Free module: Spontaneous pneumothorax - assessment and management

Introduction
Pneumothoraxes occur when air enters the pleural cavity.

When it occurs in healthy people, it is known as primary spontaneous pneumothorax (PSP). When it occurs in people
with underlying lung disease, it is called secondary spontaneous pneumothorax (SSP).

Pneumothoraxes account for 16.7 per 100 000 and 5.8 per 100 000 hospital admissions per year for men and women
respectively. [ 1 ]

What are the risk factors for primary spontaneous pneumothorax?

A major risk factor is smoking, which increases the lifetime risk of developing a pneumothorax in healthy men from 0.1
to 12%. [ 3 ]

Other risk factors for the development of primary spontaneous pneumothoraxes include younger age and increasing
height. [ 1 ]

Risk factors for the recurrence of primary spontaneous pneumothorax include smoking, tall stature, and age over 60
years. [ 4 ] [ 5 ]

What are the risk factors for secondary spontaneous pneumothorax?

The risk factors include [ 1 ] :

Chronic obstructive pulmonary disease

Asthma
Pulmonary fibrosis
Cystic fibrosis
Pneumonia
Lung cancer
Tuberculosis
Respiratory complications of HIV and AIDS
Thoracic endometriosis
Pneumothorax caused by thoracic endometriosis is known as catamenial pneumothorax.

Risk factors for the recurrence of secondary spontaneous pneumothorax include increasing age, pulmonary fibrosis,
and emphysema. [ 5 ] [ 6 ]

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Free module: Spontaneous pneumothorax - assessment and management

Clinical evaluation

General principles
You should not rely on the classical symptoms of chest pain and shortness of breath when making a diagnosis as these
may be minimal or absent. [ 2 ]

Be particularly alert to the possibility of secondary spontaneous pneumothorax in:

Patients over 50 years old

Those with a significant smoking history
Those with clinical or radiological evidence of underlying lung disease.

In secondary spontaneous pneumothorax, the patient's level of breathlessness may be disproportionate to the size of
their pneumothorax. [ 7 ] [ 8 ]

What might I find on examination?

Classical signs of a pneumothorax include ipsilateral reduced expansion, hyper-resonance to percussion, reduced air
entry, and diminished breath sounds.

In addition to these signs, patients may be:

Tachypnoeic
Tachycardic
Cyanotic
Using accessory muscles of breathing.

Patients may also present with signs of bilateral pneumothoraxes.

What are the signs of tension pneumothorax?

Signs of shock and a deviated trachea should alert you to the possibility of a tension pneumothorax.

You should consider the possibility of a tension pneumothorax:

In non-ventilated patients who present with:

Cardiac arrest
Signs of recent trauma
Hypotension and respiratory distress
In patients receiving positive pressure ventilation in an intensive care setting who have:
Rapid development of hypoxia, hypotension, tachycardia, and increased airway pressures. [ 9 ]

Clinical tip
Symptoms and signs of respiratory distress may indicate the presence of a tension pneumothorax.

What investigations should I consider?

x Ray
An erect chest x ray in inspiration is recommended for the initial diagnosis of a pneumothorax. [ 2 ]
Typically you will find displacement of the pleural line, and an air fluid level in the costophrenic angle. [ 10 ] You should
use the interpleural distance at the level of the hilum in order to estimate the size of a pneumothorax. This is described
in the British Thoracic Society's (BTS) management algorithm. [ 2 ]

Figure 1: Illustration of two methods (British and American) of measuring the size of a pneumothorax on a
chest radiograph. The British Thoracic Society guidelines recommend a measurement of the interpleural
distance at the level of the hilum (b).

Copyright © BMJ Publishing Group Ltd and British Thoracic Society. All rights reserved.

Computerised tomography (CT)

In complex or unusual cases you should consider computerised tomography (CT) as this may help with diagnosis. CT is
considered the "gold standard" for an accurate assessment of the size of a pneumothorax. [ 2 ] It can also be used to
differentiate pneumothoraxes from bullous lung disease, and identify underlying lung disease in patients with
secondary spontaneous pneumothorax.

Where the cause for a patient's shortness of breath is uncertain, a CT of the chest can help identify pneumothoraxes
not evident on plain x rays. It may also identify a cause for secondary spontaneous pneumothoraxes in patients with
early stage or previously undiagnosed lung diseases, such as emphysema. [ 11 ]

Arterial blood gas

You should consider doing arterial blood gases when a patient's oxygen saturations are below 92% on air.

