title: "Pneumothorax"
Pneumothorax
Pneumothorax = air in the pleural space causing lung collapse. Tension pneumothorax is a clinical diagnosis requiring immediate decompression - see primary survey.
Source: ANZCOR; ATLS; local ED/ICU pneumothorax + chest drain guidance.
Classification
| Type | Definition | Management |
|---|---|---|
| Simple/Primary Spontaneous | No underlying lung disease, small | Observation or aspiration |
| Secondary Spontaneous | Underlying lung disease (COPD, CF) | Usually requires chest drain |
| Traumatic | Penetrating or blunt trauma | Chest drain |
| Iatrogenic | Post-procedure (CVC, biopsy) | Depends on size |
| Tension | One-way valve effect, mediastinal shift | Emergency decompression |
Tension Pneumothorax
Tension pneumothorax is a CLINICAL diagnosis. Do NOT wait for CXR.
Signs: Respiratory distress, hypotension, tracheal deviation away, absent breath sounds, distended neck veins.
Immediate Management
Needle decompression: Use a long, large-bore cannula (ideally ~8 cm, 12- or 14-gauge). Options include 2nd ICS at/just lateral to mid-clavicular line, or 4th/5th ICS just anterior to the mid-axillary line. Then insert chest drain.
Alternative site: 4th/5th ICS just anterior to the mid-axillary line
Pathophysiology
- Air enters pleural space but cannot escape (one-way valve)
- Progressive pressure build-up
- Lung completely collapses
- Mediastinum shifts to opposite side
- Compression of contralateral lung and great vessels
- ↓ Venous return → ↓ Cardiac output → Cardiovascular collapse
Clinical Features
| Feature | Simple | Tension |
|---|---|---|
| Dyspnoea | + | +++ |
| Chest pain | Pleuritic | Severe |
| Breath sounds | ↓ | Absent |
| Percussion | Hyper-resonant | Hyper-resonant |
| Trachea | Central | Deviated away |
| JVP | Normal | Elevated |
| BP | Normal | ↓↓ (shock) |
| Heart sounds | Normal | May be muffled |
Investigations
- CXR (erect): Visible pleural line, absent lung markings beyond
- CT chest: Most sensitive, not needed if clinically obvious
- ABG: Hypoxia ± hypercapnia in large pneumothorax
On supine CXR (trauma), pneumothorax appears as deep sulcus sign (hyperlucent costophrenic angle) rather than apical air.
Management Algorithm
Primary Spontaneous Pneumothorax
- Small (less than 2cm rim), minimal symptoms: Observe, discharge with follow-up
- Symptomatic or greater than 2cm: Aspiration first (up to 2.5L)
- Aspiration fails: Chest drain (small bore 8-14F)
Secondary Spontaneous / Traumatic
- Generally requires chest drain
- Larger bore (24-28F) for haemopneumothorax
- Traumatic pneumothorax usually requires chest drain (risk of ongoing air leak)
Chest Drain Insertion
Triangle of safety: Anterior border of latissimus dorsi, lateral border of pectoralis major, line of 5th ICS, apex below axilla
Insert chest drain in the 5th intercostal space, mid-axillary line within the triangle of safety. Go above the rib to avoid neurovascular bundle.
Complications
- Chest drain: Pain, infection, bleeding, organ injury, subcutaneous emphysema
- Re-expansion pulmonary oedema: Rare, with rapid re-expansion of chronic pneumothorax
- Recurrence: 30% for primary spontaneous, consider pleurodesis/surgery if recurrent
Test Your Knowledge
What is the most appropriate initial management?
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Sources
- ANZCOR
- ATLS
- Local ED/ICU pneumothorax + chest drain guidance