Two weekends ago I was able to talk to a conference of local GPs gathered in Warrnambool. The brief was to discuss respiratory emergencies around a scenario that involved a hypothetical bus crash. Amongst other conditions we discussed management of pneumothorax.
Management of a traumatic pneumothorax is something which I am generally very happy to leave in the hands of the surgeons. Spontaneous pneumothorax is much more in my ball-park.
Spontaneous pnemothoraces – where the surface of the lung develops a ‘blow-out’ type of air leak, and the lung – as a consequence – collapses are considered as either:
- primary (no underlying lung disease) or
- secondary (underlying lung disease)
Management is different for the two different sorts of patients. The British Thoracic Society guidelines published in 2003 are excellent. They simplify evaluation of spontaneous pneumothorax, so that we differentiate in addition to the above discriminators (primary or secondary) predominantly only on whether the pneumothorax is small (less than 2cm rim between the lung edge and the ribs) or large (more than a two centimeter rim). Once that discrimination has been made, the acute management will follow along the lines indicated in the following flow charts:
Note that conservative management is very seldom pursued if the pneumothorax is secondary.
Once the emergency management plan has been implemented, the question is whether to refer for surgical treatment – either resection of blebs on the lung surface or pleurodesis (usually done videoscopically). There is around about a 40% risk of pneumothorax after the first spontaneous pneumothorax. The following is a fair list of indicators for referral for surgical intervention / referral
- second ipsilateral (same side) pneumothorax
- first contralateral (other side) pneumothorax
- bilateral spontaneous pneumothorax
- persistent air leak once a chest tube has been inserted (>5-7 days of tube drainage, air leak persist or lung has failed to fully re-expand)
- spontaneous haemothorax
- professions at risk – eg pilots, divers – where a recurrence would be disastrous.
Management of a traumatic pneumothorax is something which I am generally very happy to leave in the hands of the surgeons. Spontaneous pneumothorax is much more in my ball-park.
Spontaneous pnemothoraces – where the surface of the lung develops a ‘blow-out’ type of air leak, and the lung – as a consequence – collapses are considered as either:
- primary (no underlying lung disease) or
- secondary (underlying lung disease)
Management is different for the two different sorts of patients. The British Thoracic Society guidelines published in 2003 are excellent. They simplify evaluation of spontaneous pneumothorax, so that we differentiate in addition to the above discriminators (primary or secondary) predominantly only on whether the pneumothorax is small (less than 2cm rim between the lung edge and the ribs) or large (more than a two centimeter rim). Once that discrimination has been made, the acute management will follow along the lines indicated in the following flow charts:
Note that conservative management is very seldom pursued if the pneumothorax is secondary.
Once the emergency management plan has been implemented, the question is whether to refer for surgical treatment – either resection of blebs on the lung surface or pleurodesis (usually done videoscopically). There is around about a 40% risk of pneumothorax after the first spontaneous pneumothorax. The following is a fair list of indicators for referral for surgical intervention / referral
- second ipsilateral (same side) pneumothorax
- first contralateral (other side) pneumothorax
- bilateral spontaneous pneumothorax
- persistent air leak once a chest tube has been inserted (>5-7 days of tube drainage, air leak persist or lung has failed to fully re-expand)
- spontaneous haemothorax
- professions at risk – eg pilots, divers – where a recurrence would be disastrous.
Andrew
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