Arterial blood gases may be useful for identifying patients who remain hypoxic despite appropriate oxygen therapy.
When this occurs, you may need to refer your patient to intensive care for closer monitoring, or even ventilatory
support.

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Free module: Spontaneous pneumothorax - assessment and management

Management
This advice is based on the UK guidelines for the management of spontaneous pneumothorax, produced by the British
Thoracic Society. [ 2 ] The authors recognise that in view of the lack of high quality evidence and variation in
international guidelines and practices, the management of spontaneous pneumothoraxes remains controversial. [ 12 ]
[ 13 ] [ 14 ] [ 15 ]

General principles
Options for treatment of a pneumothorax include observation, needle aspiration, and insertion of a chest drain.

Several factors should determine your choice of treatment:

Whether the pneumothorax is primary or secondary

The extent to which the patient is symptomatic (for example, their level of breathlessness)
The size of the pneumothorax

Learning bite
Patients with underlying lung disease tolerate pneumothorax less well than patients with a primary
pneumothorax. [ 2 ]

Observation
You need to observe any patient with a pneumothorax. This includes regular assessment of vital signs such as
respiratory rate, oxygen saturations, heart rate, and blood pressure. You should also regularly assess chest expansion,
percussion, and auscultation.

You should repeat x rays at certain intervals. This includes situations where a patient's condition changes, either prior
to discharge or at follow up.

When can you manage a patient with a pneumothorax by observation alone?

In a patient with a primary spontaneous pneumothorax observation is recommended if they have minimal symptoms
and a pneumothorax of less than 2 cm. [ 2 ]

Learning bite
According to the British Thoracic Society Guidelines, observation alone may be appropriate for some patients
with a large (>2 cm) primary spontaneous pneumothorax but minimal symptoms. [ 2 ]

In a patient with a secondary spontaneous pneumothorax observation is recommended if they are asymptomatic
patients with a pneumothorax of less than 1 cm. [ 2 ]

When should you use needle aspiration in a patient with a pneumothorax?

You should attempt needle aspiration:

In a patient with a primary spontaneous pneumothorax if they are breathless or have a pneumothorax which is
greater than 2 cm [ 2 ]
In a patient with a secondary spontaneous pneumothorax if they are asymptomatic with a pneumothorax
between 1 and 2 cm in size. [ 2 ]
Which patients need to have a chest drain inserted?
This is indicated [ 2 ] :

For bilateral pneumothoraxes

For a tension pneumothorax
Following a failed needle aspiration in either primary or secondary spontaneous pneumothorax
In secondary spontaneous pneumothoraxes greater than 2 cm, or when the patient is breathless.

Clinical tip
You should not routinely apply suction to chest drains, as there is risk of re-expansion pulmonary oedema. [ 2 ] There is
also a risk that suction may keep the defect in the pleura open, due to the strong negative pressure that it exerts. [ 16 ]

Patients with re-expansion pulmonary oedema typically present with cough, shortness of breath, or chest tightness
following insertion of a chest drain, [ 2 ] this can occur in up to 14% of episodes. [ 17 ]

You should admit all patients with secondary spontaneous pneumothorax for at least 24 hours, and give them oxygen
therapy. [ 2 ] At this stage you should make an early referral to a chest physician. [ 2 ]

Which patients should be referred to a chest physician?

All patients with pneumothorax should be referred to a chest physician for follow up to review whether the
pneumothorax has resolved. [ 2 ]

The specialist will also be able to manage any underlying lung disease. They should explain the risk of recurrence to the
patient, as well as the possible need for surgical intervention. This consultation should reinforce advice on smoking
cessation, air travel, and diving.

Which patients need referral to a thoracic surgeon?

You should refer to a thoracic surgeon if a patient [ 2 ] :

Has a second ipsilateral pneumothorax

Has a first contralateral pneumothorax - that is, a first recurrent episode of a pneumothorax on the contralateral
side to the initial pneumothorax
Has a synchronous bilateral spontaneous pneumothorax
Has a persistent air leak despite five to seven days of chest tube drainage
Has no underlying lung disease and has a persistent air leak despite five to seven days of chest tube drainage
Patients with underlying lung disease, or those with a large air leak, should be referred earlier, after two to four
days
Has a failure of lung re-expansion
Has a spontaneous haemothorax
Is in a high risk profession, such as pilots and divers
Is pregnant.

