PNEUMOTHORAX

SIMPLE PNEUMOTHORAX

There is no need to insert an intercostal drain unless: (1) The patient is dyspnoeic. Or, (2) there is enough air in his pleural cavity to lower the apex of his lung about 3 cm below the top of his pleural cavity.

TENSION PNEUMOTHORAX

DIAGNOSIS The patient has severe chest pain, severe and increasing dyspnoea, and sometimes cyanosis. His chest on the side of the lesion is hyper–resonant with poor respiratory movements, and absent breath sounds. His trachea and apex beat are deviated to the other side. Sometimes he has severe abdominal pain which may confuse the diagnosis.

X–RAYS are characteristic, but you have no time to look for them. On the affected side there is: (1) collapse of the lung, (2) the absence of lung markings, (3) flattening of the patient’s diaphragm, and (4) widening of his intercostal spaces.

EMERGENCY TREATMENT ANYWHERE Let out the air with a large needle, or with any convenient instrument. This may be life–saving, so don’t wait for an X–ray. Take the largest needle you can find; in a real emergency there may not be time to sterilize it. Push it through the patient’s third intercostal space in his midclavicular line.

The air will hiss out of the needle, his trachea will return to the midline, and he will immediately breathe more easily. He will now live and you can move him. Sometimes this is the only treatment he needs. He usually needs an underwater seal drain.

LATER TREATMENT Follow this emergency treatment by connecting the needle to an underwater seal drain. If none is available, make a valve. Cut the finger off a rubber glove, make a slit in it, and fix it over the adaptor of the needle, as in Fig. 65-8. This valve will let air out, but not in. Don’t use it if there is blood in the patient’s chest, because it may become blocked. As soon as possible, insert an underwater seal drain.

If there is blood in the pleural cavity, drain this with a second tube through a lower intercostal space posteriorly, as for a haemothorax (65.2).

Deep breathing exercises will help the air to be absorbed.

DIFFICULTIES WITH A PNEUMOTHORAX

IF AIR CONTINUES TO BUBBLE OUT OF THE UNDERWATER SEAL, it may be coming from the patient’s lungs, his trachea or his bronchi. X–rays may show that his lung is partly or totally collapsed. Bronchoscopy may show a blood clot in a bronchus and no lumen behind it. If air continues to bubble out of the underwater seal after 5 days, attach a high volume low pressure suction pump to the chest tube. This may expand his lung and bring it up against his chest wall where it may seal itself. Adjust the pressure to produce bubbling only in expiration. If this fails, refer him for thoracotomy and repair of the tear.

If the patient’s LUNG HAS STILL NOT EXPANDED weeks or months after the injury he may have an undiagnosed tear in his bronchus. if possible, refer him for bronchoscopy followed by repair of the tear, or lung resection.

IF YOU SUSPECT A TENSION PNEUMOTHORAX, DON’T WAIT FOR AN X–RAY