RESPIRATORY

ResponseRight pneumothorax
Significant tension with massive mediastinal shift
Flattened right hemidiaphragm
Small amount right pleural fluid
Deep sulcus

No subcutaneous emphysema
No medical intervention (lines, drains etc)
Trachea midline
No focal consolidation

ResponseLeft sided pneumothorax - BST guideline moderate to large - 1-2cm intrerpleural measured at the hilum

ResponseLeft sided pneumothorax
Subtle pneumomediastinum present (For bonus marks!)

ResponseR pneumothorax - visible pleural line with absent lung markings
Pleural thickening/plaque - broad opacification (widespread) along right visceral pleura
Right sided pleural effusion (consolidation with effusion) - loss of right hemidiaphragm with meniscus sign
Interstitial lung disease - increased interstitial markings right lung

ResponseLeft sided pneumothorax

Visible lung edge
Absence of lung markings at left apex.

ResponseLeft sided pulmonary bulla
Left sided loculated pneumothorax
Hyperiflated left hemithorax
Emphysematous change or scarring to background lungs
NOn invasive ventilation circuit
?bullae R side upper zone

Mgmt - Immediately stop NIV and change to NRBM

Predicted US findings
R - Lung sliding present, A lines
L - Absence of lung sliding, lung point, barcode sign

ResponseLarge right sided pneumothorax (~70%)
Shift to left (radiographic tension)
Flattened hemi-diaphragm
Collapse involves all lobes
Pneumomediastinum present
Absence of lung markings
Hemithorax radiolucent compared to left

ResponseI give up. You should be able to do this by now

ResponsePleural sliding

ResponsePneumothorax
Barcode sign = Stratosphere sign
No motion of chest wall
No motion of lung

(opposite = Seashore sign = No ptx)

ResponseNo pneumothorax
“Lung pulse” - repeated vertical lines that are seen only below the pleural line. Represents the lungs Jiggle as oxygenated blood fils it. Artifact useful as not seen in PTx, only seen in lung, even unventilated lung.

ResponseNo. Trick question
This is an M mode image of cardiac motion just under the chest wall

• Lung should be bright but this is dark (as filled with blood)
• Zig-zag of movement represents movement toward/away from probe (and the lung doesn’t do this normally… except in effusions, but its with respiration not heartbeat)

ResponseImage shows IVC that collapses almost completely on inspiration. Intrathoracic pressure is very low on inspiration - therefore not a tension

ResponseIVC is behaving like a “Lead pipe” and unchanged - Suggesting high intrathoracic pressure and tension ptx

ResponseAbsence of lung sliding
Absence of comet tail artifacts
Presence of lung point sign
Loss of normal granular pattern of lung in M mode (absence of seashore sign, presence of barcode/stratosphere sign)
Lead pipe IVC suggests Tension

ResponsePrimary spontaneous (Smoking is biggest risk factor!)
Secondary spontaneous (Increased mortality)

• Asthma, COPD, TB, pneumonia, lung abscess, carcinoma, CF, Fibrosis
• Inhallation/insufflation/snorting/IVDU
• Collagen vascular disease (eg: Marfan’s syndrome)

Traumatic - Trauma/rib fractures/surgical/biopsy

M:F 6:1

ResponsePrimary vs secondary - Secondary/recurrent more likely to require intervention
Prior pneumothorax/ipsilateral pneumothorax
Known lung disease

Symptomatology
breathless/chest pain - more symptomatic = more likely tor equire intervention

Patient factors
Consent/wishes/special considerations (Employment - diver/pilot etc)

ResponseHypoxia
Hypotension
Agitation
Dyspnoea
Shock
Ipsilateral dullness to percussion
Ipsilateral decreased air entry
Contralateral hyperexpansion appearance
(Tracheal deviation is not a reliable sign)

ResponseLarge vs small
Midline shift/radiologic tension
BTS vs ATS rules - eg: >2cm interpleural = large - more likely to require intervention

ResponsePros - Fast, no radiation, portible, accurate with training (High specificicity/sensitivity), potentially avoids unnecessary intervention
Cons - Requires training, ambient bright light may make interpretation difficult, patient access may be challenging, s/c emphysema may cause artefact

ResponseRapid, can be done whilst patient trapped
Lower level of training required to perform
Patient doesn’t required sedation for procedure
Temporising only and may be ineffective
Landmark accuracy prone to error
Can cause iatrogenic vascular injury and bleeding

ResponseNeed 360 degree access, slower than needle decompression
Definitive management
Landmarks prone to error but larger area of safety vs needle
Iatrogenic intercostal vessel/nerve injury and bleeding
Needs more training to perform
Needs local anaesthetic +/- sedation
Ideally needs positive pressure ventilation

ResponseSaturations <92% on oxygen
SBP <90
RR <10
Decreased LOC on oxygen
Pre-arrest/cardiac arrest

ResponseImmediate chest decompression - Needle thoracocentesis, ICC if rapid, Finger thoracostomy then 3 sided occlusive dressing
Ensure improvement of clinical state and vital signs
Non invasive monitoring
Formal ICC with underwater seal drain
Oxygen
Manage underlying condition (Eg: Asthma give nebs)

ResponseConservative
Minimal symptomatology at rest, first primary pneumothorax wsuspected without obvious underlying structural abnormality on CXR. Stable patient on observation.Patient preference. Get progress film in 6-12 hours for stability, follow up film 2 weeks
Apparently 94% success rate for spontaneous Ptx.

Simple aspiration
16-18 ga needle, <2.5L. Faster resolution of symptoms/size in spontaneous pneumothroax. Patient preference, promotes earlier discharge

Chest drain
Pigtail 8-14F. Secondary pneumothorax suspected (recurrence/underlying lung disease), significant symptoms - chest discomfort not controlled with simple analgesia
ED indications:
Progressive hypoxia despite supplemental O2
Worsening fatigue (resp acidosis)
Progressive/increasing ptx on serial XR

Primary VATS/Pleurodesis
Access to appropriate specialty
Work related requirement (Eg: Pilot)
Recurrent Ptx

ResponsePatient refusal
Iatrogenic coagulopathy (DOAC/Warfarin)
Marked thrombocytopaenia
Active malignancy with risk of dissemination
Established ceiling of care stating not for invasive measures

ResponseMisplacement of ICC
Solid organ injury
Infection/empyema
Haemorrhage
Tube malfunction/blockage/kinking

ResponseFollow up organised (LMO vs Resp) + timing
Progress films in 2-4 weeks
High risk activity advice - No flying until full resolution + cleared by resp physician. No diving at any point (Unless sutical fixation and normal CT)
Return advice - worsening CP/SOB
Cessation of smoking