What should I advise patients on discharge?

At discharge it is important to advise patients both verbally and in writing. [ 2 ] You should explain that:

If the breathlessness recurs, they should return to the emergency department immediately
They should avoid air travel until one week after the pneumothorax has resolved radiologically
They should permanently avoid all types of diving. This includes scuba diving
The only exception to the avoidance of diving is when a patient has had bilateral surgical pleurectomy
To ensure patients can dive safely after this procedure, clinicians must be able to show that the patient has both
normal lung function and a normal CT chest following the procedure.

Clinical tip
It is important to stress the importance of smoking cessation in order to reduce the risk of pneumothorax recurrence.
Free module: Spontaneous pneumothorax - assessment and management

1. You are a junior doctor working in the medical assessment unit. You see a 23 year old man who has been short of
breath for the last three days. The shortness of breath occurred suddenly when he was playing football. There is no
past medical or family history of note, and he does not take any regular medications. He is a non-smoker. On
examination, you note that he is 1.7 m (~5 ft 6 in) tall and has decreased expansion and diminished breath sounds
on the right side.

Which of the following factors puts him at greater risk of having a pneumothorax?

Your answer Correct answer

a. His height

b. Male sex

c. His non-smoking status

d. The history of physical activity

a : His height

This man is relatively short, and increasing height increases the risk of pneumothorax. [ 1 ]

b : Male sex

Pneumothoraxes are around three times more common in men than in women. [ 1 ]

c : His non-smoking status

Smoking is associated with an increased risk of pneumothorax.

d : The history of physical activity

There is no evidence that physical activity increases the risk of developing a pneumothorax.

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Free module: Spontaneous pneumothorax - assessment and management

2. You request an erect chest x ray in inspiration on the 23 year old man. You can see a 3 cm right sided
pneumothorax, and you make a diagnosis of primary spontaneous pneumothorax. He is short of breath. On
examination, his trachea is not deviated, his heart rate is 70 beats per minute, and his blood pressure is 130/80
mm Hg.

You discuss your findings with the registrar working on the unit. He agrees with your diagnosis, and asks you what
the next stage of your management plan is.

Which of these is the correct course of action?

Your answer Correct answer

a. Needle aspiration

b. Insertion of a large bore chest drain

c. Observation

d. Insertion of a small bore chest drain

a : Needle aspiration

Needle aspiration is the correct course of action. The British Thoracic Society guidelines recommend that you
should perform a needle aspiration in patients with primary spontaneous pneumothorax if they are breathless or
have a pneumothorax greater than 2 cm. [ 2 ] In patients with a primary spontaneous pneumothorax, treatment
with needle aspiration using a 14-16 gauge needle is as effective as inserting a chest drain. It may also be
associated with a reduced rate of hospital admission and length of stay. [ 18 ] If you are performing this technique,
you should not aspirate more than 2.5 litres of air. This is because aspirating more than 2.5 litres is unlikely to
result in further re-expansion of the lung. [ 19 ] (The volume of the hemithorax is about 2 to 3 litres so if you
continue to aspirate beyond 2.5 l you are unlikely to make any further change in lung volume.)

b : Insertion of a large bore chest drain

Needle aspiration is the correct course of action. If you are performing this technique and are unsuccessful, the
next thing you should try is to insert a small bore chest drain.

c : Observation

Needle aspiration is the correct course of action. Conservative management is insufficient here, as the patient is
breathless and has a 3 cm sized pneumothorax.

d : Insertion of a small bore chest drain

The British Thoracic Society guidelines recommend needle aspiration in primary spontaneous pneumothorax
when the patient is breathless or has a pneumothorax that is greater than 2 cm. In these circumstances, needle
aspiration is as effective as chest drain insertion. [ 18 ]

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Free module: Spontaneous pneumothorax - assessment and management

3. Your registrar supervises you as you attempt needle aspiration of the pneumothorax. You are both happy that you
have used an appropriate technique, but the lung fails to re-expand. The registrar asks you what you should do
next. Which of these is the correct course of action?

