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Pneumothorax in the exam

Dr Henry Knipe and Dr Jeremy Jones et al.

Getting a film with a pneumothorax in the exam is one of the many exam set-pieces that can be prepared for.  

It is unlikely that they will give you a simple pneumothorax - so, it is worth while considering the likely causes and whether it is under tension. Miss it at your peril (both in real life and in the exam).

The film goes up and after a couple of seconds pause, you need to start talking:

Plain radiograph

There is increased lucency of the left hemi-thorax with a pneumothorax and evidence of mediastinal shift indicating tension.

I would check the time that the film was taken and whether subsequent films had been performed to see if a drain had been sited. If this is a recently taken film I would check to see if the patient was still in the department. If they were, I would find them, assess them and consider decompression of the pneumothorax with a venflon in the 2nd intercostal space, mid-clavicular line. If they were no longer in the department I would contact the clinical team looking after them urgently to communicate my findings.

There are background features to suggest COPD - hyperexpansion on the right (which is difficult to accurately assess given the tension pneumothorax), coarse bronchovascular markings and reduced subcutaneous tissue suggesting chronic disease.

Notes

  • as soon as you have seen a tension pneumothorax, you need to say so and say what you would d do - if the patient is still in the department, go and find them (or send your willing registrar)
  • if there is a pneumothorax under tension and there is a chest drain in situ, don't assume all is well - there are some tricky films with a chest tube that has been clamped (in the corner of the film) and a pneumothorax that has subsequently developed tension
  • think of some causes of pneumothorax - is there evidence of COPD or trauma?

Article information

rID: 16852
System: Chest
Section: Approach
Synonyms or Alternate Spellings:

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Cases and figures

  • Case 1: tension pneumothorax
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  • Case 2: tension with chest drain insitu
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