Pneumothorax and air-leak syndromes — formative SAQs

SAQ 1 (10)

A 16-year-old, tall and slim, presents with sudden left-sided pleuritic chest pain and breathlessness at rest. He has no known lung disease. On examination he is speaking in sentences and haemodynamically stable, with reduced breath sounds and a hyper-resonant percussion note on the left. ^{[5] [2]}

1. State the features that would tell you this is a tension pneumothorax and how that would change your immediate action. (3) ^[2]
2. Assuming he is stable, outline how you would confirm and size the pneumothorax and decide on treatment. (4) ^[1]
3. State two pieces of advice you would give him at discharge to reduce recurrence and future risk. (3) ^[5]

Model answer

Tension features and action. Tension pneumothorax is suggested by severe respiratory distress, hypoxia, hypotension and tachycardia, distended neck veins, tracheal deviation away from the affected side, and unilateral absent breath sounds. If present, it is a clinical diagnosis: I would give high-concentration oxygen and decompress immediately with a needle or finger thoracostomy followed by a chest drain, without waiting for a chest X-ray. In this stable boy those features are absent, so I can image first. ^[2]

Confirm, size and treat. I would confirm with an erect chest radiograph showing the visceral pleural line with absent lung markings beyond it, using the rim of air to grade size — a rim greater than two centimetres at the hilum defines a large leak. Point-of-care lung ultrasound is a useful bedside adjunct. For a small, stable, minimally symptomatic primary spontaneous pneumothorax, conservative management with oxygen and observation is appropriate and non-inferior; a larger or symptomatic leak is managed with needle aspiration or a small-bore chest drain, with ambulatory options in selected patients. ^{[1] [2]}

Discharge advice. Stop smoking and vaping, as both strongly increase recurrence; avoid diving permanently unless cleared and avoid unpressurised air travel until reviewed and the lung has fully re-expanded; and return immediately with recurrent chest pain or breathlessness because same-side recurrence is common. ^{[5] [1]}