Your answer Correct answer

a. Admit him for observation

b. Discharge him with respiratory follow up

c. Re-attempt the needle aspiration

d. Proceed to small bore chest drain insertion

a : Admit him for observation

You should insert a small bore chest drain following a failed needle aspiration. [ 2 ] This patient does need to be
admitted, but he also needs active intervention in view of the size of his pneumothorax and his breathlesssness.

b : Discharge him with respiratory follow up

It would be unsafe to discharge this patient now. You should insert a small bore chest drain following a failed
needle aspiration. [ 2 ] You should admit him and actively treat his pneumothorax.

c : Re-attempt the needle aspiration

You should insert a small bore chest drain following a failed needle aspiration. [ 2 ] You should not repeat needle
aspiration unless there were technical difficulties during the first attempt.

d : Proceed to small bore chest drain insertion

You should insert a small bore chest drain following a failed needle aspiration. [ 2 ]

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Free module: Spontaneous pneumothorax - assessment and management

4. You see a 60 year old woman who has a 60 pack year smoking history in the emergency department. She is short
of breath. She does not have any past of note and does not take any regular medications.

On chest examination, there is increased resonance to percussion and diminished breath sounds on the left. Her
oxygen saturations are 93% on air and she is haemodynamically stable. This is her chest x ray:

Which of these is the correct course of action?

Your answer Correct answer

a. Give high concentration oxygen and admit her for observation

b. Give high concentration oxygen and attempt needle aspiration

c. Give high concentration oxygen and perform an arterial blood gas

d. Give high concentration oxygen and insert a chest drain

a : Give high concentration oxygen and admit her for observation

The correct course of action for this patient is insertion of a chest drain. She has a likely secondary spontaneous
pneumothorax as she is older than 50, has a significant smoking history, and is also short of breath. In secondary
spontaneous pneumothorax, observation is only recommended for patients who are asymptomatic, with their
pneumothorax measuring less than 1 cm. [ 2 ]

b : Give high concentration oxygen and attempt needle aspiration

The correct course of action for this patient is insertion of a chest drain. In secondary spontaneous pneumothorax,
needle aspiration is only recommended in asymptomatic patients with a pneumothorax of between 1 and 2 cm. [
2]

c : Give high concentration oxygen and perform an arterial blood gas

The correct course of action for this patient is insertion of a chest drain. You should consider performing an
arterial blood gas if the patient's oxygen saturations are less than 92% on room air, or if you suspect carbon
dioxide retention in a patient with underlying lung disease. Neither is the case here.

d : Give high concentration oxygen and insert a chest drain

The correct course of action for this patient is insertion of a chest drain. Her chest x ray shows a left sided
pneumothorax with an intrapleural distance measuring approximately 2 cm at the level of the hilum. In patients
over 50 years, or those with a significant smoking history, you should suspect secondary spontaneous
pneumothorax. Her smoking history and a hyperexpanded chest on x ray suggest that she has obstructive lung
disease. Supplemental oxygen accelerates by a factor of 4 the reabsorption of air by the pleura. [ 20 ]

You should insert a chest drain as soon as possible irrespective of the size of the pneumothorax. This patient is
breathless, and pneumothorax is less well tolerated in patients with secondary spontaneous pneumothorax than
those with primary spontaneous pneumothorax.

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Free module: Spontaneous pneumothorax - assessment and management

5. Your registrar supervises you inserting a chest drain. Afterwards you request a repeat x ray. This shows that the left
lung has fully re-expanded. You remove the drain 24 hours later. You observe her for 24 hours more before
discharging her.

Which of these is the correct advice that the patient should get on discharge?

Your answer Correct answer

a. To avoid scuba and other kinds of diving for six weeks

b. To avoid driving for six weeks

c. To avoid physical exertion

d. To stop smoking

a : To avoid scuba and other kinds of diving for six weeks

She should avoid diving indefinitely.

b : To avoid driving for six weeks

There is no need to avoid driving following a pneumothorax.

c : To avoid physical exertion

There is no evidence that physical exertion can cause a pneumothorax.

d : To stop smoking

She should be strongly advised to stop smoking. Smoking increases the risk of recurrence.

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Free module: Spontaneous pneumothorax - assessment and management

6. A month later this patient returns to the emergency department as she is short of breath again and has pleuritic
chest pain on the left side. Her chest x ray from this admission is shown here:

The medical team admit her. They insert a chest drain and repeat a chest radiograph. This shows re-expansion of
the left lung and the chest drain is removed.

