Chest X-ray - Scenario 5
Answers to scenario questions

Answers to scenario questions

Question 1

If not already stated - what would be your initial management at the time of the first X-ray?

• Appropriate resuscitation with 'ABC' and oxygen, and management as per British Thoracic Society (BTS) guidelines for the management of pneumothorax.
• Factors to consider include the presence of symptoms (specifically breathlessness), the size of the pneumothorax, age of the patient (above or below 50), and a history of lung disease (those with lung disease are more easily compromised by a pneumothorax).
• In this case there is no history of lung disease and no breathlessness at the time of the first X-ray which shows a small pneumothorax only. Therefore, no aspiration or chest drain is required.

Question 2

If not already stated - what would be your management at the time of the second X-ray?

• Continue resuscitation measures. As the patient is now breathless intervention is required initially with attempt at aspiration. If this is not successful or fails to control symptoms then the current guidelines advise placing a chest drain.

Question 3

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 thoracic expansion on the left, hyper-resonance to percussion, absent breath sounds , and the apex beat may also be inaudible.
• The clinical details at this stage tell you that the trachea is central, however if you suggest it may be deviated you are unlikely to be criticised.

Question 4

What is the definition of a 'large' pneumothorax?

• According to British Thoracic Society guidelines a large pneumothorax measures >2 cm at the level of the hilum. This assumes uniform compression of the lung such that the lung edge remains parallel with the chest wall.

Question 5

Where would you look to find up-to-date protocols for the management of pneumothorax?

• From guidelines produced by the British Thoracic Society