or equal to 2 cm then choice will be

given to the patient , i-e three choices given to patients :-
1. Procedure avoidance
2. Rapid symptom relief ( ambulatory)
3. Rapid symptom relief ( short Term drainage By needle aspiration)
Summarised pearls :-

1. Needle aspiration done when size is less than 2 cm.

2. Chest drain done if high risk characteristic present.

Q-) what advice should be given to these patient of spontaneous

Pneumothorax....? ( PAST BCQ )

Ans. 1 Don’t go for air travel until it fully resolves.

3. Diving ( not driving) should not be done whole life, if want to

done then first go for surgical pleurectomy first.

PRACTISE BCQ :-
( Answers are given at the end of pdf)

Note :- these are those questions which have

been asked in the previous exam.
Q-1) A 33 year old man presents to ED complaining of shortness
of breath. He has no significant past medical history and has
never smoked
x-ray shows a right sided pneumothorax with an intrapleural
distance at the level of the hilum of 2.5 cm
His observations are:BP=125/84HR=95RR=24SPO2=96%

What is the most appropriate management?

1.Administer high flow oxygen
2.Insert chest drain using seldinger technique
3.Insert 24 Fr surgical chest drain
4.Admit for observation for 48 hours
5.Needle aspiration

Q-2)
=You have been asked to give a teaching session to a group of
medical students attached to the Emergency Department.
You are discussing pneumothoraces.
What is the most common condition associated with secondary
spontaneous pneumothorax in adults?
1.Asthma exacerbation
2.Collage vascular disease
3.Pulmonary malignancy
4.Chronic obstructive lung disease
5.Pneumocystis pneumonia
Q-3) A 64 year old man presents to the Emergency Department
with a 2 hour history of pleuritic chest pain and shortness of
breath.

He has a past medical history of COPD secondary to

occupational exposure and smoking.

His observations are recorded as:

Heart rate=106 beats per minute
Blood pressure=143/87 mmHg
Respiratory rate=24 breaths per minute
Oxygen saturations=92% on air
Temperature=37.3 C.

A chest x-ray is performed.

How should this patient be managed?

1.Observe for 2 hours and discharge.

2.Aspirate with 16-18G cannula.

3.Give supplemental oxygen and observe for 24 hours.

4.Insert chest drain 8-14Fr.

5.Perform arterial blood gas and await

Q-4) A 34 year old man presents to the Emergency Department

complaining of a 4 hour history of chest pain and shortness of
breath.
He describes a sudden onset of symptoms in the final hours of a
return flight from Thailand.
He has no past medical history and is a non-smoker. X-ray
showing large left sided pneumothorax.
His observations are recorded as
: Heart rate=96 beats per minute
Blood pressure=143/87 mmHg
Respiratory rate=22 breaths per minute
Oxygen saturations=95% on air
Temperature=37.3

How should this patient be managed?

1.Request a CT chest before making a decision

2.Aspirate with 16-18G cannula
3.Give supplemental oxygen and observe for 24 hours
4.Insert chest drain 8-14Fr
5.Perform arterial blood gas
Q-5:-A 23 year old soldier presents to the Emergency Department
complaining of chest pain and shortness of breath.
A chest x-ray shows a 3 cm pneumothorax.
Which of the following is a recognized risk factor for primary
spontaneous pneumothorax?
1.Marfan’s syndrome
2.Female sex
3.Excess alcohol
4.Polycystic kidney disease
5.Air travel

Q-6)
=A 19 year old man presents to ED complaining of a sudden onset
sharp chest pain which is worse when he inhales or coughs.
The pain came on 4 hours ago. He denies breathlessness or any
other symptoms. He has no past medical history and has never
smoked.

His observations are:

BP=122/85 mmhg
HR=85 bpm
RR=16 breaths/min
SPO2=98%OA
Chest x-ray demonstrates a right sided apical pneumothorax.
There is a rim of 1.2 cm between the lung margin and the chest
wall.
What is the most appropriate management for this patient?

1.Discharge with outpatient review

2.Observe in the ED for minimum 4 hours before discharge
3.Aspirate with 16-18G cannula
4.Insert seldinger chest drain 8-14 Fr
5.Admit to medicine for 24 hours observation
Q-7) =A 23 year old man presents to the Emergency Department
with an episode of chest pain which has now resolved.
He describes a sudden onset of pain after coughing.
He has no past medical history and is a non-smoker. He is
currently comfortable at rest.

His observations are unremarkable

.
A chest x-ray shows a right sided pneumothorax, measuring 18
mm at the hilar level.

How should this patient be managed?

1.Discharge with outpatient review

2.Give high flow oxygen and observe for 24 hours
3.Aspirate with 16-18G cannula
4.Admit and insert chest drain 8-14Fr
5.Endotracheal intubation

Answers :-
Ans. 1➔ E

Ans. 2➔ COPD

Ans. 3➔ DD

Ans. 4➔ BBB

Ans. 5➔ marfan syndrome

Ans. 6 ➔ A
Ans 7 :- AA