On the ward round, her medical team decide she is now fit to go home. What follow up should they arrange?

Your answer Correct answer

a. Discharge to her GP

b. Referral to a respiratory physician and a thoracic surgeon

c. Referral to a respiratory physician

a : Discharge to her GP

This patient needs both respiratory and surgical follow up. She has had two ipsilateral pneumothoraxes so the
team should arrange a thoracic surgical review to explore the options for secondary prevention.

b : Referral to a respiratory physician and a thoracic surgeon

This patient has had two ipsilateral pneumothoraxes so the team should arrange a thoracic surgical review to
explore the options for secondary prevention. Her chest radiograph on her second admission showed a recurrent
left sided pneumothorax, with the intrapleural distance measuring approximately 1 cm at the level of the hilum.
The role of the respiratory physician in this situation is to ensure continued liason with the thoracic surgeon and
continued care of the patient's underlying respiratory disease, such as optimisation of COPD management.

c : Referral to a respiratory physician

Although all episodes of pneumothorax should be followed up by a respiratory physician, review by a thoracic
surgeon is necessary in this patient as she has had two ipsilateral pneumothoraxes.

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Free module: Spontaneous pneumothorax - assessment and management

7. You are a junior doctor working in respiratory medicine and are covering the medical wards overnight. You are
called urgently to see a patient who was admitted yesterday with an acute exacerbation of chronic obstructive
pulmonary disease (COPD). He has suddenly become short of breath, hypoxic, and hypotensive. On examination
you find a deviated trachea, with decreased air entry on the right side.

You stay with the patient, start oxygen at high concentration, and ask one of the nurses to fast bleep your
registrar. She is on the next ward and arrives within seconds. The registrar asks what you should do next.

Which of these is the correct course of action?

Your answer Correct answer

a. Insert a chest drain

b. Give nebulised bronchodilators

c. Perform a needle decompression

d. Arrange for an urgent chest x ray

a : Insert a chest drain

This man needs urgent needle decompression for a likely tension pneumothorax. Once he is more stable, he will
then need a chest drain putting in.

b : Give nebulised bronchodilators

This man needs urgent needle decompression for a likely tension pneumothorax. Although he may have an
exacerbation of his COPD, the clinical picture is more suggestive of a right sided tension pneumothorax. You need
to make the management of this a priority. Tension pneumothoraxes often occur in patients with underlying lung
disease, especially during acute presentations of asthma and COPD.

c : Perform a needle decompression

This man needs urgent needle decompression. A tension pneumothorax is a medical emergency. If you are
carrying out a needle decompression of a tension pneumothorax, you should insert the cannula into the second
intercostal space in the midclavicular line. The immediate outlet of air should confirm your diagnosis.

d : Arrange for an urgent chest x ray

This man needs urgent needle decompression for a likely tension pneumothorax. Even an urgent chest x ray
would unnecessarily delay treatment.

Learning bite: tension pneumothorax

A tension pneumothorax occurs when air fills the intrapleural space and becomes trapped. In the same
way as in a simple pneumothorax, air enters through a defect or hole in the pleura.

In a tension pneumothorax, this defect becomes a one way valve. Air can enter, but cannot escape. The
trapped air displaces the other structures in the thorax, including the lungs and mediastinum. It also
impedes venous return. This results in a life threatening reduction in cardiac output, often occurring very
quickly.
Tension pneumothorax is a medical emergency. Treatment is with oxygen at high concentration and
urgent needle decompression. You should have a high level of suspicion for this diagnosis, particularly in
ventilated patients and trauma patients. It is also seen more commonly in cardiac arrest, lung disease,
and blocked, clamped, or displaced chest drains. [ 21 ]

Learning bite: needle decompression of a tension pneumothorax

As in any emergency situation, you should follow the ABC protocol when managing a patient with a
suspected tension pneumothorax. This includes starting oxygen and calling for senior help early on.

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Free module: Spontaneous pneumothorax - assessment and management

Anatomy
The correct site for emergency needle decompression of a tension pneumothorax is the second intercostal space in
the mid-clavicular line on the affected side.

The second intercostal space is identified by first palpating the sternal angle in the midline. This point is at the same
horizontal level as the second costal cartilage and rib, which is palpated by moving the fingers laterally onto the chest
wall on the affected side. The second intercostal space lies below the second rib.

