QuestionSBA
QuestionChoice
This is incorrect because needle decompression is required for a tension pneumothorax. The stem clearly states that there is no evidence of tracheal deviation and although he is slightly tachypnoeic, he is not unstable. This patient has a 3cm primary spontaneous pneumothorax. Aspiration should be tried in the first instance. Note that needles must be inserted just above ribs to avoid neurovascular damage.
53116
e
Needle decompression in the left 2nd intercostal space, mid-clavicular line, below the third rib
QuestionChoice
Although it is recommended to provide high flow oxygen to patients with pneumothoraces in order to facilitate lung re-expansion, the next best step is aspiration.  He is oxygenating well on air and at this stage, applying high flow oxygen is not a priority.
53114
c
High flow oxygen
QuestionChoice
This patient is presenting with a symptomatic, large (>2cm) primary spontaneous pneumothorax. Smoking is a known risk factor. As per the British Thoracic Society guidelines, the pneumothorax should be aspirated initially. If aspiration is successful, he can be discharged with follow up. If unsuccessful, a chest drain must be inserted.
53112
a
Aspirate
QuestionChoice
This is incorrect because this patient has a primary spontaneous pneumothorax. A chest drain is indicated once an aspiration is performed and deemed unsuccessful. Patients with underlying respiratory conditions such as asthma or COPD are classed as having a secondary pneumothorax, and if they have additional high risk factors, can necessitate a chest drain without the need for aspiration in the first instance.
53113
b
Chest drain
QuestionChoice
This is incorrect because needle decompression is required for a tension pneumothorax. The stem clearly states that there is no evidence of tracheal deviation and although he is slightly tachypnoeic, he is not unstable. This patient has a 3cm primary spontaneous pneumothorax. Aspiration should be tried in the first instance. Note that needles must be inserted just above ribs to avoid neurovascular damage.
53115
d
Needle decompression in the left 2nd intercostal space, mid-clavicular line, above the third rib
QuestionComment
Aren't needle decompression and aspiration the same thing?
54230
QuestionComment
Thoracentesis and needle decompression are both terms for a medical procedure that involves inserting a hollow needle into the chest to remove fluid or air: 

Thoracentesis: This procedure can be used for diagnostic or therapeutic purposes.
 
Needle decompression: This procedure is used in an emergency to treat a tension pneumothorax, which is a condition where air becomes trapped in the pleural space. 
55198
User
subscriber
Dr D.R.E.
User
subscriber
Serotonin Xeno
QuestionComment
Decompression is for a tension
55197
User
subscriber
Dr D.R.E.
QuestionComment
i cant lie i still havent figured out the different pneumothoraxes
57234
User
subscriber
streptocockus
QuestionComment
OK so pneumothoraces:
- Not symptomatic --> ALWAYS conservative Mx

Symptomatic AND >2cm:
     - high risk? (bilateral, Hx of PTx, unstable, >50yo with smoking Hx) --> chest drain
     - NOT high risk --> needle aspiration

- recurrent --> VATS for pleurodesis

I don't see a role for needle decompression in the BTS guidelines? pls correct me if im wrong but i think its just a thing to see in TV shows ig
61011
QuestionComment
needle decompression for tension. If aspiration fails in a non high risk patient - for chest drain insertion

62211
User
subscriber
CeCe
User
subscriber
Pseudopseudopseudopseudohypoparathyroidism
Concept
Chapter
# Summary
 
A pneumothorax is characterised by the abnormal presence of air in the pleural cavity, which may be spontaneous or traumatic in origin. Key signs and symptoms include sudden-onset shortness of breath, pleuritic chest pain, reduced chest expansion and reduced or absent breath sounds on the affected side. Chest X-ray is the key diagnostic investigation (although in cases of tension pneumothorax the diagnosis should be clinical).   Management decisions depend on the size of the pneumothorax, the patient's clinical condition and their wishes. Options include conservative management, needle aspiration, chest drain insertion or an ambulatory device. In cases of tension pneumothorax needle decompression is the initial emergency management.
 
# Definition
 
A pneumothorax refers to a collection of air in the pleural cavity which may cause collapse of the underlying lung parenchyma. 

# Classification

- They may be **spontaneous** or **traumatic** (including iatrogenic causes).

- Spontaneous pneumothoraces can be further divided into **primary** pneumothoraces (in patients without an underlying lung disease) and **secondary** (in patients with underlying lung diseases such as COPD or asthma).

- Patients aged over 50 years old with a significant smoking history who present with a spontaneous pneumothorax are generally considered to have a secondary pneumothorax. 

- A **tension pneumothorax** occurs when the defect in the pleura that has led to the pneumothorax creates a one-way valve effect whereby air can enter the pneumothorax but not leave it.
        - This causes the pneumothorax to progressively expand, putting pressure on the heart and great vessels and causing **mediastinal shift**
        - This is a medical emergency that rapidly leads to cardiac arrest if untreated
 

# Signs and Symptoms
 
There may be no signs or symptoms (small pneumothoraces may be detected incidentally on imaging) however in an emergency presentation these may include:

- Sudden onset shortness of breath
- Pleuritic chest pain
- Dry cough
- Tachypnoea and increased work of breathing

The following signs will be found on the affected side of the chest:

- Unilateral reduced expansion
- Unilateral hyper-resonance to percussion
- Reduced or absent breath sounds
- Reduced vocal resonance or tactile vocal fremitus
 
Patients with a tension pneumothorax may also have:

- Tracheal deviation to the contralateral side
- Tachycardia
- Hypotension
- Distended neck veins

# Investigations
 
Patients with a suspected tension pneumothorax should be diagnosed and treated with needle decompression based on the clinical picture, with no delay for investigations.

