Pneumothorax

PneumothoraxSpontaneous pneumothorax is one of the commonest thoracic surgical emergencies, usually associated with minor underlying lung abnormality with small blebs on the surface of the lung at the apex of the upper lobe or apical lower lobes. It is usually associated with sharp pain on the affected side and some degree of shortness of breath. Classically it affects tall thin young (asthenic) men. It is also common in patients with emphysema. In our environment it also commonly complicates pulmonary tuberculosis. It may affect sub-aqua divers with disastrous consequences as the pneumothorax enlarges as the patient ascends from deeper top shallower water. Emergency management consists of insertion of an intercostal drain when possible after chest x-ray. A needle is inserted first to aspirate air in order to ensure that the drain is in the appropriate place. When x-ray is unavailable and a clinical diagnosis of pneumothorax is made, again it should be confirmed by insertion of a needle and aspiration of air before insertion of a chest drain. If for any reason a chest drain is unavailable a needle or preferably an intravenous cannula may be inserted which may be life saving. After insertion of the needle or cannula with removal of its introducing needle, a hypodermic syringe with its bore removed and partially filled with sterile water shows continuing evacuation of air.

Usually the drain produces immediate relief and re-expansion of the lung. The drain can be removed after complete re-expansion of the lung nad no air leak for at least 24 Hours. After a second pneumothorax, if the lung fails to re-expand or if there is ongoing air leak then the patient should be referred to the thoracic surgical unit for definitive treatment. This may consist of pleurectomy with ligation of bullae, either open surgical, thoracoscopic pleurectomy with stapling of bullae or talc pleuradhesis. For patients where surgery is inadvisable because of severe underlying lung disease chemical pleuradhesis with bleomycin or tetracycin instillation may be performed.