00:01
So the next part of this talk, I’m going
to discuss pneumothorax, and that’s air
in the pleural space. There are different
types of pneumothoraces. First of all, there
are spontaneous pneumothoraces which are occurring
without any evidence of trauma. And those
are divided into primary. That means patients
with no underlying lung disease, and this
tends to be young, tall, thin man. They may
have an inherited disease of the connective
tissues such as Marfan’s which makes them much more
likely to have this or secondary pneumothorax,
and those occur in patients with underlying
lung disease such as COPD, cystic fibrosis,
etc. Then there are traumatic
pneumothoraces which
actually most often are probably iatrogenic
ones which occur during patients having needle
insertion around the thoracic cavity. So that
will be a lung biopsy or central line insertion,
something like that, where in fact, the chance
of getting a small pneumothorax is relatively
high, and of course trauma can cause a
pneumothorax as well.
01:01
So, primary pneumothoraces normally occur
around the age of 20. They’re two or three
more times common in men than women. They’re
increased in smokers and they’re increased
in patients who use recreational drugs such
as cocaine and marijuana. This also increases,
as I mentioned, in patients with Marfan’s syndrome
due to the weakness of their connective
tissue. Secondary pneumothoraces would occur
in older people, usually over 50, and they
normally have a known lung disease such as
COPD. The symptoms of pneumothorax are very
simple; sudden onset chest pain, tightness,
and dyspnoea. One moment the patient is well,
the next minute, they have a problem with
their chest. Normally, with pain initially,
and then increasing breathlessness as the
pneumothorax develops.
01:47
When you examine the patient, the pneumothorax
is usually obvious. The trachea is deviated
away from the pneumothorax affected side.
Percussion note will be resonant, in fact,
may be hyper-resonant that is quite tricky
to detect. There will be reduced breath sounds
and reduced vocal resonance. At that right-hand
side, for example, in this person with the
right sided pneumothorax, will not expand
as well as the left-hand side. And because
there are no divisions in the normal pleural
space, air will rise to the top. So with smaller
pneumothoraces, you hear the abnormalities
at the top. With a large pneumothorax, it
will be throughout the lung. So, how do you make
the diagnosis clinically?
It’s very obvious usually and you can confirm
it using a chest X-ray, and really no other
investigations are necessary acutely. And
you can see here on this chest X-ray that
the typical finding is somebody with a large
pneumothorax which has got loss of lung markings
in the periphery of the lung which is just black.
There are no visible vessels or bronchi present
there at all. And there’s a pleural line
which shouldn’t be there.
02:45
How do we treat pneumothorax? It depends on
the size. So if somebody presents with primary
pneumothorax, and it’s very small and they’re
not terribly breathless, actually, you don’t
need to do anything at all. It will probably
resolve by itself over time. You just need
to monitor with a chest X-ray, and the patient
may not even need to come into the hospital.
03:01
If it's very large. They’re probably quite
breathless and they probably require chest
drain, and therefore, they may have to come
into the hospital.
03:08
The ones in between where you have a two centimetre
rim of air around the lung, for example, the
patient is feeling a bit breathless, then
there’s a halfway step between doing nothing
and insertion with chest drain, and that’s
aspirating. This way, you put a needle in,
and similar to the pleural effusion, you suck
out a large amount of air, and you see whether
that makes a difference to the pneumothorax.
So you put the needle in, aspirate a litre
or two, do the chest X-ray, see whether the lung
has come up. If it hasn’t come up, then
they may need to come into the hospital to
have a chest drain. It depends.
03:43
If somebody has to have a pleural drain, then we
normally put the pleural drain for pneumothoraces
on an underwater seal. That means that the
tube that comes out the chest goes underwater
and that prevents air from re-entering the
pleural space once it leaves the pleural space.
03:57
This rapidly removes most of the pleural space
air and the patient would feel alot better very
shortly. The problem with pneumothoraces is
that they’re due to a small hole forming
in the visceral pleura leaking air into the
pleural space. And this hole forms spontaneously
in primary pneumothorax and will heal, but
until it’s healed, the way air leaking out
from the lung into the pleural space, and
that’s called the bronchopleural fistula.
04:26
So if somebody has a continuing bronchopleural
fistula, what will happen is the air will
drain, the air will go out into the pleural
space, and then go down the drain, and be
visible as bubbles as the patient breathes
or coughs coming underneath the underwater
drain. So, a continuing bubbling in somebody
with an inserted chest drain and a previous
pneumothorax suggests there's continuing bronchopleural
fistula, which means if you remove the drain,
all that will happen is that the air in the lung
will collapse again with a new pneumothorax.
04:56
In patients where you do have a persistent
bronchopleural fistula, and normally, we give
patients about five to seven days to heal,
then you may want to do surgery to repair
the hole. You also do surgery if the patient
presents with two primary pneumothoraces on one
side as the chances are that then they would
have the third one and the fourth one.
05:17
After one pneumothorax, the chance of recurrence is
about 30% after two, it goes up to 50%, 60%.
05:23
If you had three on the same side, then it
goes up to 70%, 80%. Hence, we suggest that
surgery is going to be required if you had
two on one side.
05:31
The treatment so far described is for primary
pneumothorax, for patients with no underlying
lung disease. With secondary pneumothorax,
the patient has a big problem because they
have an underlying lung disease, their lung reserves
their ability to cope with the small pneumothorax
or even a minimum pneumothorax becomes much
harder, and they may be much more breathless
with a very small amount of air in the pleural
space than somebody with a primary pneumothorax,
and therefore, they probably will require
chest drain. So secondary pneumothorax, most
of the patients, especially the asymptomatic,
will require chest drain to make sure that
they’re safe and they can recover from a
pneumothorax without risking respiratory failure.