inpatient / pulmonology and critical care
Pneumothorax
# Pneumothorax
Checklist
-- ABCs: stable vs unstable (tension physiology) - page thoracic surgery, consider needle decompression
-- HPI Intake: *** dyspnea, chest pain, prev PTX, smoking, h/o COPD, other primary lung dx
-- Can't Miss: tension PTX
-- Admission Orders: *** telemetry, continuous pule ox
-- Initial Treatment to Consider: oxygen, pain management, avoid NIPPV
Assessment:
-- History: *** prev PTX, smoking, emphysema, M>F, height, recent thoracic procedure
-- Clinical: *** hypoxia, hypotension, chest pain, dyspnea
-- Exam: *** ipsilateral absence of breath sounds, hyper-resonant percussion, distended neck veins
-- Data: *** CXR
-- Etiology/DDx: *** spontaneous (primary vs secondary to lung dx like emphysema), traumatic, iatrogenic (CVC, intubation, barotrauma, bronch, thoracentesis)
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
-- Chest tube vs conservative management
-- O2 with goal *** >92-94%
-- Set chest tube to *** water seal,
-- CXR daily and after changes in settings
-- Pleurodesis in refractory cases
Presenting:
Chest tube placed on *** by *** is currently set to *** (suction, water seal / gravity, clamped), with/without appropriate tidaling, with/without air leak ***
PDF coming soon!
If You Remember Nothing Else
A pneumothorax can either be treated conservatively (watch and wait) if the air space is small, the patient is asymptomatic, and is otherwise healthy. Otherwise, a patient will need to have the air drained via a chest tube. In emergency situations, including tension pneumothorax, a needle decompression should be attempted at bedside as a bridge to a chest tube. In general, avoid NIPPV.
Clinical Pearls
- Spontaneous PTX is 6x more common in men, and is most often seen in those 16-25 years old
- Can consider treating conservatively if 18-50yo, apex-to-cupula on CXR <3cm, and no dyspnea with regular activity on room air
- In general, you should try to avoid NIPPV in PTX
- If ventilated, you will likely see evidence of decreased lung compliance (increased Pplat >30)
- Upright CXR can detect PTX of 50cc, supine and portable may only be able to detect PTX of 500cc or more - try ultrasound in the case where the patient can’t sit up
- When reviewing CXR, don’t let the medial border of the scapula or a skin fold fool you
- POCUS - M-mode can be used to assess for lung sliding - absence c/f PTX; barcode sign (loss of the seashore sign” is 91% sensitive and 98% specific and is superior to CXR in diagnosing PTX
- Tension PTX is one of the H’s and T’s for a reversible cause of cardiac arrest
- Emergency needle decompression - 16G at the 5th intercostal space, mid-axillary line, above the rib
Other Resources
- Assessing for Lung Sliding and PTX on POCUS - YouTube Video - MedCram
- Demystifying Chest Drain Management (chest tubes) - YouTube Video - American Thoracic Society
- The Basics of Chest Tube Management - YouTube Video - ICU Advantage
- Chest Tube Physiology - YouTube Video - ICU Advantage