With the opposite hand, palpate the halfway point along the clavicle and then draw an imaginary line down to the
second intercostal space.

Figure 2

When inserting the needle, keep close to the superior surface of the third rib in order to avoid damaging the intercostal
neurovascular bundle that runs along the inferior surface of the second rib.

Figure 3: Diagram to show the course of the neurovascular bundle, on the inferior surface of the rib
Anatomical relations
The heart and the great vessels lie in close proximity behind the sternum and manubrium sterni. The internal
mammary (internal thoracic) vessels run vertically down, behind the costal cartilages, a finger’s breadth from the
sternum. The subclavian vessels lie superiorly, behind the clavicle.

A correctly positioned needle should avoid these major structures, but you should be aware that a serious yet rare risk
of this procedure is damage to the intrathoracic blood vessels including intercostal, pulmonary, and internal thoracic
arteries. [ 22 ]

Technique for needle decompression of a tension pneumothorax [ 23 ]

1. Create a sterile surface (eg open a dressing pack on a trolley) and place equipment on it
2. Identify the second intercostal space in the mid-clavicular line, and prepare the skin with an alcohol wipe
3. Put on sterile gloves
4. Remove the bung from a large bore intravenous cannula and insert the cannula into the thorax at this point,
keeping the needle at 90 degrees to the skin, and staying close to the superior surface of the rib below
5. A "hiss" denotes decompression of the affected hemi-thorax, when the cannula enters the intra-pleural space, and
gas escapes
6. Remove the needle stylet and dispose of it carefully into a sharps bin
7. Leave the cannula in place, and reassess the patient
8. If needle decompression is successful, then the tension pneumothorax is converted into a pneumothorax without
tension. Definitive treatment is now performed with insertion of an intercostal drain
Free module: Spontaneous pneumothorax - assessment and management

1. After your registrar checks that you understand the relevant anatomy, she supervises you as you perform a needle
aspiration of the patient's tension pneumothorax. This is successful and you then go on to insert a chest drain.

Four hours after you put in the chest drain, you are contacted by the ward. The patient has developed a cough,
shortness of breath, and a tight chest.

As part of your initial assessment, you request a chest x ray:

What is most likely to have occurred?

Your answer Correct answer

a. Displacement of the chest drain

b. Pneumonia

c. Re-expansion pulmonary oedema

d. Surgical emphysema

a : Displacement of the chest drain

The most likely complication here is re-expansion pulmonary oedema. In a patient where the chest drain has been
displaced, the patient presents with persistent or recurrent symptoms or signs of pneumothorax. The patient may
also be asymptomatic, with the displacement only picked up on repeat imaging.

b : Pneumonia
The most likely complication here is re-expansion pulmonary oedema. Although this patient's symptoms and
increased markings on the chest radiograph could be in keeping with pneumonia, the timing is more suggestive
of re-expansion pulmonary oedema.

c : Re-expansion pulmonary oedema

The most likely complication here is re-expansion pulmonary oedema. Re-expansion pulmonary oedema
manifests as cough, breathlessness, and chest tightness following insertion of a chest drain. It can be precipitated
by early chest drain suction.

d : Surgical emphysema

The most likely complication here is re-expansion pulmonary oedema. Surgical emphysema is a well recognised
complication of chest drain insertion, but does not explain the symptoms here. Surgical emphysema presents
with palpable crepitations beneath the skin. It may be identified on plain radiographs as air in the subcutaneous
tissues.

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Free module: Spontaneous pneumothorax - assessment and management

1. Which of the following is a risk factor for primary spontaneous pneumothorax?

Pre-test answer Your answer Correct answer

a. Underlying lung disease

b. Female sex

c. Physical activity

d. Smoking

That's right.

Smoking is a major risk factor for pneumothorax, increasing the lifetime risk of developing a pneumothorax in
healthy men from 0.1 to 12%. [ 3 ]

Underlying lung disease is a risk factor for secondary spontaneous pneumothorax and not primary spontaneous
pneumothorax. Pneumothoraxes are more common in men, and physical activity is not a risk factor for their
development.

2. What test should you check initially when you suspect that a patient has a spontaneous pneumothorax?

Pre-test answer Your answer Correct answer

a. An arterial blood gas

b. A CT chest

c. An erect chest x ray in expiration

d. Inspiratory erect chest x ray

That's right.

