=====Pneumothorax=====
ie air in the pleural cavity with consequences and management dependent on the degree of lung collapse
  *spontaneous
    *associated with smoking (in some studies >100x more likely), chronic lung disease eg COPD
    *often taller patients
    *NOT associated with exercise
    *hereditary
    *others - abnormal connective tissue, related to distal airway inflammation, apical ischaemia, low BMI etc
  *iatrogenic
  *traumatic
  *catamenial
    * R sided pneumothorax, generally in women 30-40y with symptoms within 48/24 of menstruation
    * cause unknown but many have associated endometriosis
    * one theory suggest PGF2, which is elevated in ovulation, causes bronchoconstriction which may be associated with small ruptures

===Presentation===
  *may or may not present with pain, SOB
  *examination findings of reduced air sounds, hyper-resonance on percussion rarely
  *deviated trachea (with tension), subcutaneous emphysema and pneumo-mediastinum on CXR
  *associated physiological signs - tachycardia, hypotension, pulsus paradoxus, ↑JVP
  *clinical symptoms associated with secondary pneumothorax are generally more severe than a similar sized primary pneumothorax
  *<wrap em>CXR should not demonstrate tension pneumothorax!! - this is a clinical finding and should have been treated before CXR!</wrap>

====Management====
[{{ :wiki:respiratory:pneumothorax.png?400|  //**BTS pleural disease guideline 2010**//}}]
  *expiratory CXR no greater accuracy than inspiratory
  *size of pneumothorax generally not as important as clinical consequences, although 'large' is generally viewed as being >2cm at apex on PA CXR in UK and >3cm in USA
    *methods of estimation of size are debatable. CT is better but exact estimation not necessarily important
    *spontaneous resolution of primary spontaneous pneumothorax (PSP) - rate of ~2% per 24/24. Resolution 4x faster with O2 therapy and therefore reserved for IP Mx

^Collins method - % = 4.2 + 4.7 (A + B + C) ||
|A is the maximum apical interpleural distance\\ B is the interpleural distance at midpoint of upper half of lung\\ C is the interpleural distance at midpoint of lower half of lung\\ {{:wiki:respiratory:pneumothorax_estimation.png?500|}} |{{ :wiki:respiratory:pneumothorax_size.png?200 |}}|
  
  *rim outline of lung parenchyma may appear more laterally in patients with lung disease and accompanying tethering/collapse/consolidation
  *guidelines vary but management usually based on likelihood of resolution and recurrence
  *a pneumothorax in a patient with pre-existing lung pathology is less well tolerated than PSP (primary spontaneous pneumothorax)
  *patients with COPD respond less favourably to emergent intervention
  *for those patients for whom conservative management is appropriate, resorption is said to occur at the rate of 1-2% of volume of pneumothorax per 24/24
  *needle aspirate is considered as effective as large bore chest drain and probably reduces need for admission and LOS. Fine bore drain if aspiration fails.
  *see flow chart


===Insertion of Intercostal Drain===
  *landmarks - ant to mid-axillary line, 5th ICS
  *remembering that neurovascular bundle lies 'below the rib above' with vein then artery then nerve. (VAN from above down)
  *2-3cm transverse incision in line with superior border of rib, to avoid the main N/vasc bundle. (there are smaller collateral branches here though)
  *blunt dissection to pleura and finger then to 'probe' canal
  *using forceps clamped on end of drain, insert into space
  *connect to drain bag
  *suturing and dressing to ensure confident fixing of drain to chest wall
{{:wiki:respiratory:intercostal_space.jpg?400|}}
----
==Inpatient management options==
  *video assisted thoracoscopic surgery with pleurectomy and abrasion
  *chemical pleurodesis eg tetracycline, minocycline, doxycycline
  *graded talc
  *open pleurectomy

=====Spontaneous pneumomediatinum====

[[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5474372/#:~:text=Spontaneous%20pneumomediastinum%20(SPM)%20or%20spontaneous,also%20known%20as%20Hamman's%20syndrome.|Resp Unit - review of 18cases - 2017]]\\ 

==References include:==
[[https://thorax.bmj.com/content/65/Suppl_2/ii18|BMJ Mx Pneumothorax 2010]]\\ 
https://handbook.ggcmedicines.org.uk/guidelines/respiratory-system/management-of-pneumothorax/\\ 
https://emedicine.medscape.com/article/424547-overview\\ 
[[https://www.resmedjournal.com/article/S0954-6111(05)00512-3/pdf|Comparison of methods for estimating pneumothorax size. Kelly et al. 2005]]\\ 
https://radiopaedia.org/articles/pneumothorax?lang=gb\\ 
[[https://err.ersjournals.com/content/19/117/217#ref-27|Europ Resp rev. Pneumothorax]]\\