emergency protocol in pneumothorax

emergency protocol in pneumothorax

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  Management of spontaneouspneumothorax Ala’Eldin Hassan Ahmed, MD, FRCP, FCCP Faculty of Medicine, University of Khartoum
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  Spontaneous pneumothorax Pneumothorax isdefined as air in the pleural space. Primary pneumothoraces arise in otherwise healthy people without lung disease. Secondary pneumothoraces arise in subjects with underlying lung disease. Differential diagnosis:  Acute severe asthma.  Acute pulmonary embolism.  Acute left ventricular failure.  Exacerbation of chronic obstructive pulmonary disease.  Mechanical airway obstruction. Directed Approach to spontaneous pneumothorax: History: There is no relationship between physical activity and onset of a pneumothorax; most pneumothraces occur at rest. Smoking is a significant risk factor. Remember that history is not a reliable indicator of the size of a pneumothorax. Physical examination:  Look for signs of respiratory distress, cyanosis, and shock; if present they indicate tension pneumothorax. Diagnostic studies: 1. Chest radiograph. Expiratory CXR is not recommended for the routine diagnosis of a pneumothorax. 2. A lateral chest or lateral decubitus radiograph should be performed if the clinical suspicion is high but the PA film is normal. 3. CT scan is only recommended when differentiating a pneumothorax from complex bullous lung disease. For a stepwise approach for management of spontaneous pneumothorax (primary or secondary) refer to flowchart. Notes:  If tension pneumothorax is present a cannula of adequate length should be promptly inserted into the second intercostal space in the mid clavicular line and left in place until a functioning intercostals tube can be positioned.  The size of a pneumothorax is divided into small or large depending on the presence of a visible rim of < 2 cm or >/= 2 cm between the lung margin and the chest wall.  If a patient with a pneumothorax is admitted for observation, high flow oxygen (10 L/min) should be given.
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   All breathlesspatients should not be left without intervention regardless of the size of the pneumothorax.  If > 2.5 L. of air were aspirated and the lung is not fully expanded (as indicated by cessation of air coming out) the procedure should be abandoned and regarded unsuccessful. • There is no evidence that large tubes (20 – 24 F) are better than small tubes (10 – 14 F). The initial use of large tubes is not recommended. • A bubbling chest tube should never be clamped or removed. • If possible, pneumothorax patient should be admitted under the care of a respiratory physician.
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  Recommended algorithm forthe treatment of primary spontaneous pneumothorax No Yes Yes No Yes No Yes No Primary pneumothorax Remove 24 hours after full expansion / cessation of air leak Shortness of breath and/or a rim of air > 2 cm on chest radiograph Simple apiration ? Successful Consider repeat aspiration ? successful Intercostal drain ? successful Suction refer thoracic surgeon after 5 days Consider discharge
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  Recommended algorithm forthe treatment of spontaneous secondary pneumothorax No Yes No Yes Yes No Yes Yes No Secondary pneumothor ax Remove 24 hours after full re-expansion / cessation of air leak Breathless + age > 50 years + rim of air > 2 cm on chest radiograph Intercostal drain ? Successful Suction ? successful Discuss chest surgeon After 3 days Aspiration ? successful Admit to hospital For 24 Hours Consider discharge
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  Recommended algorithm forthe treatment of spontaneous secondary pneumothorax No Yes No Yes Yes No Yes Yes No Secondary pneumothor ax Remove 24 hours after full re-expansion / cessation of air leak Breathless + age > 50 years + rim of air > 2 cm on chest radiograph Intercostal drain ? Successful Suction ? successful Discuss chest surgeon After 3 days Aspiration ? successful Admit to hospital For 24 Hours Consider discharge