This article has been cited by other articles in PMC. Selected References These references are in PubMed. This may not be the complete list of references from this article. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: to Am Rev Respir Dis.

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Proportion of all spont. The symptoms do not correlate closely with the size of the pneumothorax [12]. In many cases the symptoms are mild and approximately half of patients will present after more than 2 days of symptoms [13]. Secondary Spontaneous pneumothorax The symptoms are often more severe than those associated with a primary pneumothorax because lung function may already have been compromised by the underlying pathological process.

The symptoms will vary depending on the cause e. Unlike symptoms, the examination findings in primary spontaneous pneumothoraces are affected by the size of the pneumothorax. A small pneumothorax can be impossible to identify on clinical examination. This recognition and management of this complication is discussed later in the session.

Investigation Strategies Radiographs The most useful investigation is the PA chest radiograph despite the fact that it tends to under-estimate the size of a pneumothorax by virtue of it being a 2-dimensional image of a 3-dimensional structure. The diagnosis is made by the visualising the visceral pleura lung edge separated from the thoracic cage with no visible lung marking between the two.

Small pleural effusions are sometimes seen. The main indication for performing additional views would be where a secondary pneumothorax is suspected as identification of even a small pneumothorax in this setting may significantly influence management. However, the increased access to CT which is the most sensitive investigation has led to a significant reduction in the numbers of requests for additional lateral views.

Expiratory films add little to the PA radiograph and are not routinely recommended. CT CT is considered the gold standard at identification of a pneumothorax and is particularly valuable when radiographs are difficult to interpret or specific drain placement is required eg bullous lung disease, loculated pneumothoraces, surgical emphysema. However, it is highly user dependent and for patients with suspected spontaneous pneumothoraces, radiography has the advantage of identifying unexpected causes of pleuritic pain eg infection, carcinoma.

Having said this, with the increasing use of ultrasound in Emergency Medicine, in the hands of an experienced user it can now reliably detect pneumothorax better than an anteroposterior chest radiograph. Find out more: Sonographic diagnosis of pneumothorax Arterial blood gases Arterial gas monitoring may demonstrate hypoxia [21] but the information gained is unlikely to alter the management plan.

Their main use is when administering supplemental oxygen to patients with pneumothoraces secondary to COPD. Management Management depends upon whether the patient is symptomatic, whether the pneumo-thorax is primary or secondary, and its size on the PA radiograph. The guidance below is based upon the BTS guidelines Different guidelines have been adopted by other international bodies Compared to breathing room air, a pneumothorax will resolve 4 times faster if the patient is on high flow oxygen [23].

For patients with COPD, fixed concentration oxygen should be administered. Entonox diffuses into air spaces and can convert an uncomplicated pneumothorax into a tension pneumothorax. Its use as an analgesic is contraindicated in this setting. Patients with spontaneous secondary pneumothoraces less than 1cm in size and minimal symptoms do not require drainage in the ED but should be admitted for observation and supplemental oxygenation. Learning Bite Never discharge a patient from the ED with a diagnosis of a secondary pneumothorax.

As a minimum, supplemental oxygen and a 24 hour observation period is recommended. Symptomatic patients Symptomatic patients and those with large pneumothoraces, whether primary or secondary, require intervention. There are two diagrams depicting the recommended treatment algorithm for a primary and secondary spontaneous pneumothorax, these are available to download at the end of this module.

Diagram 1 Primary spontaneous pneumothoraces Diagram 2 Secondary spontaneous pneumothoraces Simple needle aspiration Needle aspiration is technique that describes aspiration of air via the chest wall without insertion of a chest drain thoracostomy tube.

Successful aspiration is associated with a much higher likelihood of discharge than chest drain insertion and fewer complications have been reported [27].

Following successful aspiration, patients with primary pneumothoraces should have a short period of observation in the Emergency Department before discharge. Recurrence rates are similar at 7 days and 1 year compared to thoracostomy tube insertion [24].

The BTS guidelines recommend use of a cannula no greater than 16G in diameter for aspiration though evidence that larger cannulae are more likely to cause a persistent pleural leakis limited. It should be remembered that narrower cannulae are also shorter and may not be long enough to reach the thoracic cavity in larger patients. Needle aspiration is less likely to succeed for secondary pneumothoraces [15] and is only recommended in this setting if the patient has a small pneumothorax cm in size and minimal symptoms.

Following successful aspiration, patients with secondary pneumothoraces should be admitted for observation. Table 5 describes a method of needle aspiration. Identification of the the 2nd intercostal space is achieved by locating the end of the 2nd rib mediall where it attaches at the manubriosternal angle. The ribspace below the 2nd rib is the 2nd intercostal space. Turn the tap again and aspirate another 50mls form the pleural cavity Continue until the patient coughs or 2. Repeat the chest radiograph.

Repeat the aspiration if necessary follow BTS guidelines If the procedure is successful, the cannula should be removed and a small occlusive dressing placed over the insertion site If the procedure is unsuccessful, the cannula should be removed and a thoracostomy tube inserted Simple Needle Aspiration Authors observations: Failure to attach the cannula to a connecting piece increases the likelihood of tube kinking or accidental removal A minimum of 2 persons are required for this procedure, one to manually secure the cannula and turn the connector, the other to perform the aspiration This is a time consuming procedure 50 times x 50 mls , particularly if it needs to be repeated, but success rates are relatively high Beware turning the tap the wrong way and inserting air into the pleural cavity!

The syringe gets very warm from the friction and increasing effort is required with each aspiration Intercostal chest drain thoracostomy tube Traditionally, the treatment for a large pneumothorax has been the insertion of a large e. Photo 2 large chest drain In the last decade there has been a move toward inserting smaller drains percutaneously.

Small drains e. In obese patients the Seldinger technique may not be technically possible as the needle may be too short to traverse the chest wall.

Whichever technique is used the landmarks are the same. Insertion in the safe triangle picture attempts to avoid injury to the long thoracic nerve and lateral thoracic artery, which sit in the mid-axillary line. This triangle is formed by the anterior border of latissimus dorsi posteriorly, the lateral aspect of pectoralis major anteriorly, and the 6th rib inferiorly forming an apex below the axilla.

In young, thin males the nipple will lie in the 5th intercostal space. Insertion of the drain just above the underlying rib minimises the risk of injury to the intercostal bundle. Photo 4 The safe triangle Both techniques are low risk in experienced hands. However, the National Patient Safety Agency [30] has issued specific recommendations following reports of 12 deaths and 15 cases of serious harm associated with drain insertion between and Recognised complications include:.





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