pneumothorax - nsw agency for clinical innovation€¦ · pneumothorax . a randomised controlled...

Pneumothorax

A randomised controlled trial of invasive versus conservative treatment of primary spontaneous pneumothorax (PSP) Professor Simon Brown, Dr Emma Ball ACTRN12611000184976

PSP

Primary Spontaneous Pneumothorax

Clearly more common in males and tall people

Watch out for Marfans Syndrome/Ehlers Danlos

Bleb

Images courtesy of Society of American Gastrointestinal and Endoscopic Surgeons

PSP

• Occasionally almost asymptomatic

• Seldom causes saturations below 92%

• Most patients notice dyspnoea on exercise

• Many recall previous episodes

Chance of recurrence

Widely quoted at 30 % after first PSP

• 60% after second

• 80 after third

Higher if you won’t stop smoking

Diving and flying

Flying thought to be ok one week after resolution (BTS guideline)

Diving- never unless pleurodesis performed

Image courtesy kuvatON.com

Blebectomy , bullectomy, apical stapling, pleurectomy or pleurodesis

Images courtesy of Society of American Gastrointestinal and Endoscopic Surgeons

Long term safety pleurodesis

Slight restrictive ventilatory defect

Talc now less popular

Intercostal Chest Catheters

It hurts!!

Complications of ICCs

Courtesy of the ICN

Where did it go!!?!??!!!?

Seldinger technique makes it safer right?

Ventricular drainage

More Complications

The PSP study

• Intubation in space picture

Typical

• Typical one

• Bilateral one

• Small effusion

• Shift with exp view

• Real tpx

TensionPX

Never take an XR of this!!

The trachea is deviated

There is hyper-resonance

The great vessels kink and blood pressure collapses

TPX

• Said to be present in 5% of retrieved trauma patients

• Did it hiss?

17 mmhg

Reliable signs of TPX

Chest pain

Respiratory distress

70% of tensions

Tachycardia

Decreased air entry

Seldom present /unreliable in TPX

Hypotension

Tracheal deviation

Hypoxia/cyanosis

TPX in a ventilated patient

A more typical precipitous collapse

Ventilatory failure followed by hypotension

Needle decompression