If not already stated - what would be your initial management at the time of the first X-ray?
Initial resuscitation with ABC and oxygen, and management as per British Thoracic Society guidelines for the management of acute asthma.
Management of pneumothorax, also as per BTS guidelines. It would be fair to suggest chest drain insertion at this point as the size of the pneumothorax is 2 cm, and because there is a clear secondary cause. However, it is clear that this did not happen in this case as there is no drain in place on the second image.
If not already stated - what would be your management at the time of the second X-ray?
The patient needs a chest drain as the pneumothorax is large. There are also signs suggesting early tension.
What clinical signs would you expect to encounter at the time the second X-ray was acquired?
Any general features of increasing respiratory compromise such as increased respiratory rate, tachycardia, cyanosis are possible.
There may be reduced expansion on the left, hyperresonance to percussion, absent breath sounds , and the apex beat may also be inaudible.
The trachea is unlikely to be significantly deviated as it appears central on the X-ray. If you mention this you are unlikely to be criticised.
What is the definition of a 'large' pneumothorax?
According to British Thoracic Society guidelines a large pneumothorax measures >2 cm at its widest point.
Where would you look to find up-to-date protocols for the management of pneumothorax, and for the management of acute asthma?
From guidelines produced by the British Thoracic Society