For other patients, an **erect PA chest X-ray** is diagnostic. 

 [lightgallery]
 

 [lightgallery1]
 
**CT chest** should be used in high-risk patients where it is not clear from the chest X-ray whether it is safe to place a chest drain.

**Arterial blood gases** are not usually indicated however they may be of use in certain situations e.g. titrating oxygen in a patient with COPD and low saturations.

# Management 

**Tension Pneumothoraces:** 

- If a tension pneumothorax is suspected, emergency management is to decompress this by inserting a large-bore cannula into the second intercostal space on the affected side, mid-clavicular line, or fifth intercostal space, mid-axillary line if a traumatic cause is suspected, as per ATLS guidelines.


- If this fails, open thoracostomy should be done immediately
- After initial emergency decompression, a chest drain should be inserted

For **primary or secondary spontaneous pneumothoraces**, management is guided by the 2023 BTS Guidelines as summarised below:

 [lightgallery2]
 
- **Conservative management** involves no intervention for the pneumothorax, and patients are monitored to ensure they do not deteriorate and any symptoms resolve
- **Ambulatory devices** (e.g. pleural vents) are one-way valves which allow air to leave the pneumothorax but not re-enter it
        - They can be inserted in a simple procedure under local anaesthetic
        - Patients can then be followed up as outpatients
- Symptomatic patients with larger pneumothoraces (usually 2cm or larger on CXR - CT may be used if unclear) or those with high-risk features (significant hypoxia, bilateral pneumothoraces, underlying lung disease, 50 or older with a significant smoking history, haemopneumothorax) require a **chest drain** and admission for monitoring
- In symptomatic patients without high-risk features but with pneumothoraces large enough for treatment (2cm or larger), management depends on their priorities
        - Conservative management allows avoidance of any procedure
        - Both needle aspiration and ambulatory devices offer more rapid symptomatic relief (ambulatory device insertion may not be available in all hospitals) 


**Follow up:**

- All patients should be reviewed in an outpatient clinic 2–4 weeks after presenting with a pneumothorax (with repeat chest imaging)
- Patients should be advised on smoking cessation if relevant
 - Advise patients not to fly until 7 days after chest imaging has confirmed resolution of the pneumothorax
 - Advise patients they should not take part in underwater diving for life (except in rare cases where they have been treated with bilateral open surgical pleurectomy)
 
# References
 
[British Thoracic Society Guidelines](https://thorax.bmj.com/content/thoraxjnl/78/11/1143.full.pdf)

[Royal College of Emergency Medicine - Spontaneous Pneumothorax](https://www.rcemlearning.co.uk/reference/spontaneous-pneumothorax/)

[Radiopaedia - Tension Pneumothorax](https://radiopaedia.org/articles/tension-pneumothorax)

[Pleural Vent Ambulatory Devices](https://www.nth.nhs.uk/resources/pleural-vent-ambulatory-device/)
331
Picture
BTS Pneumothorax Pathway
2336
BTS Pneumothorax Flowchart.png
images/rshwwsgi1704194603121.jpg
images/rshwwsgi1704194603121_256.jpg
images/rshwwsgi1704194603121_512.jpg
NxgGDQS+meF5CWxWW3qHl6FpH/jz
Topic
32
Respiratory
Picture
A left sided tension pneumothorax.
1031
Tension pneumothorax.jpeg
images/pxbwgb3x1665036171696.jpg
images/pxbwgb3x1665036171696_256.jpg
images/pxbwgb3x1665036171696_512.jpg
IggOBoCLtohgeZh3h3Z4d3eHAAAAAAA=
Picture
A large right sided pneumothorax.
716
Pneumothorax.png
images/np3ie7n71665036171715.jpg
images/np3ie7n71665036171715_256.jpg
images/np3ie7n71665036171715_512.jpg
HQgKBwBH/JeSinmOd4Vnp3h2CAAAAAAA
698
Emergency Management of Pneumothorax
Topic
39
Emergency Medicine
Video
Concept
698
Emergency Management of Pneumothorax
284
fY1cqYh
images/videos/respiratory.png
Pneumothorax 3
Condition
584
Respiratory failure
UkmlaTopic
1
Acute and emergency
10683
A primary spontaneous pneumothorax in young smokers often requires initial aspiration, especially if symptomatic and larger than 2cm.
Presentation
112
Breathlessness
UkmlaTopic
1
Acute and emergency
A 23-year-old male presents to A&E with a 2 hour history of chest pain. He has no significant past medical history. He trains as a basketball player and has a smoking history of 7 pack years. On examination, he appears distressed and he is working hard to breathe. There is no evidence of tracheal deviation. His respiratory rate is 27, and his saturations are 98% on air.  A Chest X-ray shows 3cm rim of air between the lung and chest wall.

Which of the following is the best next step in the management of this patient?
a