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Management pneumothorax post surgery (Indications for surgical referral…
Management pneumothorax post surgery
Pneumothorax
Presence of air btw parietal and visceral pleura
Range from small asymptomatic to life threatening (tension) - small <2cm, large >2cm
History
Predisposing conditions
Smoking
Underlying illness
Obstructive COAD, asthma
Suppurative - bronchiectasis, CF
Malignant
Infectious
Interstitial lung disease
other e.g. ARDS, marfans
Previous spontaneous pneumothorax
Symptoms - Dyspnoea, chest pain
Preexistant resp function - ex. tol
Social
If day case -want to know about home situation
Distance from hospital
Carers and dependents at home
Examination
Vital signs and stability (HR, RR, Sats, BP)
Pulsus paradoxus
Resp: exclude tension: midline trachea, percussion, auscultation, conscious state
Investigations
Review CXR for size
Repeat CXR in 4 hours to assess progress (increase size, tension, bilateral)
Management
Immediate
High flow 02 mask - aids reabsorption
Safe environment, monitoring
Notify surgeon
Keep fasted
Subsequent - dependent on severity
tension = urgent decompression
Large Ptx
Require admission
Likely require decompression (ICC)
If conservative management planned: may require ICU admission
Small Ptx
May be suitable for conservative management
Admission vs discharge - home dependent on:
Size and symptoms (small and asymptomatic)
Normal underlying resp function
Live close by with responsible adult
Understanding, education and written material of when and how to represent
Follow up plan (e.g. review with CXR and LMO in 1/52)
Follow up
Education
General measures for patient and summary for LMO
20% recurrence rate
No flight for at least minimum time post resolution (6/52)
No scuba diving
Repeat CXR to ensure resolution
Surgical referral if required
Smoking cessation
Classification
Primary
Usually tall, thin young males>females, may have no lung pathology
Rupture of bulla/bleb
Increased risk of smoking
Secondary
Occur in the presence of lung pathology
Obstrutive: COAD, asthma
Suppurative - bronchiectasis, CF
Infetious
Interstitial lung disease
Other e.g. ARDS, marfans
Malignant
Iatrogenic - post CVC, pleural tap, bronchial biopsy, high PIP/PEEP
Traumatic
Penetrating chest trauma
Blunt trauma
Fractured ribs and pleural laceration
Indications for surgical referral
Persistent air leak > 7 days
Recurrent spontaneous ipsilateral Ptx
Contralateral Ptx
Bilateral Ptx
First presentation with high risk occupation
Concurrent ARDS
Risk of recurrent Ptx unacceptable due to remote location