pneumothorax - ACEM Fellowship Notes

> [!references]- > - [Dunn management of pneumothorax](x-devonthink-item://6A784754-6907-461A-9FFB-C9910E7355D3) > - [Dunn pulmonary injuries](x-devonthink-item://68C7574E-C7F8-4D99-91C4-B6FE4965AF31) > - [Dunn management of pneumothorax](x-devonthink-item://6A784754-6907-461A-9FFB-C9910E7355D3) > - [tintinalli pneumothorax](x-devonthink-item://1ADC8D20-7826-44D0-9DEE-31D41057C9A3?page=64) > - [Conservative versus Interventional Treatment for Spontaneous Pneumothorax - NEJM 2020](bookends://sonnysoftware.com/ref/DL/247982) > - [British Thoracic Society Guideline for pleural disease 2023](https://thorax.bmj.com/content/78/11/1143) see also: [[Thoracostomy|ICC]] > [!treatment] > - Oxygen (4x fold ↑ reabsorption rate of air by pleura) > - if tension: > - finger or needle thoracentesis # Traumatic pneumothorax ## Sucking chest wound - allows air to pass in and out of the pleural cavity - impairs ventilatory function **management** - immediate treatment with an occlusive dressing - tube thoracostomy # primary vs secondary - primary spontaneous pneumothorax if individual without known lung disease - Secondary in patients with pre-existing lung pathology (eg COPD, interstitial lung disease or pneumoconiosis, cystic fibrosis, etc) - primary spontaneous pneumothorax if individual without known lung disease - Secondary in patients with pre-existing lung pathology (eg COPD, interstitial lung disease or pneumoconiosis, cystic fibrosis, etc) # tension pneumothorax | treatment | advantage | disadvantage | | -------------------- | ---------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | needle decompression | - can perform in anterior chest - fast uses familiar equipment | - needle may not reach pleural space - easily kinked, obstructed, dislodged - difficult to confirm tx - may cause pulmonary or vascular injury | | finger thoracostomy | - allows assessment of pleural space (lung up or down), definite access to pleural space confirmed - does not require tube attachment | - often requires anaesthesia, analgesia - no accurate measurement of blood loss - can cause s*ucking chest wound* if pt not adequately spont ventilating or on positive pressure - requires access to axilla - no blood drainage | | tube thoracostomy | - assists in maintaining patency of thoracostomy - does not require positive pressure - confirms access to pleurla space | - longer to perform - complicates transport - tube may become blocked, kinked, malpositioned, or misplaced - iatrogenic injuries from tube misplacement | # diagnosis ## ultrasound pneumothorax #pocus ![[Pasted image 20240226004002.png| bar code sign showing lack of movement of pleura, consistent with PTX]] ![[Pasted image 20240226004046.png| seashore sign seen in normal lung]] # Bronchopleural fistula persisting air leak into the pleural space - PTx not resolving in spite of properly placed chest drain (lung not re-inflating - worsening pnemomediastinum of s/c emphysema - poor alveolar ventilation i.e. large physiologic dead space **treatment** - large-bore drainage - may damage more lung - low VT, low PEEP, low RR, short inspiratory time - independent lung ventilation - surgicla repair - bronchial stenting or occlusion - PEEP to ICC - compromises drainage and risk of rapid tension pneumothorax - ECMO # Treatment ## conservative treatment - primary pneumothorax with minimal breathlessness - high rate of resolution (~95%) - ED observation for 3-6 hours and repeat CXR at that time to exclude progression of pneumothorax - admission is usually required for secondary pneumothoraces, including those managed conservatively - follow up CXR - 24 hours - 3-5 days ## British Thoracic Society Guidelines See [British Thoracic Society Guideline for pleural disease 2023](https://thorax.bmj.com/content/78/11/1143) ### Acute management for spontaneous pneumothorax - Conservative management can be considered for the treatment of minimally symptomatic (ie, no significant pain or breathlessness and no physiological compromise) or asymptomatic primary spontaneous pneumothorax in adults regardless of size. (Conditional – by consensus) - Ambulatory management should be considered for the initial treatment of primary spontaneous pneumothorax in adults with good support and in centres with available expertise and follow-up facilities. (Conditional) - In patients not deemed suitable for conservative or ambulatory management, needle aspiration or tube drainage should be considered for the initial treatment of primary spontaneous pneumothorax in adults. (Conditional) - Chemical pleurodesis can be considered for the prevention of recurrence of secondary spontaneous pneumothorax in adults (eg, patients with severe COPD who significantly decompensated in the presence of a pneumothorax, even during / after the first episode). (Conditional) - Thoracic surgery can be considered for the treatment of pneumothorax in adults at initial presentation if recurrence prevention is deemed important (eg, patients presenting with tension pneumothorax, or those in high risk occupations). (Conditional) ### Good practice points - When establishing local ambulatory treatment pathways, planning and coordination between with the emergency department, general medicine and respiratory medicine is vital. - When performing chemical pleurodesis for the treatment of pneumothorax in adults, adequate analgesia should be provided before and after treatment. - All treatment options should be discussed with the patient to determine their main priority, with consideration for the least invasive option. ## chest tube insertion - see [[Thoracostomy|ICC]] # Discharge advice - avoid air flight, scuba diving, snorkelling - ensure ready access to emergency medical service - cease smoking - **Air travel** - 6 weeks btwn resolution of PTx or definitive surgical procedure and air travel (some guidelines say 1 week if primary PTx) - CXR should confirm resolution prior to flight - still risks up to 12 months - **Diving** - permanently avoid after ptx unless had definitive preventative treatment - prior traumatic ptx may not be absolute contraindication if healed and CT normal → see expert for advice - recurrence - recurrence rate is 30% in all pts; ↓ after age 40 # Related Questions ## chest trauma - [ ] 1Q: [Chest trauma](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=5) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=6) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=3) - [ ] 2Q: [Penetrating Chest Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=42) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=19) - [ ] 3Q: [Chest and Head Trauma](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=2) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=0) -- [prop](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=64) - [ ] 4Q: [High Speed Motor Vehicle Collision](x-devonthink-item://C4CCEB12-61D5-4308-AA41-5078F3D96CC0?page=2) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=11) -- [prop](x-devonthink-item://E34679F3-102F-4E16-AF81-9D679412EDAC?page=7) - [ ] 5Q: [Chest Trauma](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=13) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=28) -- [prop](x-devonthink-item://AB9BDA6D-9CA8-4E73-9D15-B6105225A1B4?page=13) ## intercostal catheter - [ ] 11Q: [Penetrating Chest Trauma](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=42) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=19) - [ ] 12Q: [Rib Fractures](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=5) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=11) - [ ] 13Q: [Chest Trauma](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=7) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=6) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=2) ## penetrating chest trauma - [ ] 6Q: [Knitting needle to chest](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=11) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=13) - [ ] 7Q: [Shotgun wounds](x-devonthink-item://CA0CC973-6102-4C33-AB59-A43A87724DF0?page=10) -- [Answer](x-devonthink-item://9F437E5A-02D4-43FC-B795-5386EDE954F3?page=8) -- [prop](x-devonthink-item://281EC7A9-8E5A-461A-AA34-3FF490AA0EC2?page=2) - [ ] 8Q: [Chest stabbing](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=3) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=3) - [ ] 9Q: [Penetrating chest trauma](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=48) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=52) - [ ] 10Q: [Penetrating chest trauma](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=2) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=1) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=2) - [ ] 11Q: [Local Bar Shenanigans](x-devonthink-item://40F10AFA-5F29-4EE4-B149-300627B498B0?page=1) -- [Answer](x-devonthink-item://2088AEED-9FCF-4CF0-B58D-E4279D4BCC76?page=20) -- [prop](x-devonthink-item://5F365535-E019-4C8D-8402-2E764B328988?page=5) ## pneumothorax - [ ] 12Q: [Pneumothorax](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=49) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=49) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=12) - [ ] 13Q: [Pneumothorax ultrasound](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=18) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=17) -- [prop](x-devonthink-item://47692A18-39D4-4FDD-9F24-8F946DAF9CAB?page=1) - [x] DUPLICATE Q: [Pneumothorax Ultrasound](x-devonthink-item://8A1FC024-FD4E-4202-A93D-77C4E8234DC5?page=18) -- [Answer](x-devonthink-item://7EEBE66F-C2B1-4EF7-B29C-FB52D469C8CD?page=17) - [ ] 14Q: [Pneumothorax](x-devonthink-item://B9C99BB4-DAF8-4D15-BBD3-40E82B279902?page=13) -- [Answer](x-devonthink-item://DF848F67-27AB-450A-988B-159784B72957?page=13) -- [prop](x-devonthink-item://D2415799-57A6-4B32-BE9A-0120DF5500A1?page=2) - [ ] 15Q: [Pneumothorax](x-devonthink-item://5DD7C01C-AB9B-4F0E-9CC4-266700BD94E8?page=4) -- [Answer](x-devonthink-item://7CE81625-E4A6-40C1-BAEB-7E44C75B1E60?page=4) - [ ] 16Q: [Pneumothorax](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=4) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=1) -- [prop](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=61) - [ ] 17Q: [Decompression illness](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=32) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=32) - [x] DUPLICATE Q: [Chest and Head Trauma](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=2) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=0) - [x] DUPLICATE Q: [Penetrating chest trauma](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=2) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=1) - [ ] 18Q: [Pneumothorax](x-devonthink-item://EE0B8625-5F19-46CF-8208-56D79DC48BC5?page=9) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=13) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=10) - [x] DUPLICATE Q: [Chest Trauma](x-devonthink-item://2504F01B-CEAF-41E8-803B-B3AE1B07A49E?page=13) -- [Answer](x-devonthink-item://00427DF6-6D28-4FEB-A0CA-DF96DBBBCE97?page=28) ## tension pneumothorax - [ ] 20Q: [Chest Trauma](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=58) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=38)