An erect posterior anterior (PA) chest x ray in inspiration is recommended for the initial diagnosis of a
pneumothorax [ 2 ] although the value of this is limited as it can be difficult to quantify the size of a pneumothorax
on a chest x ray.

An expiratory film will not provide any additional information during your initial assessment. [ 2 ]

Remember that if you suspect a tension pneumothorax then do not delay treatment by requesting an urgent
chest x ray.

3. How should you treat a 34 year old man with a primary spontaneous pneumothorax of less than 2 cm, who is
minimally breathless?

Pre-test answer Your answer Correct answer

a. Large bore chest drain insertion

 Pre-test answer Your answer Correct answer

b. Needle aspiration

c. Observation

d. Small bore chest drain insertion

That's right.

In such a patient with a small pneumothorax who is only minimally breathless, observation alone is recommended.
[ 2 ] You should advise patients both verbally and in writing to seek medical attention if breathlessness occurs.

4. You see a 65 year old man with a 40 pack year smoking history. He has a 3 cm left sided pneumothorax on chest
radiograph. How should you treat him initially?

Pre-test answer Your answer Correct answer

a. Large bore chest drain insertion

b. Needle aspiration

c. Observation

d. Small bore chest drain insertion

That's not right. The correct answer is d.

In patients over 50 years with a significant smoking history, you should suspect secondary spontaneous
pneumothorax. If a secondary spontaneous pneumothorax is greater than 2 cm, or the patient is breathless, then
the British Thoracic Society guidelines recommend inserting a small bore chest drain with an 8 to 14 gauge drain,
as well as hospital admission. [ 2 ]

5. Which one of the following statements about chest drain suction is correct?

Pre-test answer Your answer Correct answer

a. It increases the risk of re-expansion pulmonary oedema

b. It should routinely be used following insertion of a

chest drain

c. Low volume, low pressure suction systems are

recommended

d. Optimal suction pressures should be between -20 to

-30 cm H2O

That's right.

If you apply early suction after chest drain insertion, you can precipitate complications such as re-expansion
pulmonary oedema. So you should not do this routinely. If you do use suction, for example if a pneumothorax fails
to resolve, you should use a high volume, low pressure system at pressures between -10 to -20 cm H2O.

6. What should you do first if you suspect a patient has a tension pneumothorax?
 Pre-test answer Your answer Correct answer

a. Clamp any existing chest drains

b. Insert a chest drain

c. Perform needle decompression

d. Request an urgent chest x ray

That's right.

You should treat a suspected tension pneumothorax immediately with high flow oxygen and urgent needle
decompression. Insert the needle into the second intercostal space in the mid-clavicular line. You should then
insert a chest drain. Tension pneumothoraxes may occur when existing drains are clamped or displaced.

7. In which of the following situations should you refer a patient to a thoracic surgeon after a pneumothorax?

Pre-test answer Your answer Correct answer

a. Following a failed needle aspiration

b. After a first ipsilateral pneumothorax

c. When the patient is a pilot

d. When there is a persistent air leak for 12 hours

following a chest drain insertion

That's not right. The correct answer is c.

You should refer to a thoracic surgeon in [ 2 ] :

A second ipsilateral pneumothorax

A first contralateral pneumothorax
A synchronous bilateral spontaneous pneumothorax
A persistent air leak (despite five to seven days of chest tube drainage) in patients without underlying lung
disease
Patients with underlying lung disease, or those with a large air leak, should be referred earlier; normally
after two to four days
A failure of lung re-expansion
A spontaneous haemothorax
Professions at risk (for example pilots and divers)
Pregnancy.
Following an unsuccessful needle aspiration, you should insert a chest drain.

8. After full resolution of a spontaneous pneumothorax, which of these should you instruct patients to avoid?

Pre-test answer Your answer Correct answer

a. Air travel for six weeks

b. Diving for six weeks

c. Physical exertion
 Pre-test answer Your answer Correct answer

d. Smoking

That's right.

Smoking increases the risk of recurrence of spontaneous pneumothoraxes, and so you should give advice on
smoking cessation. You should also advise patients to avoid air travel for one week after their pneumothorax has
fully resolved. They should avoid diving indefinitely unless a definitive prevention strategy such as a bilateral
surgical pleurectomy has been undertaken. There is no evidence for a relationship between physical exertion and
pneumothorax. You should give all of this advice verbally and in writing.

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