Makindo Medical Notes

⚠️ Treatment depends critically on whether it is a primary or secondary pneumothorax. Underlying lung disease = secondary, which is treated far more cautiously. 💨 Always suspect a pneumothorax in any mechanically ventilated patient with sudden deterioration (may present only as ↑ resistance to ventilation).

📖 About

• 🫁 Spontaneous presence of air in the pleural space.
• 👵 Patients >50 or with lung disease = secondary pneumothorax → require admission.

⚙️ Mechanism

• Hole in visceral pleura → air leaks into pleural space.
• Penetrating wounds (oesophagus, mediastinum, diaphragm).
• Gas-forming bacteria within empyema.

📂 Types

• 🟢 Primary: Age <50, no lung disease, minimal smoking history.
• 🔴 Secondary: Due to underlying lung disease.
• ⚔️ Traumatic: Injury-related (penetrating/blunt).

📊 Classification

• Primary Pneumothorax:
  • 👨 Tall, thin young men (20–40 yrs), often right-sided.
  • 🚬 Smoking ↑ risk (even subclinical lung disease).
  • 🌬️ Subpleural blebs rupture due to apex stress.
  • 🔁 Recurrence: ~40% within 2 years (especially smokers).
• Secondary Pneumothorax:
  • Due to 👇
    • ⚔️ Trauma (penetrating injuries).
    • 💉 Iatrogenic (biopsy, pleural procedures).
    • 💨 Ventilation (barotrauma with high PEEP).
    • 🫁 Lung disease (COPD, asthma, CF, PCP pneumonia).
    • 📉 Rare: Marfan’s, catamenial (endometriosis).

🩺 Clinical

• May be silent if small.
• Typical: sudden chest pain ⚡ + breathlessness 🫁.
• Severe: hypotension, tachycardia, cyanosis.
• Exam: hyper-resonance, ↓ breath sounds. ➡️ Tension PTX: tracheal deviation + distended neck veins.

🔍 Investigations

• 📸 CXR: Lung edge visible, no markings peripheral to it.
• 📏 Size: Small = <2 cm rim; Large = >2 cm.
• 🖥️ HRCT: For complex cases / to differentiate bullae.

💊 Management

• Initial: ABC → O₂ (with COPD caution), analgesia.
• Primary Pneumothorax:
  • Small (<2 cm), asymptomatic → discharge + 2 wk FU.
  • Large (>2 cm) or symptomatic → aspiration → if fails → chest drain.
• Secondary Pneumothorax:
  • Small (1–2 cm) → aspiration + admit overnight.
  • Large (>2 cm) or breathless → chest drain + admit.
• 🚨 Tension Pneumothorax:
  • Emergency! Needle decompression → chest tube.
  • Signs: severe distress, deviated trachea, distended neck veins, hypotension.

🛠️ Procedures

• Aspiration: 2nd ICS MCL, aspirate up to 2.5 L → repeat CXR.
• Chest Drain: Indications: >2 cm, failed aspiration, secondary PTX. Insert in safe triangle → monitor bubbling & swinging.

⚠️ Complications

• 💨 Persistent air leak → may need thoracic surgery.
• 🦠 Infection (chest drain in situ).
• 🔁 Recurrence (esp. smokers, tall males).

📚 References

• BTS Pleural Disease Guideline (2010)
• NHS: Spontaneous Pneumothorax Guidelines