QuestionSBA
QuestionChoice
The most likely diagnosis is a tension pneumothorax causing respiratory and circulatory compromise. Immediate needle decompression should be undertaken.
10017366
a
Needle decompression
QuestionChoice
This may be required eventually, however intubation and positive pressure ventilation should not take place until the pneumothorax is treated, as more air will be forced into the pleural cavity, worsening the situation.
10017369
d
Intubation and ventilation
QuestionChoice
Cardiac tamponade is a differential, however the absence of air entry over the right hemithorax and the desaturation makes this less likely. If a focussed echocardiogram demonstrates a tamponade, thoracotomy may be used to drain the blood.
10017370
e
Emergency thoracotomy
QuestionChoice
Cardiac tamponade is a differential, however the absence of air entry over the right hemithorax and the desaturation makes this less likely. A focussed echocardiogram would be useful after the patient is stabilised. In trauma, a thoracotomy is preferred to pericardiocentesis, as the tamponade will re-accumulate.
10017367
b
Pericardiocentesis
QuestionChoice
Although the patient is hypotensive and tachycardic, this patient is likely in obstructive shock due to a tension pneumothorax. A fluid bolus will likely also be administered, but needle decompression is the priority.
10017368
c
Fluid bolus
QuestionComment
This is incorrect.  New BTS guidelines suggest emergency thoracotomy into the triangle of safety is superior to needle decompression.
38455
QuestionComment
especially in a major trauma centre, expertise should be available 
38931
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Brenicus Callanders
QuestionComment
thoracostomy is not the same as thoracotomy
53439
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Ventral Kawasaki
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Gastro Chronic
QuestionComment
Why can't this be a hameothorax

48464
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Edema Dominant
QuestionComment
dangerously incorrect, may i add to 10 Jan 24 comment


61956
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anon
Concept
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# 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. 

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**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/)
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BTS Pneumothorax Pathway
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A left sided tension pneumothorax.
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A large right sided pneumothorax.
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Emergency Management of Pneumothorax
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Emergency Management of Pneumothorax
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Pneumothorax 3
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The landmarks for needle decompression in tension pneumothorax are the second intercostal space at the midclavicular line or the fifth intercostal space at the anterior axillary line, with the needle inserted above the rib to avoid the neurovascular bundle.
A 29-year-old man is taken to a major trauma centre after a high-speed car accident. They are having a CT scan of the entire body, when they deteriorate.

Observations show:

* Heart rate 113 beats/minute

* Blood pressure 90/59 mmHg

* Respiratory rate 32 breaths/minute

* Oxygen saturations 88% on 15 litres/minute oxygen (non-rebreather mask)

On examination, he is cyanosed. There is absent air entry across the right side of the thorax.

What is the most appropriate next step to take?
a