Pneumothorax

Published on 05/05/2015 by admin

Filed under Internal Medicine

Last modified 05/05/2015

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108 Pneumothorax

Instruction

Examine this patient’s chest.

Salient features

History

• Sudden onset or rapidly progessive dyspnoea

• Ipsilateral acute pleuritic pain: either sharp or a steady ache

• A small pneumothorax may be asymptomatic

• Obtain history of:

• recent pleural aspiration or insertion of subclavian line (J R Soc Med 1997;90:319–21)
• recent surgeries in head and neck
• abdominal procedures using bowel or peritoneal distension.

• History of asthma, COPD, acute respiratory distress syndrome, pneumonia, trauma to chest

• History of Marfan syndrome

• History of HIV

• History of positive pressure ventilation.

Examination

• Decreased movement of the affected side

• Increased percussion, note:

• trachea may be central (small pneumothorax) or deviated to the affected side (underlying collapse of lung) or the opposite side (large pneumothorax)
• increased vocal resonance with diminished breath sounds.

Proceed as follows:

• Look for clues regarding aetiology:

• Pleural aspiration site
• Infraclavicular region for a bruise of the central line
• Comment if the patient is thin or has marfanoid features
• Inhaler or peak flow meter by the bedside (asthma, COPD).

• Tell the examiner that you would suspect tension pneumothorax when there is tachycardia (>135 beats/min), hypotension and pulsus paradoxus.

Diagnosis

This patient has diminished breath sounds and hyper-resonant note on R/L side of the chest (lesion) caused by pneumothorax secondary to Marfan syndrome (aetiology), and is not breathless at rest (functional status).

Questions

What do you understand by the term pneumothorax?

Air in the pleural cavity.

How would you investigate this patient?

• Chest radiography, both inspiratory and expiratory phases. In critically ill patients, pneumothorax is suspected when:

• the costophrenic angle extends more inferiorly than usual because of air: the ‘deep sulcus sign’ (Fig. 108.1; Radiology 1980;136:25–7)
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